Punjab

Ludhiana

CC/15/306

Harjeet Singh - Complainant(s)

Versus

oriental Ins.Co.Ltd - Opp.Party(s)

R.G.Sharma Adv.

20 May 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 306 of  06.05.2015

Date of Decision          :   20.05.2016

 

Harjeet Singh Khurana s/o Jamiat Singh r/o 616, Sector 39, Urban Estate, Chandigarh Road, Ludhiana.

….. Complainant

Versus 

1.The Oriental Insurance Company Limited, through its Branch Manager, Miller Ganj Branch, Ludhiana.

2.The Oriental Insurance Company Limited, through its Principal Officer, Secretary/M.D. Regd.and Head Office, A/21-27, Asaf Ali Road, New Delhi-1100000.

..…Opposite parties

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.SAT PAUL GARG, MEMBER

 

COUNSEL FOR THE PARTIES:

For Complainant                     :       Sh.R.G.Sharma, Advocate

For OPs                         :       Sh.Rajeev Abhi, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Complainant got cashless medical claim policy No.233902/48/2015/54 for period 3.4.2014 to 2.4.2015 from OPs. Complainant suffered from heart attack (Acute myocardial infarction with left ventricular failure), due to which, he was admitted in Hero Heart DMC Hospital for treatment on 10.10.2014, but he was discharged from there on 27.10.2014. Complainant has been getting the medical claim policy from the OPs since from 2005-2006 to until 2014-2015 continuously. No claim on the basis of this policy has ever been submitted earlier. Complainant informed about his health to Ops well in time because he informed the P.R.Department of Hospital about the cashless insurance card available with him. That hospital informed the insurance company about this treatment during admission of the complainant in hospital. Despite all this, cashless claim of the complainant was rejected by the insurance company. Medical claim for reimbursement denied because the cashless treatment earlier was denied. Bills and other documents regarding expenses on treatment were submitted by the complainant on 19.11.2014, but the claim of the complainant was rejected vide letter dated 18.2.2015. Immediately thereafter, the complainant approached OPs through letter dated 12.3.2015, but OPs again informed the complainant as if claim of the complainant had already been rejected. This intimation was given by the OPs vide letter dated 16.3.2015. Rejection of the claim in the garb of clause 4.1 of the policy alleged to be illegal and as such, by pleading deficiency in service on the part of OPs, directions sought to Ops to pay Rs.2 lac to the complainant because he spent Rs.4 lac on his treatment. Interest @18% p.a. on the claimed amount also sought along with litigation expenses of Rs.15,000/-.

2.                In joint written statement filed by Op1 and OP2, it is pleaded interalia as if complaint is not maintainable being barred under section 26 of the Consumer Protection Act, 1986(hereinafter referred to as the ‘Act’); complicated question of law and facts are involved, due to which, matter can be decided by the Civil Court of competent jurisdiction after record of elaborate evidence. Besides, it is claimed that complainant is estopped by his act and conduct from filing the present complaint. Admittedly, the complainant has obtained Oriental Bank Mediclaim Policy from Ops with validity from 3.4.2014 to 2.4.2015 for insured sum of Rs.2 lac. As per condition No.4.1 of the policy, the company not liable to make any payment in respect of any incurred expenses by the insured in connection with or in respect of pre-existing health conditions or disease or ailment/injuries. That exclusion clause also to apply to any complications arising from the pre-existing ailments/diseases/injuries and as such, it is claimed that in view of the fact that the complainant suffered from ailment of hypertension for the last 15 years, but diabetics for the last 18 years, the claim was duly rejected, particularly when the inception of the insurance policy in question was since from 3.4.2012 onwards and not earlier thereto. Admittedly, the complainant lodged the claim for reimbursement of the medical expenses incurred on treatment in DMC Hospital Unit Hero DMC Heart Institute, Ludhiana from 10.10.2014 to 27.10.2014. That claim was processed after receipt of the documents by the Medi Assist India TPA Pvt. Ltd. On perusal of submitted documents, it transpired as if the complainant suffered from Hypertension and Diabetics for the last 15-18 years as referred above. These facts were not disclosed by the complainant in the submitted proposal form at the time of obtaining the insurance policy. Request for cashless hospitalization was rejected by the TPA M/s Medi Assist India TPA Pvt. Ltd. vided letter dated 12.10.2014. As ailment of hypertension and diabetics during investigation was found to be present prior to the inception of the policy and as same was beyond the coverage of the terms of the policy,so claim of the complainant was recommended to be repudiated. That repudiation alleged to be done as per exclusionary clause 4.1 of the policy. After receipt of letter of repudiation dated 18.2.2015, the complainant sent representation through letter dated 12.3.2015, which was replied vide letter dated 16.3.2015 reiterating as if the claim of the complainant falls under the exclusionary clause 4.1 of the policy. Claim of the complainant was also referred to Dr.B.C.Singla of Dr.Singla Clinic, 392, Baba Balak Nath Mandir Road, Ghumar Mandi, Ludhiana for his opinion. Said doctor vide report dated 18.7.2015 gave opinion as if the complainant is known case of D.M.Type 2 for the last 18 years and of Hypertension for the last 15 years etc. Further, he opined that Diabetics also affect the heart muscle, which in turn causes systolic and diastolic heart failure. So, it was found that in case, complainant had regular policy for more than 3 years, only  then  his medical claim  will be genuine. However, medical claim submitted in the 3^rd year of policy and as such, the same alleged to be barred by clause 4.1 of the policy. Each and every other averment of the complaint denied by praying for dismissal of the complaint with costs and by claiming that there is no deficiency in service on the part of OPs.

3.                Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.P1 to Ex.P17 and thereafter, his counsel closed the evidence.

4.                On the other hand, Sh.Rajeev Abhi, Advocate for OPs tendered in evidence affidavits Ex.RA of Sh.Naresh Singla, Branch Manager of Oriental Insurance Co.Ltd, Ex.RB of Ms.Abha Mathur of M/s Medi Assist India TPA Pvt. Ltd, Ex.RC of Dr.B.C.Singla and even tendered documents Ex.R1 to Ex.R28 and thereafter, closed the evidence.

5.                          Written arguments submitted by OPs alone. It is not submitted by the complainant. Oral arguments addressed and were heard. Records gone through minutely. 

6.                It is vehemently contended by  counsel for the complainant that complainant is getting the cashless medical claim policy from the OPs since prior to 2011-2012 and as such, repudiation of claim is illegal because case of the complainant does not fall under the purview of exclusionary clause 4.1 of the policy Ex.P1. Rather, after taking us through contents of affidavits Ex.RA to Ex.RC, it is argued that each of deponents of these affidavits claimed as if in their opinion, the medical claim policy of the complainant is for more than 3 years and as such, claim case is genuine for settlement. These submissions advanced by the counsel for the complainant has no force because documents produced by the complainant and OPs establishes as if the medical claim policy was purchased by the complainant for the first time for the period from 3.4.2012 to 3.4.2013 and not before that.

7.                Complainant vide letter Ex.P7 of date 15.10.2014 was called upon to provide policy of year 2011-12 and 2012-2013 by disclosing that in case, information in that respect not received, then cashless benefit will be denied as per clause 4.1. Complainant through reply Ex.P8 claimed that three latest policy copies had been sent earlier and he had been covered with medi claim policy since from 2005-2006. Further through letter Ex.P8, complainant disclosed that insurance card issued by the Oriental Insurance in 2010-2011, 2011-2012 are being submitted by him. However, the insurance cover notes for the period from 2005-2006 to 2011-2012 has not been submitted by the complainant through letter Ex.P8. Copies of insurance cards for period from 2010-2011 and 2011-2012 except one are    not placed on record on this file by the complainant. However, the complainant has placed on record copy of insurance cover note Ex.P9=Ex.R1 for proving that he purchased the medical claim policy for the period from 3.4.2014 to 2.4.2015. Ex.P10 is copy of persons covered by the insurance policy. Name of     complainant figures in Ex.P10. Likewise, insurance policy cover note Ex.P11=Ex.R2 produced to show as if the complainant was covered under the medical claim policy for the period from 3.4.2013 to 2.4.2014. Ex.P12 annexed with Ex.P11 discloses as if complainant is the insured person. The policy cover note Ex.P13=Ex.R3 along with Ex.P14 establishes that the complainant was insured under the medical claim policy for the period from 3.4.2012 to 2.4.2013. So, from these documents, it is made out that the medical claim policies were purchased by the complainant w.e.f.3.4.2012 onwards and not before that.

8.                In policy documents Ex.P9=Ex.R1 and Ex.P11=Ex.R2, the previous policy numbers are mentioned, but in Ex.P13=Ex.R3, the previous policy number has not at all been mentioned. So by keeping in view the contents of Ex.R3=Ex.P13, it is obvious that the complainant was not having any medical claim policy with OPs prior to 3.4.2012. If such policy would have been held by the complainant prior to 3.4.2012, then previous policy number would have been mentioned in Ex.R3=Ex.P13 in a same manner as it was mentioned in Ex.P9=Ex.R1 or Ex.P11=Ex.R2. So, submissions advanced by the counsel for OPs has force that medical claim policy of the complainant started w.e.f.3.4.2012 onwards and not before that.

9.                Counsel for the complainant takes us through proposal form meant for the account holder/Employee of Oriental Bank of Commerce for arguing that details of medical claim policy with expiry date 31.3.2012 are given in it and as such, this document establishes as if the complainant was holding medical claim policy of Rs.2 lac even prior to 31.3.2012. However, after going through the said proposal form, it is made out that authorization was given by the complainant to OBC to debit the premium payable under the policy to his bank account No.5111-201-1000284 with OBC Branch EC-BJSDC, Ludhiana. So, this Proposal Form just authorized the bank to debit the premium amount from the account of the complainant with OBC to OPs. On which date, this debit amount took place, qua that no material produced on record. Until and unless, the said premium amount received by the OPs, till then Ops were not under obligation to issue any policy. Rather, this proposal form is of date 30.3.2012 and as such, virtually this un-exhibited proposal form authorized OBC branch of bank to send its premium on behalf of complainant after 31.3.2012. It was on account of this that policy Ex.R3=P13 started w.e.f.3.4.2012 with validity ending on 2.4.2013.  So,               in the absence of production of any documentary evidence on record, it has to be held that actually the complainant started having the medical claim policies w.e.f.3.4.2012 onwards and not before that.

10.              If copies of insurance cards Ex.P15 and Ex.P16 are produced on record, then they shows as if the complainant may have been policy holder with insurance company being employee, but these documents do not at all establish that the complainant was holding medical claim policy even prior to 3.4.2012. Therefore, benefit of these documents Ex.P15 and Ex.P16 not available to the counsel for the complainant. Perusal of Ex.P16 reveals as if Sh.H S Khurana is Ex-Employees of National Fertilizers Limited, Noida. After going through Ex.P15, it is made out as if it is a card issued by Genins India TPA Ltd, Third Party Administrator in Health Insurance. However, Ex.P16 has address of MDIndia Healthcare Services (TPA) Pvt.Ltd, Pune. It is not the claim of the complainant that he purchased policy from OPs, who appointed Genins India TPA Ltd, a third party administrator. Being so, Ex.P15 and Ex.P16 pertains to different policy, than the medical claim policy in question. In policies documents Ex.P9, Ex.P11 and Ex.P13, M/s Medi Assist India, Bangalore is TPA. So, TPA in the policies Ex.P9, Ex.P11 and Ex.P13 is different than one mentioned in Ex.P15 and Ex.P16. In such circumstance, it was obligatory on the part of complainant to prove that while purchasing the policy Ex.P13, he requested for portability of medical claim policy, but request in that respect has not been submitted either through Ex.P2 or through any other document. So, contents of Ex.P1 are correct that Oriental Bank Medical Claim Policy purchased by the complainant is in 3^rd year because he while purchasing the said policy, neither requested for portability and nor the same was allowed. So, submissions of counsel for the complainant has no force that  complainant continuously insured with OPs for the last more than 5 years. Rather, that insurance cover for health provided to the complainant w.e.f.3.4.2012 until his treatment on 27.10.2014. So,  the claim for insurance put forth by the   complainant in 3^rd year of the policy. Submissions of counsel for the Ops has force in view of the above discussion.

11.              In affidavits Ex.RA to Ex.RC, it has been specifically mentioned that if complainant had regular policy for more than 3 years, then his case for settlement will be genuine. However, as discussed above, this medical claim put forth in the 3^rd year of policy and as such, repudiation of claim is justified in view of the clause 4.1 of Ex.R1.

12.              That clause 4.1 reads as under:-

“Pre-existing health condition or disease or ailment/injuries: Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 3 years of this policy being in force continuously.

For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered provided the renewals have been continuous and without any break in period, subject to portability condition.

This exclusion will also apply to any complications arising from pre existing ailments/diseases/injuries. Such complications shall be considered as a part of the pre existing health condition or disease.

13.              Proposal Form Ex.R11 was submitted by the complainant by claiming that he is in good health and free from physical and mental diseases or infirmity or major complaints. However, in the initial evaluation report of DMC & Hospital, Ludhiana (Ex.R12), it is mentioned as if the complainant provisionally diagnosed for DM, HTN and ACS. In Ex.R14, Progress report of complainant as patient in DMC & Hospital, Ludhiana, it is mentioned that complainant having complaints of type 2 DMX for the last 18 years, but HTN for the last 15 years. Even in the Out Patient Card Ex.R15, it is mentioned that complainant having problem of DM & HTN. In discharge summary Ex.R20 of the complainant, it is mentioned that complainant diagnosed finally as patient of Diabetes Mellitus Type II, Hypertension CAD with Acute Coronary Syndrome. It is on account of this that investigation was got conducted by Ops from Dr.B.C.Singla. So, from the hospital records of DMC & H, Ludhiana as well as from the report of Dr.B.C.Singla Ex.R28, it is made out that the complainant was suffering from Diabetes Mellitus Type II for the last 18 years and from Hypertension for the last 15 years. That fact was concealed by the complainant while submitting the proposal form as referred above and as such, complainant concealed the material facts of his pre-existing disease/ailment at the time of submitting the proposal form. The claim for cashless medical claim facility put forth in the 3^rd year of policy and as such, repudiation of claim certainly is in accordance with clause 4.1 of the terms and conditions of the policy Ex.R1 referred above. So, repudiation of the claim through letter Ex.R6 and repudiation request for cashless authorization through letter Ex.R9 is proper.

14.              In cases Ram Swaroop Agarwal and another vs. New India Assurance Co.Ltd.-I(2014)CPJ-615(N.C.); Chalamani Narasa Reddy vs. New India Assurance Co.Ltd.-II(2009)CPJ-55(Andhra Pradesh State Consumer Disputes Redressal Commission, Hyderabad) and Prema and others vs. Life Insurance Corporation of India Ltd-IV(2006)CPJ-239(N.C.), it has been held that when discharge summary issued by the hospital says that policy holder was known case of diabetes and hypertension for last 15 years, then case covered by clause 4.1 of the medical claim policy, due to which, repudiation of claim is justified. Same is the position in the case before us and as such, repudiation of claim is justified, particularly when the complainant suppressed the material facts of his suffering of diabetes mellitus and hypertension while filling the proposal form on 30.3.2012. Even in case Sapna Arora vs. Life Insurance Corporation of India and others-I(2009)CPJ-588(Punjab State Consumer Disputes Redressal Commission, Chandigarh), it has been held that when history given  by the insured himself recorded in the discharge certificate of hospital points to his suffering from Diabetes Mellitus Type 2 prior to filling of proposal form, then repudiation of claim is justified. Same is position in the case before us. Suppression of pre-existing disease even has been held to be a valid ground for repudiation of the medical claim in case titled as Oriental Insurance Company Limited vs. Shanti Parshad Goyal and others-I(2013)CPJ-152(Haryana State Consumer  Disputes Redressal Commission,Panchkula).As written versions of the insurance company is based on medical history disclosed by the complainant at the time of hospitalization and as such, it is made out that complainant did not disclose about pre-existing disease despite sufferance, due to which, repudiation of claim is justified. This     in fact is the ratio of case titled as Shakuntala R.Khosla vs. Oriental Insurance Co.Ltd.-II(2012)CPJ-78(Maharashtra State Consumer Disputes Redressal Commission, Mumbai).

15.              Therefore, as a sequel of the above discussion, the present complaint merits dismissal and the same is hereby dismissed without any order as to costs. Copies of order be supplied to the parties free of costs as per rules.

16.                        File be indexed and consigned to record room.

 

 

                      (Babita)                                       (G.K.Dhir)

                       Member                                          President

Announced in Open Forum

Dated:20.05.2016

Gurpreet Sharma.