CONSUMER DISPUTES REDRESSAL COMMISSION-VII
DISTRICT: SOUTH-WEST
GOVERNMENT OF NCT OF DELHI
FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN
SECTOR-20, DWARKA, NEW DELHI-110077
CASE NO.CC/322/21
Date of Institution:- 04.10.2021
Order Reserved on:- 05.02.2024
Date of Decision:- 13.06.2024
IN THE MATTER OF:
O. P. Swami
S/o Sh. Mehar Chand Swami
R/o D-184, ShyamVihar, Phase I,
Goyla Road, Road No.6, Najafgarh,
New Delhi - 110043 .….. Complainant
VERSUS
The Oriental Insurance Co. Ltd.
Through its Divisional Manager
88, Janpath, Connaught Place,
New Delhi – 110001 .…..Opposite Party
Suresh Kumar Gupta, President
- The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations that he is son of Kamla Devi i.e. insured who has given special power of attorney to him as he is well acquainted with the facts of the case being her son. He is duly authorized to sign and verify the complaint. OP has issued group mediclaim policy i.e. PNB-Oriental Royal mediclaim policy for its account holders. His mother has been the policy holder since 2010. The OP has denied the hospital bill of the insured when she remainedadmitted to BLK Super Specialty Hospital from 20.10.2020-31.10.2020. The first policy was renewed after 36 days of the date of expiry through PNB however the policy has been in operation without any break from 2011. The policy was transferred to New India Assurance Co. from 27.07.2018 and sum insured was increased from Rs.3 lakh to Rs.7 lakh. The current policy bearing no.272900/48/2022/5100-001 from 27.07.2021-26.07.2022 for insured sum of Rs.7 lakh was issued. This policy was the fourth policy from the OP. The TPA of the OP has authorized the hospital for a treatment of Rs.25000/- on 21.10.2020 and later enhanced the amount to Rs.2 lakh on 23.10.2020 and again enhanced to 88% of the total surgery expenses up to Rs.336137/- on 26.10.2020 out of the total estimated expenses of Rs.420173/-. On 30.10.2020, TPA has abruptly repudiated the entire claim of the hospital on the ground of pre-existing disease is covered after a period of three years in terms of the policy. All the diseases are covered under group insurance policy without any condition of pre-existing disease. TPA has approved a bill of Rs.179672/- out of Rs.319800/- upon which complainant has to pay a sum of Rs.140128/- to the hospital. OP has never supplied any copy of rules and regulations to the complainant and thereby wrongly assessed the claim. The claim was wrongly repudiated by the OP. The complainant has filed the complaint before the office of Insurance Ombudsman on 21.01.2021 which was rejected on 10.08.2021. There is deficiency of service on the part of OP. Hence, this complaint.
- The OP has filed the reply with the averments that initially the sum insured was Rs.3 lakh which was enhanced to Rs.7 lakh. The patient has undergonewhipple surgery in 2012 as per discharge summary. The insured was diagnosed with an ailment which comes within the ambit of pre-existing disease in terms of the clause 4.1 and 4.2 of the policy so the claim is settled by taking into account for the policy for the year 2017 by restricting to sum insured Rs.3 lakh. The claim will be settled for Rs.7 lakh in the absence of pre-existing diseases. The documents at the time of pre-authorization are not available with TPA. The authorization was revised as per the terms and conditions of the policy.The sum insured of Rs.7 lakh will be applicable on the fourth policy. The claim was passed by keeping in view the sum insured of Rs.3 lakh due to pre-existing diseases. The clause 5.3 (III) (b) of the terms and condition of the policy was rightly invoked. There is no deficiency of service on the part of OP.
- The complainant has filed the rejoinder wherein he has denied the averments of written statement and reiterated the stand taken in the complaint.
- The parties were directed to lead the evidence.
- The complainant has filed his own affidavit in evidence and corroborated the version of complaint and placed reliance on the documents Ex.CW1/A to 1/I.
- The OP has filed the affidavit of Sh. Rajpal, in evidenceand corroborated the version of written statement and placed reliance on the documentsAnnexure-R1 to R5.
- We have heardthe complainant and Ld. Counsel for the OP and perused the entire material on record.
- It is clear from the material on record that the insured has been employee and account holder of PNB. PNB has taken Group Mediclaim Policy for its employees. The insured has been the policy holder since 2010. The insured has ported herpolicy from PNB OrientalMediclaim Policy to New India Flexi Floater Group MediclaimPolicy in 2017 andsum insured was enhanced from Rs.3 lakh to Rs.7 lakh.The insured again ported her policy back to PNB-Oriental Mediclaim policy in the year 2020 and policy bearing no.272900/48/2021/6094 for enhanced sum of Rs.7 lakh was valid from 27.07.2020 – 26.07.2021 was issued. The policy is Ex.CW1/D.
- The insured was admitted to BLK Super Specialty Hospital on 21.10.2020 where she was diagnosed with FU/C whipple procedure where she underwent exploratory laparotomy with adheslolysiswith gasterojejunostomy. She was discharged on 31.10.2020 which is apparent from Ex.CW1/C.
- The initial authorization,on the basis of available documents, was granted by TPA. The hospital raised the bill of Rs.319800/-. The TPA, on the receipt of entire documents, invoice, the authorization as per the terms and conditions of the policy and approved the bill for a sum of Rs.179672/- which is apparent from Ex.CW1/G. The revision was made by the TPA as case is covered under exclusion clause 4.1 and 4.2 of the terms and conditions of the insurance policy.
- Clauses 4.1 and 4.2 of the terms and conditions of the insurance policy speaks about the pre-existing disease. Insured is a case of pre-existing disease as this fact is nowhere controverted by the complainant or insured.
- The initial sum insured was Rs.3 lakh which was enhanced to
Rs.7 lakh in 2018-2019. The treatment in question was taken during continuation of the policy Ex.CW1/D. Clause 5.3 (III) (b) of the terms and conditionsof the insurance policy says that if the policy is renewed for enhanced sum then clauses no.4.1 and 4.2 as applicable to a fresh policy shall apply to additional sum insured as if a separate policy has been issued for the difference. In respect of Pre-existing diseases or for adisease/ailment/injury for which treatment has been taken in the earlier policy period, the enhanced sum insured will be available only after three continuous renewals with the Increased Sum Insured.
- The sum insured was enhanced in 2018. The treatment has been taken in 2020. The three consecutive renewals of the policy have not taken place in order to avail the benefit of enhanced amount of sum insured. The claim was revised by the OP by keeping in view the policy 2017 which was rightly done as three continuous renewals have not taken place.
- The claim has been rightly revised by the TPA which was in accordance with the clause 5.3 (III) (b) of the terms and conditions of the insurance policy. There is no deficiency of service on the part of OP.
- In view of above discussion, the complainant has failed to substantiate the allegations as set out in the complaint and accordingly the complaint is dismissed.
- 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 13.06.2024.
