O R D E R
K.S. MOHI, PRESIDENT
The complainant has filed the present complaint against the O.Ps u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken a mediclaim policy bearing No.272202/48/2009/544 for the period from 11.08.2008 to 10.08.2009 for himself, his wife and daughter. It is alleged that at the time of last renewal of policy as per the advice of the O.P-2 the insured sum was enhanced to Rs.4,00,000/- each and premium of Rs.35,520/- was paid for the said policy. On 13.02.2009 wife of the complainant was admitted to Fortis FLT. Rajan Dhal Hospital, New Delhi for replacement of her knee with other complications and since she was covered with the mediclaim policy issued by OP-1, the O.P-2 was informed about the said admission and after filling the required form O.P-1 issued an interim payment of Rs.2,00,000/- for the said surgery against the estimate issued by the Hospital amounting to Rs.3,59,548/-. It is alleged that complainant approached the O.P-2 for the balance payment the O.P-2 vide its letter dated 11.02.2009 informed the hospital that since the insurance coverage of Smt. Neeru Kapoor is effective w.e.f. 11.08.2007, hence the cashless facility for the joint replacement is not being processed as per clause 4.3 of the mediclaim policy. It is further alleged that the complainant without entering into controversy cleared the bill of the hospital and get his wife discharged on 20.02.2009 and lodged his claim for the remaining amount of Rs.1,86,787/- with the O.Ps. It is alleged the to the utter surprise of the complainant the O.P-2 vide letter dated 31.03.2009 informed the complainant that the insurance company has passed the claim of Rs.4,450/- only and no reason/ justification was given for the deductions made by them in the claim. On these facts complainant prays that O.P be directed to pay the claim amount of Rs.1,86,787/- alongwith interest and also to pay cost and compensation as claimed.
2. O.P appeared and filed the written statement. In its written statement O.P has not disputed that complainant had taken policy refer to above. It is alleged that as per terms and conditions No.4.3 of the insurance policy. Condition No.4.3 of the insurance policy reads as under;
“4.3 During the period of insurance cover, the expenses on treatment of following ailment/ disease/ surgeries for specified periods are not payable if contracted and / or manifested during the currency of the policy.
XXIII. Joint replacement due to degenerative condition. 4years
XXIV. Age related osteoarthritis and osteoporosis. 4years”
It is further alleged that the sum insured four years ago was Rs.2,00,000/- under policy No.272402/2005/218. The TPA of the O.P has processed the claim on this sum insured as for the increased sum insured the disease becomes the pre-existing disease and the benefit of the increased sum insured can be given only after four years. The answering O.P has already paid amount of Rs.1,95,550/- through cashless and has sent discharge voucher for remaining amount of Rs.4,550/- but the complainant has not submitted the said discharge voucher with the answering O.P and due to which the answering O.P was unable to pay the remaining admissible claim of Rs.4,550/-. As soon as the complainant submits the discharge voucher of remaining amount of Rs.4,550/-, the answering O.P is ready to make the payment of Rs.4,550/-. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit affirming the facts alleged in the complaint and has proved documents exhibited as Ex. CW-1/1 to CW-1/7. On the other hand Sh. B.S. Sharma, Sr. Divisional Manager has filed affidavit in evidence on behalf of O.P (OIC) testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case and have heard submissions of Ld. Counsel for the complainant.
5. The controversy involved in the present case is as to whether the partial repudiation of claim of the complainant was justified or not. Admittedly the complainant has been executing mediclaim policy right from the year since 2003 without gap and till 2007 to 2008 the sum insured remained Rs.2,00,000/- for each member of the family. However in the lastly renewed mediclaim policy from 11.08.2008 to 10.08.2009 the sum insured was enhanced from Rs.2,00,000/- to Rs.4,00,000/- for each member and premium of Rs.35,520/- was paid on said policy. The wife of claimant underwent knee operation for which complainant incurred an amount of Rs.3,59,548/- out of which the O.P-1 made payment of Rs.2,00,000/- only in sum insured for the previous policy and rejected the remaining claim while relying on clause 4.3 of the mediclaim policy. The main plea put forth on behalf of O.P-1 is that previously the sum insured for each family member of the complainant was Rs.2,00,000/- which stood paid by O.P and that they were not obliged to make the remaining payment on account of clause 4.3 of mediclaim policy. Both the pleas taken by O.P as stated above are un-warranted and unjustified. As per their own admission of documents filed on record, the mediclaim policy in question Ex.CW-1/1 for the period from 11.08.2008 to 10.08.2009 clearly indicates that sum insured for each member of complainant family was Rs.4,00,000/-. Therefore, to restrict amount up to Rs.2,00,000/- was totally uncalled for because the ailment was suffered by wife of the complainant during the operation of current policy from 11.08.2008 to 10.08.2009. Thus the plea taken by the O.P-2 is that the complainant was entitled to Rs.2,00,000/- only is totally self-contradictory. Now coming to clause 4.3 of the medicalim policy which reads as under;
“4.3 During the period of insurance cover, the expenses on treatment of following ailment/ disease/ surgeries for specified periods are not payable if contracted and / or manifested during the currency of the policy.
XXIII. Joint replacement due to degenerative condition. 4years
XXIV. Age related osteoarthritis and osteoporosis. 4years”
The aforesaid clause restricts the payment of claim if the disease mentioned therein occurred within 4 years. However, in the instant case the complainant has been in continuous process of insurance since 2003-2004 and he suffered ailment in 2009, therefore, the period of 4 years had gone by that time. Therefore, this contention of the O.P holds no water. The result is the repudiation the claim of the complainant by O.P was whimsical and was on frivolous grounds. Therefore, we hold that there is a deficiency in service.
6. We award a sum of Rs.1,86,787/- with interest @ 6% from the date institution of the complaint till payment, the further award of Rs.10,000/- towards harassment mental agony loss of time which will also include cost of litigation.
Copy of this order be sent to the parties as per rules.
Announced this 10th day of March, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
