CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/618/13

          Date of Institution:-    12.11.2013

          Order Reserved on:- 13.12.2023

                     Date of Decision:-      29.02.2024

IN THE MATTER OF:

Mr. Harbans Lal

R/o L-1/169A D.D.A. Flats, Kalkaji,

New Delhi - 110019

.….. Complainant

VERSUS

1. The Manager (Branch Code No.D.O. 23 (Sarai Jullena)

The Oriental Insurance Company Ltd.

2/13-14 Sarai Jullena (Police Station Sarita Vihar)

New Delhi – 110025

2. M/s Vipul Med Corp TPA Pvt. Ltd.

(TPA ID No.YA0000000331)

515 Udyog Vihar Phase-V,

Gurgaon - 122016                                     .…..Opposite Parties

                                                                       ORDER

Per Dr. Harshali Kaur, Member

1. The complainant purchased a medical policy from the OP to pay the hospitalisation expenses for medical/surgical treatment at any nursing home/hospital in India. The policy was Happy Family Floater Policy no.272100/48/2012/1193 and included all his 6 family members, i.e. himself, his wife, daughter, two sons and his father, Mr Jugal Kishore.
2. The policy had a total insured sum of Rs.7 lakh for the period from 18.10.2011 to midnight of 17.10.2012 (Annexure-A-1/ Colly no.1 to 3), which was later renewed for the period 18.10.2012 to 17.10.2013. The renewed policy had the policy number 272100/48/2013/2014 (Annexure-A-2/ Colly no.1 to 3).

3. The OP-1 issued the medical card for getting medical treatment for Sh. Jugal Kishore vide ID no.0420430004344906 valid from 18.10.2011 (Annexure-A-3). The father of the complainant, Sh. Jugal Kishore visited the Batra Hospital and Medical Research Center at Tugalkabad Institutional Area, Mehrauli Badarpur Road, in the OPD, suffering from severe pain in the lower part of his abdomen on 24.06.2013. he paid Rs.500/- on account of OPD registration and was examined by Dr. Vijay Hangloo. The Doctor who examined the complainant's father found the disease of "Umbilical Hernia" and advised immediate surgery. Annexure-A-4 & A5 annexed by the complainant are the cash receipt of Rs.500/- dated 24.06.2013 and the medical prescription card, respectively.

4. The complainant's father was admitted for surgery through indoor treatment of the umbilical hernia. The estimated cost of Rs.40000/- was given for the treatment of his father, who is the beneficiary under the Happy Family Floater Policy of the complainant. An authorisation letter for treatment and guarantee of the payment of the estimated expenses of the indoor treatment of Sh. Jugal Kishore was emailed to the said hospital dated 25.06.2013 with authorisation number 040IA0614545 of the claim number 140IA1679 to OP-2 (Annexure No. A-6/Colly No.1).
5. The father of the complainant, Sh. Jugal Kishore underwent surgery of the Ventral Paraumbilical Hernia with Dense Adhesions and was admitted for the period 30.06.2013 to 04.07.2013 as noted in the record of discharge summary annexed at (Annexure No. A-7).

6. The hospital received a rejection letter towards the previous authorisation of the complainant's claim for his father's treatment from OP-2 through email dated 04.07.2013 towards the total bill of Rs.49,786/- for the period 30.06.2013 to 05.07.2013 despite previous authorisation letter for treatment and guarantee of payment of the expenses of estimated amount Rs.40000/- of the treatment of "Ventral Paraumbilical Hernia" (Annexure No.A-8). The complainant has annexed the bill issued by the hospital at Annexure No.A-9/Colly No.1 to 6.

7. Thereafter, the complainant paid the bill of Rs.49,786/- towards his father's treatment through ICICI Credit card on 05.07.2013. The copy of the cash receipt no.13-14/31774 dated 05.07.2013 is annexed at Annexure No.A-10. The complainant has also annexed the treatment documents at Annexure No.A-12.

8. The complainant alleges that he purchased the prescribed medicines and has also annexed the invoices for the said medicines at Annexure No. A-13. Therefore, he submitted the claim form of Rs.50,878/- to OP-2 (Annexure No. A-14). However, no action was taken by the OPs, who had rejected the complainant's claim towards his father's treatment despite the fact that Sh. Jugal Kishore was a beneficiary of the cashless hospitalisation mediclaim policy issued to the complainant, and OP-2, TPA of OP-1, had also issued an authorisation letter for treatment and guaranteed payment of the estimated amount of Rs.40,000/-.

9. Alleging deficiency in service on the part of the OPs, the complainant filed the present complaint under section 12 of the Consumer Protection Act, 1986, praying for payment of Rs.50,878/- towards the treatment of the complainant's father, Rs.20,000/- towards compensation and Rs.10,000/- as legal cost.

10. On notice, OP-1 filed their reply wherein it is stated that the policy was first obtained by the complainant from the OP effective from 18.10.2011 to 17.10.2012 and later renewed for one year from 18.10.2012 to 17.10.2013. The patient was aged about 61 years and was hospitalised w.e.f. 30.06.2013 with the diagnosis of Ventral Paraumbilical Hernia with Dense Adhesions vide discharged summary issued by the concerned hospital. However, when OP-2 processed the cashless claim authorisation and found that the patient had contracted the ailment/disease, which falls in the second year of policy since its inception and thus comes under Exclusion Clause no.4.3. Hence, OP-2, who is the TPA of OP-1 denied the claim of the complainant vide email dated 04.07.2013.

11. Further, condition no.4.3, the exclusion clause of the "Happy Family Floater Policy" stipulates that "during the period of insurance cover the expenses on treatment of following ailment/disease/surgeries for the specific periods are not payable if, contracted and/ or manifested during the currency of the policy". The OP also alleges that the complainant has suppressed and concealed the relevant facts while obtaining the policy in question from the OP, and hence, the complaint deserves to be dismissed at a heavy cost. The OP has also annexed a copy of the Happy Family Floater Policy, which contains the Terms and Conditions. When OP-2 did not appear despite several opportunities. OP-2 was proceeded ex-parte vide order dated 24.08.2015.

12. Thereafter, the complainant filed his rejoinder to the reply of OP-1 and his affidavit in evidence, reiterating what he stated in his complaint. OP-1 filed the affidavit of Sh. Jasbir Singh Kalsi, Divisional Manager for the OP, also echoed the reply filed by the OP-1.

13. The complainant filed his written arguments as did OP-1, after which the Ld. Counsel for the complainant addressed oral final arguments. OP-1 sought time to address oral arguments, which was allowed and 7 days were given to the OP to address arguments before us. None appeared for the OP to address the arguments. Hence, the order is pronounced today.

14. Having thoughtfully considered the rival contentions of the parties and perusing the material on record, we find that the complainant took a Happy Family Floater Policy from the OP, which was applicable from 18.10.2011 to 17.10.2012 and renewed till 17.10.2013. The policy covered the medical claims of the complainant and his family members, including his father Sh. Jugal Kishore, who was the beneficiary under said policy.
15. The father of the complainant, Sh. Jugal Kishore visited Batra Hospital and Medical Research Centre, New Delhi, suffering from severe pain in his abdomen on 24.06.2013. On the advice of the treating Doctor, the father of the complainant, who was diagnosed with umbilical hernia, was admitted for surgery in the hospital. The complainant, through the hospital, sent the complete details of his father's treatment with the log of expenses to the tune of Rs.40,000/- to OP-2. OP-2 authorised the medical payment of the medical treatment of his father (Annexure No. A-6/Colly No.1).

16. The complainant's father underwent surgery and treatment for Ventral Paraumbilical Hernia with Dense Adhesions on 30.06.2013 and was discharged on 04.07.2013. The complainant has annexed the discharge summary issued by the hospital at Annexure No. A-7. To the complainant's surprise, despite authorisation of his father's treatment and guarantee of the payment of Rs.40,000/- by OP-2, the TPA of OP-1, his claim was rejected vide email dated 04.07.2013. OP-2 rejected his cashless Mediclaim policy claim based on exclusion clause no.4.3 of the Terms and Conditions of the policy in question, which is gross negligence and deficient service by the OPs.

17. A bare perusal of the exclusion clause no.4.3 of the Terms and Conditions of the Happy Family Floater Policy is below:-

“The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy.

If these diseases are pre-existing at the time of proposal the exclusion no 4.1 for pre-existing condition SHALL be applicable in such cases.

If the continuity of the renewal is not maintained with the Company then sybsequent cover SHALL be treated as fresh policy and clauses 4.1., 4.2., 4.3., SHALL apply uless agreed by the Company and suitable endorsement passed on the policy. Similarly, if the sum isnured is enhanced subsequent to the inception of the policy, the exclusions 4.1., 4.2., and 4.3 will apply afresh for the enhanced portion of the sum insured for the purpose of this section.

Point no. (iii) Surgery of Hernia is not payable as it was manifested within 2 years during the currency of the policy opted by the complainant. The complainant stated that he first took the policy on 18.10.2011 for one year till 17.10.2012 and thereafter renewed it till 17.10.2013. His father underwent surgery for hernia on 30.06.2013, which squarely falls within the two-year bracket of initiating his policy in which the complainant's father was a beneficiary, which would have expired on 17.10.2013.

18. Neither has the complainant denied receiving the terms and conditions of the policy, nor has he alleged that he did not have the policy document anywhere in his testimony. Moreover, he would surely have read the Terms and Conditions along with the Exclusion Clause before opting for the policy and signing the same, thereby agreeing to the terms and conditions mentioned therein. Hence, we dismiss the complaint and leave the parties to bear their respective costs.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 29.02.2024.