BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 51 of 2016
Date of Institution: 04.02.2016
Date of Decision: 30.06.2016
Mr.Tarlok Singh son of Sh.Jassa Singh, resident of 1799, Verka Patti Hardass, Amritsar.
Complainant
Versus
The Oriental Insurance Company Limited, through its Chairman/ Managing Director/ Principle Officer, service through its Branch Office at Dwarka Deesh Complex, Queens Road, Amritsar through its Branch Manager.
Opposite Party
Complaint under section 12 & 13 of the Consumer Protection Act, 1986 as amended upto date.
Present: For the Complainant: Sh.Deepinder Singh, Advocate
For the Opposite Party: Sh. Sandeep Khanna, Advocate
Coram
Sh.S.S.Panesar, President
Ms.Kulwant Kaur Bajwa, Member
Mr.Anoop Sharma, Member
Order dictated by:
Sh.S.S. Panesar, President.
1. Sh.Tarlok Singh has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that he has been taking the Health Insurance policy from the Opposite Party for himself, his wife and daughter and the last policy taken vide policy No. 233300/48/2016/2730 covering risk period from 31.08.2015 to 30.08.2016, copy of the cover note is annexed with the complaint. The complainant is a consumer as provided under the Act and is competent to invoke the jurisdiction of this Forum. The complainant unfortunately fell ill and felt heavy pain in his chest overnight of 31.08.2015 and got admitted in IVY Hospital from 31.08.2015 till his discharge on 2.9.2015 and the claim for his hospitalization and medical treatment was referred to Opposite Party for cashless treatment as the said policy issued by Opposite Party is on cashless terms. However, the request for the cashless treatment was denied by Opposite Party on the frivolous ground that the treatment taken was of pre existing disease, which is against the true facts. The complainant had no pre existing disease and the treatment is of emergency nature and the complainant paid the amount to the treating hospital for the medical expenses and lodged the claim immediately with the Opposite Party for the medical expenses on the treatment which amounting to Rs.1,35,000/-. The complainant thereafter making the futile visits to Opposite Party and Opposite Party has denied the genuine claim vide repudiation letter dated 6.1.2016 after four months, on the frivolous grounds of pre existing disease. The complainant has sought the following reliefs vide instant complaint.
a) Opposite Party be directed to pay the claim of Rs.1,35,000/- alongwith interest @ 12% per annum thereon from the date of payment till realization:-
b) Opposite Party be directed to pay the compensation of Rs.50,000/- to the complainant.
c) Opposite Party be directed to pay the costs of the present litigation.
d) Any other relief to which the complainant is found under the law, equity and justice be also allowed.
Hence, this complaint.
2. Upon notice, Opposite Party appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that the present complaint is not maintainable, since in the light of terms and conditions of the medi-claim policy it was found that the claim is not payable as per exclusion clause 4.1 which reads as under:-
“The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of Pre-existing Health Condition or disease or ailment/ injuries. Any ailment/ disease/ injuries/ Health Condition which are pre existing (treatment/ untreated/ declared/ undeclared 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 on 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 compensation arising from pre existing ailment/ disease/ injuries. Since complications shall be considered as a part of the pre-existing health condition or disease.”
On the scrutiny of the claim documents, it was found that the complainant was admitted in Ivy Hospital on 31.8.2015 with the diagnosis as a case CAD.POST MI ANGINA. As per discharge summary, the complainant was having chest pain since 1 day i.e. 30.8.2015 which falls in the Break-In-Policy-Period. Hence, the disease was pre existing one and not payable in the light of the exclusion clause 4.1 of the policy in question. Resultantly, the Opposite Party intimated the complainant vide letter dated 6.1.2016 clearly stating that the present claim was not payable and the same was repudiated accordingly; that as per the terms and conditions of the policy in question, the claim has to be reported within 48 hours of admission in a hospital, but before discharge from the hospital. However, the complainant had failed to intimate the Opposite Party regarding his hospitalisation within the stipulated period. Hence, the complainant has violated the basic terms and conditions of the policy and is not entitled to the relief claimed for; that as per the terms and conditions of the policy in question, the claim documents have to be submitted with insurance company within 7 days of discharge from the hospital, but the complainant has failed to submit the said requisite documents with Opposite Party within the stipulated period. As such, the complainant has violated the basic terms and conditions of the policy in question and is not entitled to the relief claimed for; that the complainant has not approached this Forum with clean hands and has concealed the material facts. In number of judgements, it has been held that any person who approaches the court with unclean hands is not entitled to get any relief; that as the claim has already been repudiated on merits in the light of terms and conditions of the policy in question, therefore, no consumer dispute survives. Hence the complainant has no right to file the present complaint. On merits, the facts narrated in the complaint have specifically been denied and a prayer for dismissal of the complaint with costs was made.
3. In his bid to prove the case, complainant tendered into evidence his duly sworn affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copy of policy schedule Ex.C2, copy of discharge card Ex.C3, copy of medical bill Ex.C4, copy of repudiation letter Ex.C5 and closed his evidence.
4. On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.Gurdeep Singh, Divisional Manager Ex.OP1, copy of repudiation letter Ex.OP2, terms and conditions Ex.OP3 and closed the evidence.
5. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
6. Ld.counsel for the Opposite Party has vehemently contended that policy in dispute commenced w.e.f. 31.8.2015 to 30.08.2016 whereas the complainant got himself admitted in Ivy hospital on 31.8.2015 with alleged pain in chest occurring on 30.08.2015. The disease which was diagnosed a case CAD.POST MI ANGINA was pre existing disease & fell within Break-In-Policy-Period. As per clause 4.1 of the terms and conditions of the policy in question, the claim was not payable. Clause 4.1 is reproduced as under:-
“The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of Pre-existing Health Condition or disease or ailment/ injuries. Any ailment/ disease/ injuries/ Health Condition which are pre existing (treatment/ untreated/ declared/ undeclared 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 on 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 compensation arising from pre existing ailment/ disease/ injuries. Since complications shall be considered as a part of the pre-existing health condition or disease.”
It was further contended that the complainant was under duty to report for his admission in hospital within 48 hours of admission but before discharge from the hospital. But however, the complainant had failed to intimate the Opposite Party regarding his hospitalisation within the stipulated period. It is further case of the Opposite Party that the claim documents were required to be submitted with insurance company within 7 days of discharge from the hospital, but however, the claim has been filed after the stipulated period which has been rightly repudiated by the Opposite Party vide repudiation letter, copy whereof is Ex.OP2. Ld.counsel for the Opposite Party has vehemently contended that the claim of the complainant has been rightly repudiated as per exclusion clause 4.1 of the policy. There is no merit in the complaint and the same is liable to be dismissed with costs.
7. However, from the appreciation of the facts and circumstances of the case, it becomes evident that the complainant has been obtaining the Health Insurance policy from the Opposite Party for himself, his wife and daughter and lastly the complainant purchased the policy bearing No. 233300/48/2016/2730 covering risk period from 31.08.2015 to 30.08.2016 from Opposite Party, copy whereof is Ex.C2. Unfortunately, the complainant fell ill and felt heavy pain in his chest overnight of 31.08.2015 and got himself admitted in Ivy Hospital from 31.08.2015 till his discharge on 2.9.2015, copy of discharge summary accounts for Ex.C3. It is the admitted case of the parties that it was a cashless policy. However, the cashless treatment was denied by the Opposite Party on the frivolous ground that the treatment taken was of pre existing disease. But however, the stand of Opposite Party that it was pre existing disease has no takers because the complainant fell ill on 31.8.2015 and was got admitted in the hospital on the same day. Policy in dispute also covers risk period w.e.f. 31.8.2015 to 30.8.2016, which itself proves the stand of the complainant. Opposite Party has wrongly come to the conclusion that the disease suffered by the complainant was pre existing in nature. For that purpose, they have relied upon the discharge summary but no medical proof of earlier treatment obtained by the complainant has been pressed into service before this Forum. In such a situation, the rejection of the claim under clause 4.1 of the insurance policy in dispute has no legs to stand on. We are of the considered view that the claim of the complainant has been rejected without any reasonable ground. It was incumbent upon the Opposite Party to have produced the record of other hospital(s) from where the complainant got the treatment for his alleged pre existing disease or atleast the treating doctor should have filed an affidavit to that effect. In the absence of such an evidence, the discharge summary can not be relied upon for reaching the conclusion that the complainant suffered from pre existing disease of CAD.POST MI ANGINA. As such, we hold that the Opposite Party is deficient in service and the claim of the complainant has been rejected without any reasonable cause.
8. The complainant has placed on record the copy of invoice/ bill Ex.C4 for reaching the conclusion that the complainant incurred an expenditure of Rs.1,35,000/- on his treatment as an indoor patient. There is absolutely no rebuttal to that evidence. As such, the complainant is entitled to the medi-claim to the tune of Rs.1,35,000/- alongwith interest @ 9% per annum from the date of filing the complaint until full and final recovery. The costs of litigation are assessed at Rs.2,000/-. Compliance of this order be made by Opposite Party within 30 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order executed through the indulgence of this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated: 30.06.2016. (S.S.Panesar)
President
(Anoop Sharma) (Kulwant Kaur Bajwa)
Member Member
hrg
