Chandigarh

DF-II

CC/427/2016

Ravinder Kumar Goswami - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

D.K. Singal Adv. & Ammish Goel Adv.

29 May 2017

ORDER

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

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Consumer Complaint  No	:	427 of 2016
Date  of  Institution	:	13.6.2016
Date   of   Decision	:	29.5.2017

 

 

 

 

 

Ravinder Kumar Goswami aged 57 years son of late shri C.L. Gosain resident of House No.3327, Sector 27D, Chandigarh 160019.

                …..Complainant

Versus

 

1.   Oriental Insurance Company Limited SCO No.47, Sector 47-D, Chandigarh 160047 through its Divisional/Branch Manager.

 

2.   Vipul Medcorp TPA Pvt. Ltd. SCI No.98, first floor, Industrial Area, phase -2, Chandigarh 160002 through its Managing Director.

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

         SH. RAVINDER SINGH             MEMBER

 

 

For complainant(s)      :     Sh. D.K. Singal, Adv.  

 

For OPs                 :     Sh. J.P. Nahar,Adv.

 

 

RAVINDER SINGH, MEMBER

 

 

     Briefly stated, the complainant purchased  Happy Family Floater Policy from OP No.1 vide policy No.231301/48/2013/730 valid from 15.10.2012 to 14.10.2013  having coverage of upto Rs.3 lakh covering his all the family members.  It is pleaded that at the time of taking policy on 13.10.2012 the complainant had revealed the fact that he was deployed stent on 12.7.2009 at Mukat Hospital and Heart Institute, Chandigarh.  Thereafter the policy was renewed from time to time and last it was renewed for the period from 15.10.2015 to 14.10.2016. It is pleaded that in the year 2015, the complainant again felt pain in his chest and after taking various medical opinion, he got his angiography from PGI on 23.12.2015 and three stent were inserted and was discharged on 24.12.2015.  Intimation regarding the same was given to OP No.2. Thereafter the complainant submitted his claim of Rs.1,87,379/- alongwith all the requisite documents. Later on the complainant received an email dated 4.2.2016 from OP No.2 asking the reason for delay of submitting the documents, which was duly explained by the complainant. It is alleged that the OPs lingered on the issue on one pretext or the other and ultimately vide email dated 29.3.2016 repudiated the claim of the complainant on account of pre-existing disease being not covered under the policy for first four years of the policy. Alleging the said act of OPs as deficiency in service, this complainant has been filed for issue of directions to OPs for payment of medical expenses.

 

 

2       Opposite Party No.1 has filed reply stating therein that the complainant has chosen silver plan of the policy  and the policy terms and conditions were sent to him. It is asserted that the claim lodged by the complainant was of a pre-existing disease which was covered under the policy only after four claim free years. As per exclusion clause 4.1 all the pre-existing disease or related conditions are excluded for four years from taking the policy for the first time. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

3           No separate reply has been filed on behalf of OP No.2 by the counsel who is also appearing on behalf of OP No.1. 

4           The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Party No.1 made in the reply.

5           Parties led evidence in support of their contentions.

6           We have heard the ld. Counsel for the parties and have also perused the record.

7           The complainant was admitted in PGIMER, Chandigarh  on 23.12.2015 and discharged on 24.12.2015 after angiography/medical treatment. The claim of the complainant for Rs.1,87,379.50 i.e. the medical expenses incurred by him was turned down by the OPs citing clause 4.1 of Happy Family Floater Policy. Clause 4.1 of the policy is reproduced 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 4 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. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to following exclusions.

 

8       The complainant admittedly undergone angiography on 12.7.2009 at Mukat Hospital, Chandigarh. He disclosed this fact while taking the policy  No.231301/48/2013/730 on 13.10.2012 after payment of premium of Rs.8780/-. The Policy ibid was valid from 15.10.2012 to 14.10.2013 for medical insurance cover of Rs.3 lakh. The complainant admittedly renewed policy further for the period 15.10.2013 to 14.10.2014, 15.10.2014 to 14.10.2015 and 15.10.2015 to 14.10.2016 after payment of premiums.

9           Obviously, the complainant has valid insurance as on 23.12.2015 when he was hospitalized for angiography in PGI Chandigarh. He has not suppressed any fact about his earlier angiography done on 12.7.2009 while initiating the proposal for health insurance policy, which he took on 13.10.2012 from the OPs.

10         The Hon’ble Division Bench of Punjab and Haryana High Court in LPA No.1537 of 2011 (O&M) decided on 26.8.2011 titled as IFFCO TOKIO Genereal Insurance Company Ltd. Vs. Permanent Lok Adalat (Public Utility Services) , Gurgaon and others, has considered the matter in which the substantial question of facts and law was identical as in the present complaint. The Hon’ble Division Bench in its judgment has reproduced the observation of Hon’ble Single Judge as below:-  

"Sole submission before this Court is that claim has been declined in terms of the conditions of the policy and such a claim would not be admissible. This defence to me would sound highly unfair. Why would one take a policy of medi-claim if he is not to get his claim for genuine treatment taken? It is for the Insurance Company to see and not to issue a policy where they find that such person is not entitled to claim on account of treatment of the existing disease. The petitioner (respondent No. 2?) had been paying the premium for the last three years. He may be suffering from this disease since 2002 but need to seek treatment arose only in 2010. One would not take mediclaim policy just for the purpose of paying premium. The ground advanced by the petitioner to deny this claim is unfair and unreasonable. Respondent No.2 had a valid policy from the petitioner and they must now honour the same. I do not find any justification to interfere in the order passed by the Lok Adalat."

 

         The Hon’ble Division Bench while concurring with the decision of the Hon’ble Single Judge has held that the exclusion clause in the policy is unfair, unreasonable and unconscionable and held the same to be not applicable in the case of the claim of the insured person therein.

11         The principle of law laid down in the above case is squarely applicable in the instant case. As such the claim of the complainant for medical reimbursement of  Rs.1,87,379/- on account of treatment on 23.12.2015 in PGI is admissible inter-alia  on the grounds:-

(a)   The complainant has valid medical insurance policy which was valid upto 14.10.2016.

(b)   The complainant had undergone angiography on 23.12.2015 after lapse of more than 6 years from his previous angiography on 12.7.2009.

   

12.     The exclusion clause as relied upon by the OPs being unfair is misconceived and without merit and not sufficient enough to decline the genuine claim of the complainant.

13.    Keeping in view the above facts the complaint is hereby allowed with direction to OPs to pay claim of Rs.1,87,379.50 to the complainant alongwith litigation cost of Rs.5000/- within 30 days from the date of receipt of certified copy of this order.

14.      In case the OPs failed to comply with the order within given time then they shall also be liable to pay additional compensatory cost of Rs.20,000/- to the complainant.  

        The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

29.5.2017  

                                                                                       Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

(PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER