Haryana

Yamunanagar

CC/476/2012

Varun Datta S/o Vippon Dutta - Complainant(s)

Versus

Oriental Insurance Company Ltd. - Opp.Party(s)

Anita Sharma

14 Dec 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                          Complaint No. 476 of 2012.

                                                                                          Date of institution: 15.05.2012 

                                                                                          Date of decision: 14.12.2016

 

Varun Dutta aged about 22 years son of Shri Vippon Dutta resident of House No.1194, Opposite Panchaiti Gurudwara, Choti Line, Yamuna Nagar.

                            …Complainant.

                                             Versus

1. The Oriental Insurance Company Limited, Branch Office, opposite Hindu Girls College, Jagadhri, District Yamuna Nagar, through its Branch Manager.
2. Vipul Med Corp. TPA Private Limited, SCI No.98, First Floor, Industrial Area, Phase-2, Chandigarh-160002 through its Manager.

                                               

                                                                                                                                    …Respondents

 

BEFORE:         SH. ASHOK KUMAR GARG…………….. PRESIDENT.

                          SH. S.C.SHARMA………………………….MEMBER.

 

Present:           Smt. Anita Sharma, Advocate for complainant.

                         Shri Sushil Garg, Advocate for OP No.1.

                         OP No.2 already ex parte.

 

ORDER

 

1                      The present complaint has been filed under section 12 of the Consumer Protection Act, 1986.

2.                     Brief facts of the present complaint, as alleged by the complainant, are that complainant purchased a Family Health Insurance Medi claim policy bearing No. 261701/48/2011/3014 from the OP No.1 Insurance Company which was valid from 17.01.2011 to 16.01.2012 for a sum of Rs.1,50,000/-. Due to certain disease Ankylosing spondylitis with backache, the complainant was got admitted in Goel Hospital, Sawan Puri, Jagadhri on 10.02.2011 and discharged on 19.02.2011. Doctors of Goel Hospital referred the complainant to Indian Spinal Injuries Centre, New Delhi. Thereafter, the complainant applied to get reimburse of the amount of Rs.11,986/- under the said insurance policy as the complainant remained under treatment in Goel Hospital and Indian Spinal Injuries Centre, New Delhi.  Thereafter, complainant continuously pursued his case and completed all the formalities, but despite all of that, the OPs Insurance Company repudiated the claim of the complainant vide letter dated 08.09.2011 by stating that the disease to the complainant is genetic in origin. Thereafter, in reply to the said finding, the complainant furnished the certificate issued by Dr. Mahavir Goel, Orthopedic Surgeon to the OPs Insurance company wherein the said doctor categorically stated that “the said disease does not transmit by birth but can happen at any stage of life”. But despite all this the OPs flatly refused to accept the claim of the complainant. Hence, this complaint, praying therein that OPs be directed to pay/refund the amount Rs.11986/- to the complainant along with interest and also to pay compensation as well as litigation expenses.

3.                     Upon notice, OP Insurance Company appeared and filed its written statement by taking some preliminary objections such as complaint is not maintainable; there is no negligence or deficiency in service on the part of the OPs Insurance Company; complainant has no cause of action; complainant has no locus standi to file the present complaint; complainant has concealed the true and material facts; this Forum has no jurisdiction to entertain and decide the present complaint; the complainant diagnosed as a case of Ankylosing spondylitis with Backache, the disease is genetic in origin and the claim was not admissible under clause 4.15 of the Medi-claim policy, hence the claim of the complainant was rightly repudiated by the OPs Insurance Company and on merit all the contents of the complainant were controverted and reiterated the stands taken in the preliminary objections.

4.                     Complainant failed to adduce any evidence despite so many opportunities, hence the evidence of the complainant was closed by Court order vide order dated 05.05.2016. However, at the time of filing the complaint, complainant filed his short affidavit and copy of emails Annexure 1, photocopy of OPD Card of Indian Spinal Injury Centre as Annexure 2 and 3, photocopy of OPD Bill of Goel Hospital as Annexure 4, Lab report Thyrocare as Annexure 5, photocopy of OPD slip of Goel Hospital as Annexure 6; application  for lodging the claim on 20.04.2011 with Vipul Medi Corp, TPA Private Limited as Annexure 7; Repudiation letter dated 08.09.2011 as Annexure 8, certificate issued by Dr. Mahavir Goel, Orthopedics  Surgeon as Annexure-9, letter dated 01.02.2012 written by complainant to Vipul Medi  claim, TPA as Annexure 10, photocopy of Insurance Cover note as Annexure 11, photocopy of query letter as Annexure 12, photocopy of another email as Annexure 13, photocopy of lab report as Annexure 14, Reminder/Query  letter issued by TPA as annexure 15, photocopy of Single paper of Indoor File as Annexure 16, photocopy of cash receipt of Indian Spinal Injury Centre as Annexure 17, query letter issued by Vipul Medi claim TPA as Annexure 18, Original pay head ticket of Goel Hospital as Annexure 19.

5.                     On the other hand, ld. counsel for the OP No.1 tendered into evidence affidavit of Shri Abash Toppo, Assistant Manager, Divisional Office, Oriental Insurance Company as Annexure RW/A, photocopy of inquiry letter issued by TPA as Annexure R1, photocopy of reminder issued by TPA as Annexure R2, photocopy of repudiation letter dated 08.9.2011 as Annexure R3, photocopy of rejection letter issued by TPA to the OP No.1 Insurance Company as Annexure R4, photocopy of Insurance policy with its terms and conditions as Annexure R5 and closed the evidence on behalf of OPs.

6.                     We have heard the counsels of both the parties and have gone through the pleadings as well as documents placed on the file very carefully and minutely.

7.                     It is not disputed that complainant obtained a family health Insurance Policy bearing No. 261701/48/2011/3014 valid from 17.01.2011 to 16.01.2012 for a sum of Rs.1,50,000/- from the OP No.1 Insurance Company which is duly evident from the copy of Insurance policy (Annexure R5). It is also not disputed that complainant remained admitted in the Goel Hospital from 10.02.2011 to 19.02.2012 which is duly evident from the copy of Bill dated 06.03.2011 (Annexure 4 and Annexure 6) and Bed Head Ticket of Goel Hospital (Annexure 19). It is also not disputed that Doctor of Goel Hospital Jagadhri referred the complainant to Indian Spinal Injury Centre which is duly evident that from the OPD cards issued by Indian Spinal Injury centre as (Annexure 2 and 3). It is also not disputed that complainant lodged his claim for reimburse of Rs.11,986/-  vide letter dated 20.04.2011 (Annexure 7) with the Vipul medi Crop. TPA Private Limited of the OPs insurance company. The only plea of the complainant is that genuine claim of the complainant has been wrongly repudiated by the OPs on the false and flimsy ground, whereas the complainant was entitled to get the reimbursement of the said amount from the OP No.1 Insurance Company as he was duly insured under the Health Insurance Policy for the said period.

8.                     Learned counsel for the OP No.1 Insurance Company Shri Sushil Garg, Advocate, argued at length that OP No.1 Insurance Company has rightly and legally repudiated the claim of the complainant vide its letter dated 08.09.2011 (Annexure R3) and draw our attention towards the letter issued by the Vipul Medi Crop TPA dated 15.09.2014 (Annexure R4) in which the claim of the complainant was repudiated on the ground that “Insured was suffering Ankylosing spondylitis with HLAB-27 Positive and this disease is genetic in origin. So, the claim was not admissible as per clause 4.15 (Genetic disorder) of the terms and conditions of t he medi claim Insurance policy. Hence, claim of the complainant has been rightly repudiated by OP No.1Insurance Company.

9.                     After hearing both the parties, we are of the considered view that there is deficiency in service on the part of the OP No.1 Insurance Company as at the time of Insurance, a person is got medically examined from the competent medical practitioner authorized by the Insurance Company. If the complainant was suffering from genetic disease then why it has not come into examination of the patient by the medical practitioner of the Insurance Company. There is no explanation, It is not the case of the insurance company that prior to issuance of Insurance policy in question, the complainant was not got examined from the competent medical practitioner authorized by the Insurance Company. In case of 2014 (3) CPJ, Page No.221 (NC), it is held by the National Commission Dispute Redressal Commission, New Delhi that authorized doctor of the insurance company  examined insured, assessed fitness and after complete satisfaction, policy was issued. It cannot be presumed that the deceased was aware of multiple myloma/blood cancer and he concealed previous illness. Repudiation not justified. In another case 2014(3) CPJ, Page No.552 (NC), Hon’ble National Consumer Dispute Redressal Commission, New Delhi held that concerned doctor who allegedly treated and recorded that patient was admitted with history of pulmonary Hypertension for the last 2 years, was not examined by the petitioner to prove Photostat copy of discharge card relied upon by the petitioner nor the affidavit of doctor has been placed on file and Foras below were right in declining to rely upon the photocopy of discharge card produced by petitioner to establish that petitioner while obtaining insurance policy concealed the true facts that he was suffering from Pulmonary Hypertension. Repudiation not justified.

10.                   Similarly is the position of the case in hand. Neither the doctor of the TPA OP No.2 who examined the record of patient has not filed any affidavit nor has been examined to prove the Photostat copy of record of the medical examination. Whereas, on the other hand , the treating doctor, Dr. Mahavir Goel, Orthopedics Surgeon of Goel Hospital, Jagadhri has issued a certificate (Annexure 9) mentioning therein that the disease Ankylosing spondylitis with Backache does not transmit by birth but can happen at any stage of life. Even, as per this certificate also the claim of the complainant has been wrongly repudiated by the OP No.1 Insurance Company.

11.                   Keeping in view the facts and circumstances of the case law referred above and to avoid further litigation, we are of the considered view that claim of the complainant has been wrongly repudiated by the OPs Insurance Company vide letter dated 08.09.2011 (Annexure R3) and the same is hereby set aside.

12.                   Resultantly, this complaint is hereby partly allowed with no order as to cost, with the direction to OP No.1 Insurance Company to pay Rs.11,986/- to the complainant with interest @ 7% per annum from the date of filing the present complaint till realization. Order be complied within a period of 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be supplied to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Pronounced in open court:

Dated: 14.12.2016.                                                                 

                                                (S.C.SHARMA)                        (ASHOK KUMAR GARG)

                                           MEMBER                                PRESIDENT

                                                                                               DCDRF Yamuna Nagar