Haryana

Kurukshetra

10/2016

Bhim Singh - Complainant(s)

Versus

OIC - Opp.Party(s)

Shekhar Thakur

26 Oct 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

Complaint Case No.10 of 2016.

Date of instt.11.1.2016. 

                                                                        Date of Decision:26.10.2018.  

Bhim Singh son of Latae Bhagwan Dass, resident of House No.254, Sector-3, Urban Estate, Kurukshetra.      

                                                                  …Complainant. 

                        Versus      

1. Oriental Insurance Company Limited, Registered Office at Oriental House, P.B. No.7037, A25/27, Asif Ali Road, New Delhi through its Managing Director.
2. Oriental Insurance Company Limited Branch Office, Kurukshetra, Sebharawal Market, Railway Road, Kurukshetra, Haryana, through its Branch Manager.
3. Medi Assist India TPA Private Limited, B-20, Sector-2, Noida, through its Manager.

…Opposite parties.

 

Complaint under section 12 of Consumer Protection Act.                   

 

Before       Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Trikha, Member.

Present :    Sh. Shekhar Thakur, Adv. for complainant.

 Sh. R.K.Singhal, Adv. for OPs No.1 & 2.

 Op No.3 exparte.

ORDER

 

                    This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by Bhim Singh against the Oriental Insurance Company Limited and others, the opposite parties.

2.             Brief facts of the present complaint are that the complainant has hired the services of opposite party no.1 by taking its medi-claim insurance product/policy named PNB-Oriental Royal Medi-claim policy bearing No.261303/48/2014/1086 for the period valid w.e.f. 29.10.2013 to 28.10.2014 from OP No.2 by making the premium amount of Rs.6,830/- and such policy was again renewed by the complainant from OP No.2 on 29.10.2014 by making the payment amount of Rs. 6,830/-.  Since the complainant has hired the services of Ops No.1 and 2 by paying premium of Rs.6,830/- each time for aforesaid policies of the complainant while filing the proposal form, already told OP No.2 that he was the patient of diabetes and was not suffering from any other ailment during filling the proposal form.  The complainant was assured by OP no.2 that under such PNB Oriental Royal Medi-claim Policy, he would get reimbursement of reasonable and necessary expenses of hospitalization and or domiciliary expenses as detailed in Para No.1.2 of prospectus for illness/diseases contracted or inquiry sustained by the insured persons during the policy period up to the limit of sum insured.  In the month of May, 2015 to July, 2015, the complainant suffered with the body symptoms of breath difficulty and to proper evaluation and management, the complainant approached Fortis Escorts Heart Institute on 13^th July, 2015 and consultant Dr. Atul Mathur and Dr. Yugal K. MITRE advised him to get admission in the above said Hospital.  The complainant contacted the OP No.3 i.e. T.P.A. and requested for cashless treatment, but OP No.3’s official assured that instead of cashless treatment, he would get reimbursement of all expenses of hospitalization and ancillary expenses and asked the complainant to resume his treatment with his own costs and accordingly, the complainant was admitted on 13^th July, 2015 for his necessary treatment.  The above said doctors confirmed that the complainant had not any family history of Ischemic Heart Disease. The complainant underwent Coronary Angiography on the same day which revealed double vessel disease and Coronary Artery Disease and to treat this disease, he underwent surgery on 14.7.2015 and remained admitted till 24^th July, 2015 and the same doctor Atul Mathur under his certificate dated 28.9.2015 confirmed that the complainant has double vessel disease since 13.7.2015 and not earlier.  Again on 26^th July, 2015, the complainant suffered with body symptoms of loose motion 3-4 episode, 1 episode of vomiting, pus discharge from sternotomy site.  The complainant approached Fortis Escorts Heart Institute for further evaluation and management on same day and was admitted in the above said hospital and treated for ineffective diarrhea.  The complainant spent about Rs,3,21,068/- as whole in the hospital for necessary treatment and allied expenditure during the period of 13^th July, 2015 to 26^th July, 2015.  The complainant received e-mail dated 21.9.2015 from OP No.3 requiring certain documents relating with claim and the complainant vide its letter dated 1.10.2015, provided all the claim documents to Op No.3 and requested for early disposal, but to dismay and shock of complainant, the OP No.2 repudiated the claim of the complainant vide letter dated 2.12.2015 by saying that since CAD is related to diabetes and the ailments are found to be present prior to the inception of policy and is going beyond the coverage of present policy.  As per exclusion clause, CAD is not covered under exclusion clause and further the Ops without any evidence or base, assumed and presumed that CAD was pre-existing since from inception of 1^st policy dated 29.10.2013.  No medical evidence was provided to complainant to prove this fact that the complainant suffered with this condition pre-existingly from inception of 1^st policy dated 29.10.2013.  The complainant visited the office of Ops many times and requested for reimbursement but they did not pay any heed.  Hence, there is deficiency in service on the part of the opposite parties towards the complainant.  Hence, in such like circumstances, the present complaint was moved by the complainant with the prayer to direct the Ops to pay Rs.3,21,068/- on account of mediclaim and to pay Rs.10,000/- as compensation for mental agony and physical harassment.

3.             Upon notice, opposite parties No.1 & 2 appeared before this Forum, whereas Op No.3 did not appear and opted to proceed against exparte vide order dt. 01.06.2016.  Ops No.1 & 2 contested the complaint by filing the written statement taking certain preliminary objections to the effect that the complaint is not maintainable in the present Forum; that the complainant has no locus standi to file and maintain the present complaint; that the complainant has not come before the forum with clean hands and had concealed the true and material facts and as such, the complainant is not entitled for any relief; the true facts are that on perusal of the claim documents, it was found that patient was admitted with case of DM type-2, CAD, CAG, double vessel disease with LMC, LV DYSFUNCTION for which surgical management was done during hospitalization.  Inspection of the policy from Oriental Insurance is from 29.10.2013.  From indoor case papers, it is noted that patient is known case of diabetes since three years and coronary ARTERY disease. Since, CAD is related to diabetes and the ailments are found to be present prior to the inspection of policy and are going beyond the coverage of present policy. Thus, the answering OPs have no liability as per the terms and conditions of the policy of insurance and the claim was repudiated by the competent authority as per exclusion clause No.4.1 of the policy of insurance.

        So, the claim of the complainant was rightly repudiated and he was informed accordingly vide letter dated 2.12.2015.  Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of Ops and as such, the complaint of the complainant is liable to be dismissed. On merits, the contents of the complaint were denied. Preliminary objections were repeated. Prayer for dismissal of the complaint was made.

5.            The complainant tendered into evidence his own affidavit as Ex.CW1/A, photo stat copies of mediclaim policies as Ex.C1&C2, photo stat copy of prospectus as Ex.C3, photo stat copy of discharge summary as Ex.C4, photo stat copy of certificate as Ex.C5, photo stat copy of discharge summary as Ex.C6, photo stat copy of certificate as Ex.C7, photo stat copy of request for information as Ex.C8, photo stat copy of letter as Ex.C9, photo stat copy of another letter dated 2.12.2015 as Ex.C10, photo stat copy of letter dated 16.12.2015 as Ex.C11, prospectus as Ex.C12, photo stat copy of terms and conditions as Ex.C13, photo stat copy of Hospitalization benefit claim form as Ex.C14, photo stat copy of medication advised discharge as Ex.C15, photo stat copy of condition on discharge as Ex.C16, photo stat copy of operation notes as Ex.C17, photo stat copy of peripheral arterial doppler report as Ex.C18, photo stat copies of interpretation summary as Ex.C19 & C20  and thereafter closed the evidence.

6.             On the other hand, the Ops tendered into evidence affidavit of R.S. Bahlan, Sr. Manager as Ex.RW1/A, policy schedule as Ex.R1, prospectus as Ex/R1/A, discharge summary as Ex.R2, progress notes sheet as Ex.R3, copy of letter dated 8.7.2015 as Ex.R4, copy of another letter dated 2.12.2015 as Ex.R5 and certificate of Dr. Atul Mathur as Ex.R6 and thereafter closed the evidence.

7.            We have heard learned counsel for the parties and have gone through the record carefully.

8.             Learned counsel for the complainant contended that on 29.10.2013, the complainant has taken mediclaim policy, Ex.C1 from the Ops No.1 & 2 on payment of Rs.6830/- and the said policy was renewed on 29.10.2014, which is Ex.C2.  The complainant unfortunately fell ill on 13.07.2015 and was admitted in Fortis Escorts Heart Institute, Delhi.  On 13.07.2015 the angiography of complainant was done by the doctors and they issued a document, which is Ex.C14 wherein the doctors mentioned  that he is suffering from CAD (Coronary Artery Disease) and bypass surgery was done by the doctors.  It was also contended by the counsel of complainant that the complainant was admitted two times in the hospital, first time on 13.07.2015 and discharged on 24.07.2014, which is clear from the discharge summary, Ex.C4 and second time he was admitted on 26.07.2015 and discharged on 27.07.2015, which is clear from the discharge summary, Ex.C6.  The counsel of complainant contended that the complainant has already mentioned in the proposal form which was submitted at the time of taking the policy that he is suffering from diabetes.  The other contention of counsel for complainant is that they have applied for cashless treatment but the Ops refused to give cashless policy.  The next contention of counsel for complainant is that the complainant lodged the claim with the Ops No.1 & 2 and submitted the required documents vide letter Ex.C9 but the Ops repudiated the claim of complainant vide letter Ex.C10 on the ground of exclusion clause No.4.1 of the policy that the complainant is suffering from pre-existing disease (diabetes) and CAD is connected with diabetes.  The counsel of complainant placed reliance upon the copy of order dated 30.01.2014 passed by Hon’ble Madras High Court in case titled as Manivasagam Vs. NIC bearing W.A. (MD) No.956 of 2011, wherein in para No.8 of this order, it is clearly mentioned that “Coronary Artery Disease is not a pre-existing disease at the time when the policy was issued”.  The counsel of complainant also placed reliance upon the order dated 11.04.2014 passed by Hon’ble State Commission, U.T. in case titled as OIC Vs. Ruhi Sharma, wherein in para No.9 of said order, the Hon’ble State Commission, U.T. has taken the view of Hon’ble Supreme Court in case titled as P.Vankat Naidu Vs. LIC, 2011(4) CLT Supreme Court page 494=IV (2011) CPJ page 6.

8.             On the other hand, learned counsel of Ops No.1 & 2 argued that after the second year of taking the policy, the complainant fell ill.  He argued that patient is known case of diabetes since three years and coronary artery disease. Since, CAD is related to diabetes and the ailments are found to be present prior to the inspection of policy and are going beyond the coverage of present policy.  The second point raised by the counsel of Ops No.1 & 2 is that the complainant is bank employee and the policy was taken from the bank and the proposal form was sent to their office and it was not in the knowledge of Ops that whether the complainant has mentioned regarding the disease or not.  The next contention of counsel for Ops No.1 & 2 is that they have not issued the cashless policy to the Ops because they have found about the pre-existing disease to the complainant as mentioned in the document Ex.R4. The counsel of Ops No.1 & 2 placed reliance upon the case law cited in 1996(2) CPJ page 156 titled as NIC Vs. Rais Abbas Naqvi decided by Hon’ble National Commission and 2011(2) CPR page 280 titled as OIC Vs. Mr. Pankaj Jain (NC). 

9.             From the pleadings and evidence of the case and on appraisal of rival contentions of both the parties, we are fortified with the contentions of counsel for complainant.  There is no merit in the  submissions of counsel for Ops No.1 & 2.  In view of facts and circumstances of the case, we are of the considered view that the Ops  have wrongly repudiated the claim of complainant and they are deficient while rendering services to the complainant.  The authorities submitted by counsel for complainant are fully applicable to the facts of present case, whereas the authority submitted by counsel for the Ops is not disputed but the same is not applicable to the facts of instant case.          

10.            Thus, as a sequel of above discussion, we allow the complaint and direct the Ops to pay Rs.3,21,068 to the complainant alongwith interest @ 9% p.a. from the date of filing of this complaint till its realization.  The Ops are further directed to pay Rs.50,000/- as lump sum compensation on account of harassment, mental agony including the cost of litigation.  Let the order be complied with within 30 days, failing which, penal action under Section 27 of the Consumer Protection Act, 1986 would be initiated against the Ops.  All the Ops are jointly and severally liable.  A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.

Announced in open court:

Dt.:26.10.2018.

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Trikha),           (Neelam)       

Member                             Member.