Haryana

Kurukshetra

162/2016

Satish KUmar - Complainant(s)

Versus

OIC - Opp.Party(s)

K.K.Aggarwal

31 Oct 2018

ORDER

BEFORE THE  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KURUKSHETRA.

 

Complaint Case No.162 of 2016.

Date of instt: 08.06.2016. 

                                                            Date of Decision:31.10.2018.

Satish Kumar Kansal son of Beni Parshad, resident of village and post office Ismailabad, District Kurukshetra.

•  

                        Versus

1. The Manager, Oriental Insurance Company Limited, Sabarwal, Market, Railway Road, Kurukshetra.(Insurer for medi claim policy No.261303/48/2015/22781)
2. The Manager, Punjab National Bank, village and post office Ismailabad, District Kurukshetra.

………Opposite parties.

 

       Complaint under section 12 of Consumer Protection Act.            

 

Before       Smt. Neelam Kashyap, President.

                Sh. Sunil Mohan Trikha, Member.

Present :    Sh. K.K.Aggarwal, Adv. for complainant.

                 Sh. R.K. Singhal, Adv. for Ops.

                   

ORDER

                    This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Satish Kumar against the Manager, Oriental Insurance Company Limited and another, the opposite parties.

2.             Brief facts of the present complaint are that the complainant is subscriber of the OP No.1 through OP No.2 and paid the subscription amount of Rs.6,830/- valid for the period 12.2.2015 to 11.2.2016, so the complainant is consumer qua the Ops.  The total amount was payable by the Ops for which they have charged the above said amount of Rs.5,00,000/-. The complainant was medically examined by the penal doctors of the OP No.1 and the complainant was found fit and thereafter the policy was issued by the OP No.1.  The complainant was treated by Max Hospital, Chandigarh and admitted on 18.12.2015 and operated upon by heart surgeon for ailment i.e. CAD pertaining to heart. All the required documents and bill were submitted to the Op No.1 for making the claim amount but the Op No.1 has repudiated the claim vide letter dated 2.3.2016 on false and illegal grounds.  Hence, it amounts to deficiency in service on the part of Ops. So, the present complaint has been moved by the complainant with the prayer to direct the Ops to pay Rs.4,50,000/- along with interest @18% per annum, Rs.20,000/- as damages/compensation for mental agony and physical harassment, Rs.20,000/- for compensation on account of deficiency in service and Rs.2,500/- as litigation expenses.

3.            Upon notice, opposite parties appeared. OP No.1 contested the complaint by filing written statement alleging therein that the complainant has not approached to this Forum with clean hands as he has suppressed the material facts to get the claim; that the true and material facts of the case are that  the policy in question was in its first year and the claim of the complainant was not covered under the policy of insurance as per exclusion clause No.4.2 and the same was repudiated by the competent authority; that some illness are not covered for the first two years and the disease suffered by the complainant falls under the said category and the expenses of treatment of said illness for specified period of two years are not payable.  Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of answering Op and as such, the complaint of the complainant is liable to be dismissed with costs.  On merits, the contents of the complaint were denied to be wrong.  Preliminary objections were repeated.  Prayer for dismissal of the complaint was made. 

4.            OP No.2 also contested the complaint by filing written statement alleging therein that the complainant had informed the answering OP regarding his treatment in the hospital and the answering OP immediately taken up the matter with the concerned authority; that the insurance company had informed the answering OP that the claim has been repudiated by the competent authority as the same was not payable as per terms and conditions of the policy. Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of answering Op and as such, the complaint of the complainant is liable to be dismissed with costs. On merits, the contents of the complaint were denied to be wrong. Preliminary objections were repeated. Prayer for dismissal of the complaint was made. 

5.             Ld. Counsel for the complainant tendered into evidence affidavit, Ex.CW1/A and documents Annexure-A to Annexure-R and thereafter, closed the evidence on behalf of complainant.

6.             On the other hand, ld. Counsel for the Ops tendered into evidence affidavit, Ex.RW1/A and documents Ex.R1 to Ex.R5 and thereafter closed the evidence on behalf of Ops.

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

8.             Learned counsel for the complainant contended that the complainant has taken the medi-claim policy valid from 12.02.2015 to 11.02.016 for a sum of Rs.5,00,000/- from the Op No.1 through Op No.2 and the complainant paid Rs.6830/- to the Op No.1.  The complainant was admitted in Max Hospital, Chandigarh on 18.12.2015 and was operated by the said hospital for the ailment i.e. CAD pertaining to heart.  The complainant has submitted all the documents to the Op No.1 but his claim was repudiated by the Op No.1 vide letter dt. 02.03.2016, Annexure-E on the ground that the claim of the complainant was not covered under the policy of insurance as per exclusion clause No.4.2 (xviii), wherein it was mentioned that “during the period of insurance cover, the expenses on treatment of Diabetes for specified period of two years are not payable if contracted and/or manifested during the currency of the policy”.  The next point which was raised by the counsel of complainant that at the time of illness, the Op No.1 has not given the amount to the hospital for the treatment which was admitted by the Op No.1 at the time of giving the medi-claim policy to the complainant.  He further contended that the complainant was not suffering from diabetes at the time of taking the policy.  The Ops have not shown any document relating to that disease.    

9.             Learned counsel for the Ops contended that in the Annexure-E, it was wrongly mentioned the word diabetes.  It is a clerical mistake but in reality, the claim was repudiated on the ground of clause 4.1 which was mentioned in the policy because the complainant was suffering from hypertension at the time of taking the policy, which is pre-existing disease.  In the document Ex.R1/A, it was mentioned in clause xvii-hypertension within 2 years.  The claim could not be given to the complainant as per exclusion clause 4.1 and 4.2 of the terms and conditions of the policy.  The exclusion clause 4.1 shows about the pre-existing disease and exclusion clause 4.2 is a table regarding the illness of policy-holder within 2 years of the policy.  The counsel of Ops contended that the medical reports Ex.R3 & Ex.R4 discharge summary clearly shows that the complainant is suffering from hypertension.

                Ensuing the arguments, the counsel of complainant further contended that at this stage, the Ops cannot claim at the time of arguments that it was a clerical mistake which was mentioned in the repudiation letter, Annexure-E because there is no mention regarding the same in the written statement.  The counsel of complainant further contended that there is no document on the file regarding hypertension  that the complainant was suffering from hypertension at the time of taken the policy, so, his claim should be given.  He further contended that the complainant incurred the amount of Rs.2,31,931/- on his treatment, so, his claim should be given.

10.            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.  In view of facts and circumstances of the case, we are of the considered view that the Op1 hs wrongly repudiated the claim of complainant and they are deficient while rendering services to the complainant.  The complainant has demanded the amount of Rs.4,50,000/- in the relief para of complaint but he has placed on file the bills, Annexure-J to Annexure-O total amounting to Rs.2,31,931/-, so, we are of the considered view that the complainant is entitled to the amount of Rs.2,31,931/-.           

11.            Thus, as a sequel of above discussion, we allow the complaint against Op No.1 and direct the Op No.1 to pay Rs.2,31,931/- to the complainant alongwith interest @ 9% p.a. from the date of filing of this complaint till its realization.  The Op No.1 is 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 Op No.1.  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.:31.10.2018.  

                                                                        (Neelam Kashyap)

                                                                        President.

 

(Sunil Mohan Trikha),          

                        Member.