Delhi

East Delhi

CC/405/2014

VIPIN - Complainant(s)

Versus

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

14 Feb 2020

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.       405/2014

                                                                                                   Date of Institution               12/05/2014

                                                                                                   Order reserved on               14/02/2020

                                                                                                   Date of Order                       17/02/2020

 

In matter of

MrVipinArora

s/oSh Dina NathArora

R/o- M-144, Nr Charch Lane

Laxmi Nagar, Delhi 110092………………….……………...…………….Complainant                             

Vs

 

The Oriental Insurance Co. Ltd.

CBO-12, Shakarpur,

A-159, Shakarpur, VikasMarg, Delhi 110092

 

The Oriental Insurance Co. Ltd.

1/28, Sunlight Insurance Building,

Asaf Ali Road, New Delhi- 110002 …..………………….….…………..Opponents

 

Complainant’s Advocate- Mr BK Sodhi& BK Mishra

Opponent’s Advocate-      BhupeshChandna

 

Quorum   ShSukhdev  SinghPresident

Dr P N Tiwari                Member

MrsHarpreetKaur      Member                                                                                             

 

Order by Dr P N Tiwari- Member  

Brief Facts of the case                                                                                                

Complainant had individual medishieldpolicy from IFFCO TOKIO from 20/03/2007 and continued from 20/03/2008 to 19/03/2009and then renewed again from 20/03/2009 to 19/03/2010 (Ex CW1/1, 1A& 1B) having sum insured Rs. 1.5 Lakhs for his parents and his family of two children. Thereafter complainant opted portability to the present OP which was allowed (Ex CW1/2) as Happy Family Floater Policy for sum insured 7 lakhs from the same date.

It was stated that father of complainant had fallen in house and sustained right knee injuryand was admitted in hospital on 13/10/2012 where he was diagnosed  a case of Osteo Arthritis Knee with Sub-luxated Lateral Miniscus and ACL Tear Right Knee. After lab tests and MRI, it was confirmed the diagnosis as ACL Tear right knee with OS Knee. On 14/10/2012, Arthroscopy was done under SA and repair was done (Ex CW1/3) and incurred treatment bill Rs 96,555/-which was paid. Complainant submitted claim for reimbursement to TPA/eMeditak (Ex CW1/4). TPA asked clarification from treating doctor which was clarified as OA for about one year and Strain due to Rotatory Injury in right knee since 04 months (Ex CW1/4A).

The claim was repudiated on 05/03/2013 under policy terms and conditions Section 4 and sub clause 24 as “Age related Osteoarthritis and Osteoporosis”(ExCW1/5). Despite of inquiring from TPA no reply was received, so sent a legal notice on 19/02/2014 for passing his claim. When no reply was received from TPA/OP, complainant filed this complaint for deficiency in services of OP and claimed treatment bill Rs 96,555/-with 18% and compensation Rs 2 lakhfor harassment and Rs 33,000/- as litigation charges.

OP in their written statement denied all allegations of deficiency of OP. It was submitted that claim was rightly rejected under exclusion clause 4of policy terms and conditions as claim was filed much beyond the required period of 07 days from the date of discharge from hospital. Here claim was repudiated under policy terms and clause 4 and 4.3 of Happy Family Floater Policy which reads as –

“the expenses on treatment of following ailments/diseases/surgery for the specific periods are not payable if contracted and /or manifested during the currency of the policy under point no. xxiii - means AGE RELATED OSTEOARTHRETIS AND OSTEOPOROSIS.

Under condition 5.5—Final claim along with originals of hospital bills/cash memos/reports/claim form and list of documents as listed below should be submitted to the company/TPA within 7days of discharge from the hospital/nursing home.

 

OP also submitted policy terms and conditions (Ex OPW1/Anne.A) and justified repudiation under exclusion under section 4, 4.3 xxiii where treatment of osteoarthritis was covered after four years of continuous policy without claim. So repudiation of claim was justified on delay submission of claim documents and Osteoarthritis treatment was covered only after four years of continuous policy without claim. Thus there was no deficiency in their services and prayed for dismissal of complaint.

Complainant in his rejoinder stressed that he had taken present poicy from OIC in portability from IFFCO TOKIO and his family mediclaim policy was continued since 2008. He had never taken claim and present claim pertains to accidental injury of his father who got slipped in house and sustained right knee injury for which repair was done by orthopedic surgeon.

He also submitted his evidences on affidavit and affirmed on oath himself that all the facts and evidences were true and correct and nothing had been submitted wrongly or hidden. He relied on his first policy (Ex CW1/1 to 1B) and thereafter policy from OIC (Ex CW1/2). All claim documents as hospital’s discharge summary, bills, claim form were on record (Ex CW1/3to 5).As rejection was not justified so legal notice was given (Ex CW1/6). Hence, his claim be passed.

 

OP submitted evidences on affidavit through MrRajeev Chopra, Sr. Div. Manager with OP and affirmed on oath that the present claim was lodged in 2^ndyears policy and as per their terms and conditions though portability was given (Ex OPW1/Anne.A) having guidelines of IRDA under ref. IRDA/HLT/MISC./CIR/030/02/2011.It was also stressed that claim was lodged after 7 days from discharge from hospital and treatment taken pertains to Osteoarthritis under exclusion policy terms and conditions. Hence claim was rightly repudiated.

 

Complainant and OP submitted their written synopsis and taken on record.

OP also submitted two citations supporting their stand of rejection under exclusion clause 4. They were a)- AjitSantokhchandSuranavs NIC, RP 3029/2014decided on 05/04/2017 where it was laid down that B/L TKR done in old age related ailment was not reimbursable within four years of policy terms and condition and RP was dismissed. But here in the present case, no TKR was done, but treatment was for repair of ligaments of right knee where complainant’s father had osteoarthritis as per MRI reports. Hence this citation was not applicable.

b)-The second citation was OIC vsRajinder Singh, RP 3455/2006,decided on 30/03/2017 where claim was payable within 30 days waiting period only under accident, but Revision Petition pertains to “shunt infection”, and infection could not be due to accident and RP was dismissed. Here in present complaint case, treatment pertains to accidental injury to his right knee ligaments due to fall in his house. Hence, presentcitation is also not applicable. OP submitted further clarification for justifying repudiation by way of an opinion of panel doctor(Ex OPW1/Anne.B) where it was stated that repudiation was justified as claim was in 3^rd year of policy so was not payable. As this was a mere explanation of exclusion term 4.3 xxiii without supporting affidavit and not given by an Orthopedic Surgeon who could have explained about Osteoarthritis and Osteoporosis and their line of treatment. No explanation about Right Knee ligament’s injury repair due to accidental falling was explained as injury was confirmed by MRI Knee. Hence,submitted opinion isnot admissible.

 

Arguments were heard from both the party’s counsels at length and after perusing materials on record. Order was reserved.

Before coming to the conclusion of this case, we have framed some clarifications / explanations as under –

1. Whether there was continuity of policy tenure.
2. Whether repudiation of claim was justified by OP in reference to exclusion clause 4, 4.3 and 5.5 in ref. to nature of injury.

1- Whether there was continuity of policy tenure ?

By perusing exhibit of policy details on record, it has been seen that complainant had mediclaim from IFFCO TOKIO from 2007 and thereafter with present OP after allowing portability. Policy tenure was continued. There was no break in policy. Supporting portability as per point 3 of IRDA circular exhibit OPW1/B, policy was regular and without breakage or claim when policy was in continuation. So repudiation was not justified by OP.

2-Whether repudiation of claim was justified by OP in reference to exclusion clause 4, 4.3 and 5.5 in ref. to nature of injury. By scrutinizing section 4.3 xxiii that treatment for Osteoarthritis was payable after 48 months of continued policy, but here evidence supporting repudiation, opinion submitted by OP’s panel doctor does not specify nature of injury and age related problems of bones.

The opinion was neither forwarded by orthopedic surgeon nor supported by affidavit, hence, not admissible.It is very clear that ACL tear can occur irrespective of age, but seeing the nature of treatment given clearly showed that repair of ligament of right knee was done under SA. In osteoarthritis, a chronic ailment of joints and in major joints (Hip or Knee) total replacement is done. For this surgical process, exclusion clause is applicable. Here in this case, complainant’s version in complaint and discharge summary, it is clear that injury to the ligament in right knee was due to strain on knee joint and tear of ligaments in right knee were confirmed by MRI. No treatment for Osteoarthritis (joint replacement) or Osteoporosis (Osteoplasty) was done. Hence, defence taken by OP under exclusion clause 4 and 4.3 of policy terms and condition does not sustain.

As far as 5.5 clause (delay in submission of claim documents) concerned, it wascorrect,  but taking natural justice version and continuity of policy tenure which was without break and without claim has to be taken for consideration. As sum insured is seven lakhs and insured is old aged person, requires medical help by mediclaim policy only. So, this can be ignored and directions may be issued to the insured accordingly. After going through entire facts and evidences on record, we come to the conclusion that we allow present complaint and pass the following order-

1-OP shall reimburse treatment expenses Rs 96,555/-within 30 days.

2-There shall be no other order to compensation or litigation cost.

 

Copy of this order be sent to the parties as per section 18(6) of the Consumer Protection Regulation 2005 (in short CPR) and file be consigned to Record Room under section 20(1) of the CPR.

(Dr) P N Tiwari – Member                                                                       Mrs Harpreet Kaur- Member                                   

                                      

                                                   Mr Sukhdev Singh - President