DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Anand Kumar Malik, aged 40 years, son of Shri Hari Chand Malik, resident of House No. 377, Sector 11, Panchkula.

              ---Complainant

Vs

[1]  Oriental Insurance Company Limited, having its Registered and Head Office at “Oriental House”, A-25/27, Asaf Ali Road, New Delhi – 110002, through its General Manager/ Authorized Representative.

[2]  Oriental Insurance Company Limited having its Office at SCO No. 109-111, Sector 17-D, Chandigarh through its General Manager/ Authorized Representative.

[3]  M/s Raksha TPA Pvt. Limited, having its Office at 15/5 Mathura Road, Faridabad – 121003, through its General Manager/ Authorized Representative.

2^nd Address: -

     2^nd Floor, SCO No. 181, Sector 7-C, Chandigarh, through its General Manager/ Authorized Representative.

---- Opposite Parties

BEFORE:    SH. LAKSHMAN SHARMA             PRESIDENT

MRS.MADHU MUTNEJA               MEMBER

           SH.JASWINDER SINGH SIDHU        MEMBER

Argued By:    Sh. Divanshu Jain, Counsel for Complainant.

Sh. Parminder Singh, Counsel for Opposite Parties No.1 & 2.

Opposite Party No.3 ex-parte.

PER MADHU MUTNEJA, MEMBER

1.        The instant complaint relates to non-payment of medi-claim insurance by the Opposite Parties to the Complainant.

          Factually speaking, the Complainant had purchased a medi-claim insurance cover from Opposite Party No.1 vide Policy No. 231202/48/2009/1458, Cover Note No.CHD-C374231, valid from 18.11.2009 to 17.11.2010. At the time of issuance of Policy, the Complainant was assured that the “policy shall pay for hospitalization expenses for medical/ surgical treatment taken as an in-patient at any Nursing Home/ Hospital in India as defined in the Policy”. The Complainant has stated that one day, he suffered acute cervical pain in his neck for which treatment was required.  The Complainant visited NINS Brain and Spine Hospital and on advice of the doctors got surgery done for the ailment, which was C5-C6 PIVD with right nerve compression of the cord. The said Hospital also informed Opposite Party No.3 (T.P.A) at the Toll Free Telephone No. about the ailment of the Complainant and the tentative amount of expenditure to be incurred on the Surgery. The surgery was performed on 24.01.2010. Thereafter, the Complainant pursued the matter with Opposite Party No.3 a number of times, but the claim was not paid as Opposite Party No.3 kept saying that they had not received complete papers and hence, the claim could not be processed. The Complainant was discharged on 27.01.2010 (Discharge Summary Annexure C-3). The Complainant had to pay complete expenses from his own pocket. The Complainant thereafter, filed his claim vide Claim Form dated 3.2.2010 giving complete information about the ailment along with all relevant documents. However, the claim was not paid despite many representations and visits by the Complainant to the Opposite Parties. The claim was eventually repudiated by the Opposite Parties as per Annexure C-18, on the following ground: -  

“Disease for which the patient was admitted in the Hospital i.e. PIVD comes under 1^st two years of exclusion.”

          Not aware about the aforesaid Clause 4.3, the Complainant has stated that he visited the office of the Opposite Parties, where he was handed over papers, in which Clause 4.3 is mentioned. The Complainant has stated that this was for the first time when he came to know about the existence of such clause.  

          Alleging deficiency in service and harassment due to denial of a genuine claim on false and flimsy grounds, the Complainant has filed the present complaint, with a prayer that the Opposite Parties be directed to pay: -

a]    Rs.80,000/- incurred on Surgery and other Hospitalization expenses;

b]    Rs.10,000/- incurred on Tests (MRI, CT Scan’s);

c]    Rs.2,500/- incurred on telephone and postage;

d]    Rs.21,000/- towards litigation expenses; 

e]    Rs.2,00,000/- as compensation for deficient services, mental agony and harassment;

2.        Notice of the complaint was sent to Opposite Parties seeking their version of the case. However, despite service, nobody has appeared on behalf of Opposite Party No.3, therefore, it was proceeded against exparte on 28.03.2012.

3.        The Opposite Parties No.1 and 2 in their joint reply have taken the preliminary objection that there is no deficiency in service on their part, as the claim was repudiated because the disease of the Complainant came under the Exclusion Clause 4.3 of the Policy. As per this clause PIVD (Surgery for Prolapsed inter vertebral disk) unless arising from accident is not covered under 1^st two (2) years of policy. As the claim made by the Complainant was within the 1^st two years of policy, it was not payable. The claim was repudiated on the recommendations of the T.P.A. (Opposite Party No.3) as per letter at Annexure R-2. It has been stated that Opposite Parties No.1 & 2 have no role to play in processing of the claim, as all claim forms and bills have been submitted t Opposite Party No.3 for processing.

          On merits, answering Opposite Parties have admitted the issuance of medi-claim policy to the Complainant, but have reiterated that they have no role to play in the processing of the claim as this is the job of Opposite Party No. 3. The claim of the Complainant was repudiated as per Exclusion Clause 4.3 of the Policy, because PIVD was not covered in the 1^st two years of the Policy. A copy of the insurance policy, along with terms and conditions had been duly supplied to the Complainant and he was very well aware about the exclusion clause. Also, it was renewal of the earlier policy effective from 18.11.2008 to 17.11.2009. The Complainant had himself filled the proposal form, in which he had mentioned that he had understood and accepted the policy conditions, exceptions, thus, allegations that the Complainant is not aware about the policy conditions are incorrect and the complaint is liable to be dismissed. Denying all other allegations, Opposite Parties have prayed for dismissal of the complaint.

4.        Parties led evidence in support of their contentions.

5.        We have heard the learned counsel for the Complainant and learned counsel for OPs No.1 & 2, OP No.3 already ex-parte and have perused the record.

6.        The medi-claim policy taken by the Complainant is in its 2^nd year and the claim has been repudiated by the Opposite Parties relying on the terms and conditions of the policy. The Complainant has stated specifically that he was not aware of the terms and conditions of the policy. Hence, the ground of repudiation of claim came as a surprise to him. Opposite Parties in reply have placed on record the policy as well as the proposal form filled in and signed by the Complainant. The declaration of the Complainant in the proposal form is reproduced hereinbelow: -

“I/we further declare that I/we have read the prospectus and have understood the same. I accept the policy, subject to terms, exceptions and conditions prescribed therein and further disclose that on the event of finding anything contrary to what has been declared to me, I/we shall be held responsible for all consequences thereof and insurance company shall incur no liability under this insurance.”  

          Hence, after this declaration the Complainant cannot at this stage allege the fact that he is not aware of the terms and conditions. Especially, now in the 2^nd year of operation of policy. The recommendation of Opposite Party No.3 at Annexure R-2 is as under: -

“PT ADMITTED AND DIAGNOSED PIVD. C5C6 DISSECTOMY DONE. MANAGED CONSERATIVELY AND DISCHARGED WITH FOLLOW UP. AS THE POLICY IS IN 2^ND YEAR OF INCEPTION. AND PIVD COMES UNDER 1^ST TWO YEARS OF EXCLUSION. HENCE THE CLAIM IS NON PAYABLE AS PER CLAUSE 4.3 OF THE POLICY. PIVD.

7.        Looking at the terms & conditions of the policy, it is evident that the claim is not payable in the 2^nd year. The contention of the Complainant that he is not aware of the terms and conditions of the policy have been proved to be wrong by the Opposite Party as per the annexures placed on record. The Complainant has not rebutted this evidence. 

8.        In the given situation, it is safe to deduce that the Complainant was well aware of the terms and conditions of the policy and in such a situation the claim is definitely not payable. The complaint is accordingly dismissed. No costs.

9.        Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

01^st October, 2012.                                             

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

(MADHU MUTNEJA)

 MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER