Delhi

East Delhi

CC/216/2015

SUNDER LAL - Complainant(s)

Versus

O.I.C - Opp.Party(s)

17 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 216/15

 

Shri Sunder Lal

S/o Late Shri Kashi Ram

R/o B-13/2, South Anarkali

Krishan Nagar, Delhi – 110 051                                                 ….Complainant

Vs.

1. The Oriental Insurance Co. Ltd.

Regd. & H. No. A-25/27, Asaf Ali Raod

New Delhi – 110 002

 

2. The Oriental Insurance Co. Ltd.

CBO-12, A-159, Vikas Marg

Shakarpur, Delhi – 110 092

 

3. M/s. E-Meditek (TPA) Services Pvt. Ltd.

TPA Address: 577, Udyog Vihar, Phase-V

Gurgaon, Haryana, Gurgaon-122 016                                                    ….Opponents

 

Date of Institution: 27.03.2015

Judgment Reserved on: 17.11.2017

Judgment Passed on: 11.12.2017

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Ms. Harpreet Kaur Charya (Member)

 

JUDGEMENT

            The present complaint pertains to allegations of deficiency in service by the complainant Shri Sunder Lal against the Oriental Insurance Co. Ltd.,       Asaf Ali Road (OP-1), the Oriental Insurance Co. Ltd., Vikas Marg (OP-2) and       M/s. E-Meditek (TPA) Services Pvt. Ltd. (OP-3).

2.         Facts in brief are that the complainant got Silver Plan – Happy Family Floater on 25.02.2013 vide policy no. 271701/48/2013/2737 from OP for      Rs. 3,00,000/- as Basic Cover and Rs. 4,50,000/- as personal accident cover policy, valid from 25.02.2014 to 24.02.2013 and got it renewed from 25.02.2014 to 24.02.2015 for personal accident cover of S.I. Rs. 5,00,000/- and basic cover of Rs. 3,00,000/-.

            On 6^th September 2014, the complainant Shri Sunder Lal complained of chest pain at night for which he visited Kumar Clinic, Ram Nagar where he was advised to visit hospital.  On 07.09.2014, the complainant underwent cardiac surgery and transplant of Everolimus Eluting Coronary Stent system              REF 1011709-15 and got discharged from Pushpanjali Crosslay Hospital, Vaishali on 10^th September 2014.  It has been stated that the claim, vide                            no. 122091401278 was lodged with OP-3, where the officials at Pushpanjali were asked to send the revised estimate as the estimated expenses were on higher side.  It has been alleged that OP-3 in collusion and connivance with OP-1 and OP-2 denied cashless facility on the pretext “that the patient has history of HTN since paste 4 years, for which there was waiting period of          4 break free years as per policy terms and conditions, but policy period starts from 2013 onwards so do not fill requirement.”  The complainant paid hospital bills of Rs. 2,49,220/- after borrowing the same. 

            It has further been stated that the amount was not reimbursed despite fulfilling all documentary and other formalities.  More documents were demanded by OP-3 on 18.09.2014 and 30.09.2014 regarding the past treatment records, sticker of stent used in surgery etc., which was duly replied by the complainant vide letter dated 20.01.2014 stating that he did not suffer from any disease, but the claim of the complainant was rejected.  Legal notice dated 27.02.2014 demanding reimbursement of claim of Rs. 2,49,220/- alongwith interest @ 18% was sent to OP, which was replied by letter of dated 04.03.2014 where OP denied to reimburse the claim as per their earlier decision.  Hence, the present complaint seeking directions to OP to reimburse Rs. 2,49,220/- alongwith 18% interest p.a. till realization, Rs. 50,000/- as compensation for mental agony and harassment and Rs. 15,000/- as litigation expenses. 

            Complainant has annexed photocopy of election card (Annexure-A), Copy of policy and receipts for the same (Annexure-B), declaration by the family doctor of the complainant (Annexure-C), repudiation letter    (Annexure-D), copy of claim (Annexure-E), copy of letters sent by OP-3 to the complainant (Annexure-F & G), reply submitted by the complainant (Annexure-H), copy of payment receipts and invoices regarding the treatment (Annexure-I), legal notice and its postal receipt (Annexure- J & K) and reply of legal notice sent by OP-2 (Annexure- L & M) alongwith complaint.  

3.         Notice of the present complaint was issued to OPs, thereafter reply was filed on behalf of OP1 and OP-2 where in their defence they stated that the complainant had obtained the policy from OP for the first time on 25.02.2013 and had concealed material facts from OP while signing the proposal form.  It was submitted that as per discharge summary, the complainant was hospitalized w.e.f. 07.09.2014 to 10.09.2014 and admitted with “C/O CAD-ACUTE AWMI, LVEF-35%, DOUBLE VESSEL DISEASE (CAG07/09/2014) PRIMARY PTCA + STENT TO LAD (07/09/2014, HYPERTENSION” and it was after scrutiny the claim of the complainant was found to be rejected under Section 4 of exclusion clause of policy terms and conditions.  Thus, claim being found inadmissible under conditions 4.1 and 4.3 was rightly repudiated vide letter dated 13.01.2015.

 

 

 

“Clause 4 EXCLUSIONS:

The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of :

4.1 Pre-existing health condition or disease or ailment/injuries: Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 4 years of this policy being in force continuously.

For the purpose of applying this condition, the date of inception of the policy taken from the company, for each insured person of the family, shall be considered, provided the renewals have been continuous and without any break in period.

This exclusion will also apply to any complications arising from pre existing ailments/diseases/injuries.  Such complications shall be considered as a part of the pre existing health condition or disease.  To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to- hypertension and hypertension nephropathy“.

            It was submitted that the complainant did not fulfill the cashless claim formalities thus the same could not be processed.  Further, it was stated that the complainant had submitted the claim form only on 18.09.2014 i.e. after a stipulated period of 7 days and during scrutiny, it was found inadmissible thus it was rejected again vide repudiation letter dated 13.01.2015.

            Clause 5.a of terms and conditions dealing the fraud/ misrepresentation/concealment was also reproduced.  Rest of the contents of the complaint were denied, thereby stating that OP had repudiated the complainant’s claim as per terms and conditions.  Thus, no deficiency in service or unfair trade practice could be attributed on their part.       

4.         In rejoinder to the WS filed on behalf of OPs, the complainant denied the contents of the reply and reiterated those of the complaint.  Discharge summary dated 10.09.2014 was annexed alongwith rejoinder.

5.         Evidence by way of affidavit was filed by the complainant, where he has deposed on oath the contents of the complaint and has got exhibited photocopy of election card of the deponent (Ex.CW-1/A) (OSR), photocopy of election card (Annexure-A), Copy of policy and receipts for the same (Ex.CW-1/B), copy of letters sent by OP-3 to the complainant and reply submitted by the complainant (Ex.CW-1/C), copy of payment receipts and invoices regarding the treatment (Ex.CW-1/D), legal notice and its postal receipt (Ex.CW-1/C&D) and reply of legal notice sent by OP-2 (Ex.CW-1/E&F), discharge summary (Ex.CW-1/G).

            He has stated that he never had hypertension or diabetes or any other old disease and has filed a declaration to the effect by family doctor as has got it marked as Mark-A, copy of claim form is Mark-B.

            OP-1 and OP-2 examined Shri Khemchand, Sr. Divisional manager, who has reiterated the contents of their reply and has relied on Ex.OP-1&2/A (colly.), copy of policy schedule alongwith terms and conditions; copy of repudiation letter as Ex.OP-1&2/B.

6.         We have heard the arguments addressed on behalf of Ld. Counsel for both the parties and have perused the material on record.  It is an admitted fact that the complainant had filed a claim in the second year of the policy.  The first policy cover was from 25.02.2013 to 24.02.2014 and claim was in policy no. 271701/48/2013/2737 with period from 25.02.2014 to 24.02.2015.  The complainant is aggrieved by repudiation of his claim under exclusion clause 4.  Combined reading of  Ex.OP1&2/B i.e. policy terms and conditions, which has already been reproduced by OP in their WS as well as the discharge summary, where in past history, hypertension has been mentioned, further OP has placed on record the inpatient department papers, which also mentioned “history of hypertension x 9 years and no history of DM”.  This implies that the complainant was suffering from hypertension, in rebuttal the complainant too has placed on record a letter by his family doctor, who has stated that the complainant was not suffering from hypertension, this letter cannot be of any help to the complainant as the claim has been filed in the second year of policy which falls under exclusion clause 4.1.  It is settled principle of law that terms and conditions of the policy have to be strictly construed.  Hence, OP has rightly repudiated the claim.  Thus, present complaint is dismissed being devoid of merits without order to cost.    

              Copy of the order be supplied to the parties as per rules.

File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member    

 

            (SUKHDEV SINGH)

             President