Delhi

East Delhi

CC/395/2014

SURESH GOYAL - Complainant(s)

Versus

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

13 May 2014

ORDER

                     DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

                        CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092

  

                                                                                           Consumer complaint no.        395/2014

                                                                                           Date of Institution                13/06/2014

                                                                                           Order reserved on                01/02/2019        

                                                                                           Date of Order                        04/02/2019                                                                                  

In matter of                                                                                                              

Mr. Suresh Goyal                                                                                                   

s/o- Late Sh. J P Goel

R/o- M-2, Akash Bharti Apptt.    

Patpargunj, I P Extn.  Delhi 110092..……….……………...…………….Complainant                             

                                                                                         

                                                                                  Vs

1-The Director,

Oriental Insurance Co. Ltd.

Oriental House, A-25/27,

Asaf Ali Road, New Delhi-110002 

 

2- The Branch Manager, 

Oriental Insurance Co. Ltd.

A-159, Vikas Marg, Shakarpur, Delhi 110092

 

3-Ms Lata Jain, Agent

Oriental Insurance Co.

K-66, Laxmi Nagar, Delhi 110092

 

4- E-Meditek (TPA)

Plot no. 577, Udhyog Vihar, Phase V,

Gurgaon, Haryana 122016 ………....................………....…………..Opponents

 

Complainant’s Advocate                   Niraj Jha & Gitanju Suraj

Advocate for OPs (1-3)                      Bhupesh Chandna

Opponent 4/TPA                                Mr B S Arora  & Asso. Advocates

 

Quorum        Sh Sukhdev  Singh       President

                       Dr P N Tiwari                Member

                       Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari,  Member

Brief Facts of the case  

                                                                                             

Complainant ported his mediclaim policy from United India Insurance Co. (UIIC) to present OP/OIC  as Happy Family floater Policy Silver Plan vide no. 271701/48/2012/1167 for a sum assured 3 lacs having tenure from 05/09/2011 to 04/09/2012 (Anne. C1). It was stated that complainant had mediclaim policy from 02/09/1996 to 04/09/2009 without break from UIIC. Complainant stated that he suffered Right Tibia bone and Left Femur fracture in road traffic accident (RTA) about 15 years back.

In 2003, he suffered Osteomyalitis Rt. Leg and took treatment in hospital. All these facts were disclosed to OP1 at the time of porting in 2010. In his second year policy with OP, he got admitted again on 13/09/2012 in St Stephen’s Hospital for right leg problem and was discharged on 21/04/2012 vide discharge summary (Anne, C-2). Hospital intimated E-Meditak / OP4 (TPA) for cashless vide claim no. 100041202742. When no cashless was given so paid hospital bill a sum of Rs 70,240/-(Anne. C-3 colly). Despite of repeated demanding certain treatment documents by TPA from St Stephen’s hospital, no documents were provided (Anne. C-4 to 6), so, due to the deficiency in services of hospital, his genuine claim was not passed and claim was closed as “No Claim”.  It was stated that complainant repeatedly  followed up with OP4 and OP1, when no relief was given, so filed this complaint and claimed his treatment bill with compensation for harassment Rs One Lac with 24% interest.

OP1 submitted written statement jointly on behalf of OP2,3 & 4 and denied all the facts and allegations against OPs as stated in the complaint. It was admitted that the present policy no. 27170/48/2012/1167 was a second year issued by OP for a sum insured Rs 3 lacs for four members in his family under Happy Family Floater policy after complainant opted present OP policy from UIIC after filling policy proposal form. Complainant was admitted in St Stephen’s Hospital from 13/04/2012 to 21/04/2012, but despite of repeated intimations, complainant did not submit required claim documents to OP4 or to OP1, so his claim was put as “No Claim”. On scrutiny of treatment papers taken from hospital, it was noticed that complainant was admitted under the diagnosis “FUC of Chronic OM (Osteo-myalitis) Rt. Tibia and Abscess Rt. Knee in K/C/O DMT2 & HTN”. The swelling in Rt leg and abscess was reported for the last one week. The cashless request was received by OP4 on 19/04/2012 where complainant was admitted on 13/04/2012.

After scrutiny of discharge summary, it was revealed that complainant had old h/o RTA for which he developed OM in Rt Tibia bone and was treated in 2003. Complainant had not disclosed about old injury as fractures for which he was admitted in 2003 and took treatment, whereas he took present policy in 2010 to 2011 and did not disclose his RTA injuries. Hence, this fact came under exclusion clause 4.1 as pre existing injury.

It was also stated that complainant did not submit any previous year policies from 1996 as stated in his complaint. Thus, this claim fallen in 2^nd year policy under exclusion clause 4.1 which reads as –

 

‘Pre existing health condition or disease or ailment/injuries: any injuries/ ailment/ disease/ health condition which are pre existing (treated /untreated, declared/undeclared or not declared in the policy 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 person up to 4 years of this policy being in force continuously’.

 

As no intimation by the complainant received in 7 days from the date of loss, claim was put as “NO CLAIM”. Hence there was no deficiency in the services of OPs. When OP did not receive required documents even in repeated reminders, claim was put as No Claim as mandatory treatment documents and policy details were pending since long. Hence, claim was put under ‘No Claim’ category, so OP was not liable to for any deficiency in their services.

Complainant submitted his rejoinder and denied all the replies submitted by OP in their written statement. He relied on all the facts of his complaint as true and correct. He submitted evidences through his own affidavit and stated on oath that all his evidences were correct which were submitted with complaint as policy documents (Ann. C1), Discharge summary (Ann.C2) with hospital bill, TPA’s letters (Ann.C4to6) and submission of required documents by TPA (Ann.C7). Despite of submission of documents, OP did not process, so his claim was genuine and be passed.  

OP submitted evidences on affidavit through Mr Khem Chand, Sr Div Manager Legal with OP who reaffirmed on oath that their Closure of Claim was justified on the basis of non submission of required treatment documents and non disclosure of material facts related to old injuries/RTA in his policy proposal form. It was necessary to disclose all the relevant information pertaining to personal health in proposal form which was a vital document for OP and not disclosing by complainant pertains hiding material facts. It was well accepted fact that OP issued policy based on good faith and all the information disclosed by the policy seeker was mandatory. Despite of reminding repeatedly by OP4/TPA at hospital and at his residence, no required documents were submitted for claim process. Hence, closure of claim was justified by OP based on policy terms and condition.

OP relied on their evidence as claim year policy terms and conditions (OPW1/1) which states in detail about the exclusion clauses on page 10 under sub clause 4.1 which reads a -‘Pre existing health condition or disease or ailment/injuries: any injuries/ ailment/ disease/ health condition which are pre existing (treated /untreated, declared/undeclared or not declared in the policy 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 person up to 4 years of this policy being in force continuously’.

So, under this definition and based on discharge summary, RTA and its complication as ‘OM’ was present in 2003 and complainant took policy in 2010, so complainant had clear knowledge of his injuries and had to put in his policy proposal form which he did not do so intentionally. Hence, RTA and its complications were put under Pre existing ailments. Complainant had not submitted all his policies from 1996 as stated in his complaint to see the continuity of policy tenure and any benefits given for portability from UIIC to present OP. OP relied on reminders sent to complainant dated 20/04/2012, 21/04/2012, 30/05/2012, 08/08/2012 and 05/10/2012 to provide required claim documents which were not submitted by the complainant. These informations were very essential to scrutinize the claim process. OP also submitted written submissions supporting their defense so taken on record.

 

Arguments were heard from OP counsel in detail, but complainant did not put his appearance on the date of arguments and even on earlier dates of hearing (25/07/2017, 10/12/2017, 23/02/2018 20/07/2012, 05/10/2018. After perusal of file and evidences on record, order was reserved.

                                                                                  

After perusal of all the documents on record including terms and conditions of the policy, it is clear that complainant has not submitted required treatment documents as asked by OP and also had not submitted all policy documents from 1996 onward. The fact of RTA leading to complication much before inception of present policy, justified as a pre existing condition under exclusion clause 4.1 of policy terms and condition. ‘OM’ (Osteo-Myalitis) is a chronic bone infection which starts after bony injury may be due to RTA or any other means, but RTA is being the common. Still the claim was not repudiated by OP, so in the interest of natural justice, we give one more chance to complainant to comply all the required documents as per their (OP4) requirements within 30 days from the receiving of this order and thereafter OP4 shall complete claim process within 45 days. There shall be no order to cost. 

 

The first free copy of this order be sent to the parties as per the Section 18 (6) of the Consumer Protection Regulation, 2005 (in short the CPR) and file be consigned to Record Room under Section 20(1) of the CPR.

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member  

                                                         Shri  Sukhdev Singh  President