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

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Dr. Sukhchain Singh Bhullar, MBBS, ENT Delhi University, Consultant/ Surgeon Silver Oaks Hospital, Mohali and Apollo Clinic, Chandigarh, resident of H.No. 3004, Ajanta Enclave, Sector 51-D, Chandigarh – 160 047.

              ---Complainant

Vs.

1]   Oriental Insurance Co. Limited, through its Managing Director, Head Office, Oriental House, P.B. No. 7037-A, 25/27 Asaf Ali Road, New Delhi – 110 002.

2]   The Regional Manager, Oriental Insurance Company, Regional Office, Surendra Building, SCO No. 109-111, Sector 17-D, Chandigarh.

3]   Captain Mahesh Sharma, Third Party Authorization (TPA) C/o Safeway TPA Services Pvt. Limited, 6/2, 1^st Floor, Kirti Nagar Ind. Area, Near SBI, New Delhi – 110 015.

---- Opposite Parties

BEFORE:   MRS.MADHU MUTNEJA            PRESIDING MEMBER

SH. JASWINDER SINGH SIDHU    MEMBER

Argued By:    Sh. Pradeep Bhanot, counsel for Complainant. 

            Opposite Party No.1 ex-parte.

            Sh. Vishwajit Bedi, Counsel for Opposite Party No.2.

            Opposite Party No.3 ex-parte.

PER MADHU MUTNEJA, PRESIDING MEMBER

1.          The Complainant along with his family members was part of a Group Medi-claim Tailor made Policy of M/s Alchemist Multi Specially Hospital, Sector 21, Panchkula, effective from 7.7.2009 to 24.3.2010 (08 months and 17 days). The Complainant has alleged that normally insurance cover is for a one year term and this shorter period was done without his express consent. Further, as the Complainant’s insurance cover had lapsed much earlier, he was uninsured for a period of 03 months and 14 days without his knowledge and any mis-happening would not have been covered by the Opposite Parties (Policy Annexure C-1). The Complainant had paid Rs.18,141/- vide Cheque dated 29.6.2009; whereas, the insurance premium because of shorter term was Rs.17,356/-. The Opposite Parties refunded the difference vide a cheque which has not been encashed by the Complainant till date, which according to him signifies that his premium paid to Opposite Parties is Rs.18,141/- for a complete one year term i.e. till 06.07.2011 and not on 25.03.2010. It is also alleged that the Opposite Parties have been corresponding with the Complainant at the wrong address and no mails have been received by him. 

          It is averred that the wife of the Complainant was treated at CMC (Chhuttani Medical Centre), SCO 52-54, Sector 17-C, Chandigarh from 02.08.2008 (8:00 a.m.) to 04.08.2008 (8.00 p.m.). The bill for Rs.33,910/- was raised (Annexure C-3 and C-3(I)). The Complainant submitted his wife’s claim No. 1577/08 through Opposite Party No.3, which has been repudiated on the ground of pre-existing disease, vide letter dated 14.9.2009 (Annexure C-3(A)).

          The Complainant has alleged that the Opposite Parties had conducted a comprehensive medical check-up of his wife before issuing a policy. It is well settled in consumer law that an insurance company cannot repudiate a medical claim on grounds of pre-existing disease, as it is incumbent on the insurance company to conduct a complete medical examination before issuing a policy and to specifically mention in the insurance policy any aberration in the health of the insured. It is further averred that a complaint in this regard was also sent to the Ombudsman (Insurance) (Annexure C-4). Efforts were also made to resolve the dispute with the Opposite Parties. As the payment has not been made, the Complainant has filed the present complaint, with a prayer to indemnify him with a sum of Rs.18.00 lacs as compensation and Rs.50,000/- for mental and physical harassment, besides costs of litigation

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 Parties No.1 and 3, therefore, they were proceeded against exparte on 10.12.2012 and 10.04.2013 respectively.

3.          Opposite Party No.2 in its reply has maintained that there is no deficiency in service on its part and the Complainant has unnecessarily impleaded it into false and frivolous litigation. 

          On merits, the issuance of the policy to the Complainant has been admitted to be matter of record. However, the allegations about the shorter period of insurance and gap in insurance has been denied. It is pleaded that the Complainant had become part of the Group Medi-claim Tailor Made Policy through Opposite Party No.3 by depositing with him a premium of Rs.18,141/- through Cheque dated 29.6.2009. Rs.785/- has been refunded to the Complainant by the Opposite Parties No.1 & 2, as he has approached the Opposite Parties No.1 & 2 through Opposite Party No.3 on 29.6.2009 and his policy became effective from 7.7.2009 to 24.3.2010. So proportionate premium only was received through Opposite Party No.3 and the Complainant and his family members were added in the Group Medi-claim Tailor Made Policy issued to M/s Alchemist Multispecialty Hospital, Sector 21, Panchkula through Endst. No. 231202/48/2211/003 with effect from 7.7.2009 to 24.3.2010 (Copy of receipt and policy at Annexure R-1 & R-2). It is asserted that the Complainant was admitted in Chhuttani Medical Centre, Sector 17, Chandigarh from 2.8.2008 to 4.8.2008, which was earlier to the issuance of the Policy by Opposite Parties No.1 and 2.

          Claim of the Complainant was repudiated on 16.7.2009 by Safeway TPA Services for another Policy. It has been specifically mentioned in the repudiation letter by the Opposite Party No.3 as under:-

“we have been officially appointed as a TPA to administer your Medi-claim Policy of the New India Assurance Co. Ltd. We have received the claim documents for the claim for hospitalization of Dr. Sukhchain Singh Bhullar”

          Also, the Complainant has written a letter to the Ombudsman on 14.5.2010 in which it has been clearly mentioned that Mrs. Sukhjeet Kaur was insured with NIAC Ltd. from 27.8.2007 to 26.8.2008. The Opposite Parties No.1 & 2 have therefore pleaded that they are not liable to pay any compensation to the Complainant as the wife of the Complainant was not insured with Opposite Parties No.1 & 2 at the time when she was hospitalized. Hence, denying all other allegations and stating that the Complainant is not entitled for any claim, answering Opposite Party has prayed for dismissal of the complaint.  

4.          Parties were permitted to place their respective evidence on record, in support of their contentions.

5.          We have heard the learned counsel for the Complainant and learned counsel for Opposite Party No.2 (Opposite Parties No.1 & 3 being ex-parte) and have perused the record.

6.          Annexure C-1 placed on record by the Complainant is a Group Medi-claim Tailor Made – Endorsement Schedule issued in the name of M/s Alchemist Multispecialty Hospital, Sector 21, Panchkula. The total premium is Rs.17,356/- and the policy is effective from 7.7.2009 to 24.03.2010. Annexure C-3A is the rejection letter dated 14.09.2009, issued by the Safeway TPA Services Pvt. Limited to the Complainant, wherein the date of admission and discharge has been shown to be 18.02.2008 to 21.02.2008, which is prior to the date of issuance of the Policy by the Opposite Parties. The relevant excerpt of the repudiation letter reads as under:-

“………We have been officially appointed as a TPA to administer your Mediclaim Policy of the New India Assurance Co. Ltd. We have received the claim documents for the claim documents for the hospitalization of Dr. Sukhchain Singh Bhullar.

On going through the submitted documents for the hospitalization as mentioned above, our medical team is of the opinion that the claim does not fall under the purview of the policy for the following reasons:-

16/7/09

Complication of Pre Existing Disease. Clause 4.3

Hence we regret to convey, that the claim is not payable…………”

7.          It is evident from the aforesaid repudiation letter (Annexure C-3A) that the insurance claim has been repudiated by the TPA as an representative of the New India Assurance Co. Limited and not as a representative of the Opposite Parties No.1 and 2, as during the tenure of hospitalization, the Complainant was not in any way associated with the Opposite Parties No.1 and 2 or a beneficiary to the insurance policy. Furthermore, the contents of letter dated 14.5.2010 (Annexure C-4) written by the Complainant to the Ombudsman (Insurance) also clear the whole picture. The relevant excerpt of said letter is reproduced hereinbelow:-

“…….It is stated that NIAC has denied my genuine claim of my wife Mrs. Sukhjeet Kaur. She was insured by NIAC vide Pol. No. 350204/70/07/87/ 00000395 period 27.8.07 to 26.8.08 papers attached for your action.

She was operated upon at CMC hospital, Sector 17-C, Chandigarh. Claim amount is approx. 50,000/-.

Please do the needful and oblige………..”

8.          It is clear from the letter reproduced above that the Complainant is aware that the indemnifier for the medi-claim demanded in this complaint is New India Assurance Co. It is also evident that the Complainant is well aware that neither he nor any of his family members were insured with the Opposite Parties No.1 & 2 at the time of hospitalization and the instant complaint against the Opposite Parties is nothing but a futile attempt to get undue advantage where it is not due. It is a frivolous complaint and warrants dismissal only.

9.          We accordingly, dismiss the complaint with no order as to costs.

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

Announced

31^st May, 2013                            

Sd/-

(MADHU MUTNEJA)

PRESIDING MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER