DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No. 243/2011
Sh. Amarjeet Singh
A-1/68, Sec-3, Rohini,
Opp. Jaipur Golden Hospital,
New Delhi-110085 ….Complainant
Versus
1. Oriental Insurance Company Ltd.
Through its Manager
Jeevan Bharti Building, 9th Floor, Tower-1,
Cannaught Place, New Delhi-110001
2. M/s MD India Heath Care Services (TPA) Pvt. Ltd.
Plot No.18/13, WEA Ground Floor, Ganga Plaza,
Pusa Lane, Karol Bagh,
New Delhi-11004 ….Opposite Parties
Date of Institution : 14.07.2011 Date of Order : 29.01.2018
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
Briefly stated, the case of the complainant is that the complainant had taken a mediclaim policy No. 215502/48/2011/2219, namely, Happy Family Floater Policy from OP No.1. The said policy was valid from 14.06.2010 to 13.06.2011 and the complainant had paid Rs.6508/- towards the policy and the complainant’s wife was also covered in that policy. It is submitted that the complainant was regularly getting his health checkup and was fit and healthy. On 14.09.10 the complainant felt some pain in his chest and visited the Max Hospital for check up. After checkup he was admitted as a precautionary measure for proper checkup. He was admitted on 15.09.10 in the said hospital and was discharged on 23.09.10. Thereafter, the complainant applied for the claim of the expenses under the mediclaim policy and submitted all the documents with the OP. Since then, the complainant had regressly followed his case but till date the claim has not been settled. On being aggrieved and unsatisfied with the reply and conduct of the OPs, the complainant has filed this complaint. It is pleaded that due to negligent, unethical, unfair and unprofessional attitude OPs are not only guilty of deficiency in service but have caused substantial financial loss to the complainant besides causing mental harassment and agony and discomfort in his life and family. The complainant has prayed as follows:-
- Direct the OPs to reimburse the medical bill of Rs.161818.36p with interest @ 18% till the making of the payment,
- Direct the OPs to pay Rs.1 lac to the complainant towards mental agony and harassment,
- Direct the OPs to pay Rs.25,000/- to the complainant towards litigation and miscellaneous expenses.
OP No.1 in its reply has inter-alia stated that the complainant submitted the papers relating to the alleged medical treatment. The claim of the complainant was duly processed by the TPA of the OP No.1 i.e. OP No.2 who after scrutinizing the claim documents submitted by the complainant repudiated the claim of the complainant vide claim rejection/repudiation statement dated 13.04.11 on the following observations:-
“1. Policy coverage for Sh. Amarjeet Singh is for 1 year/s.
2. Current illness Coronary Artery Disease + Hypertension + diabetes Mellitus is since 20 yrs as per Doctor Consultation.
3. As per discharge summary patient is hospitalized for Coronary Artery Disease + Hypertension + diabetes Mellitus, as Htn – 15-20 Yrs & Dm- 7-8 yrs and as IC adr reply policy is in the 1st year so disease is pre-existing to the policy inception; hence claim is repudiated under clause 4.1.
4. As per Policy terms and conditions, claim is not payable under clause no.4.1.”
It is submitted that there is no deficiency in service on the part of OP No.1 in processing the claim of the complainant. It is prayed that the complaint be dismissed.
OP No.2 has been proceeded exparte vide order dated 04.10.12 passed by our predecessors.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. Rajender Kumar, DM has been filed in evidence on behalf of the OP No.1.
Written arguments have been filed on behalf of the parties.
We have heard the arguments on behalf of the complainant. None appeared on behalf of the OP No.1 to advance oral arguments despite opportunity given in this behalf.
Admittedly, the complainant has taken a mediclaim policy No.215502/48/2011/2219, namely, Happy Family Floater Scheme from OP No.1 which was valid from 14.06.2011 to 13.06.2011 and the complainant was admitted in the Max Hospital from 19.09.10 to 23.09.10. The complainant submitted all the papers with the OP for passing his claim. The OP vide letter dated 12.04.11 which is Annexure OP1/1 repudiated the claim on the above reproduced grounds.
The complainant has filed the discharge summary dated 23.09.10 which proves that the complainant was admitted in the hospital on 14.09.10 and discharged on 23.09.10 and the complainant himself had informed the treating doctors that he had a past history of Angina on exertion for 2-3 months and he was taking tab. Amlovas, Tab. Telma H. and had past history of hypertension and Type II diabetes mellitus. He had undergone CABG (Coronary Artery Byepass Graft Surgery) for 4 arteries. We mark the copy of discharge summary as Mark A for the purposes of identification. The complainant has also filed a certificate dated 01.11.10 issued by the Max Hospital wherein it is stated that “This is to certify that Mr Amarjeet Singh, 56 years old male is Hypertensive for 15-20 years and also a known case of insulin dependent Diabetes for 7- 8 years as per the record of the hospital.” We mark the copy of the certificate as Mark B for the purposes of identification.
It is evident from the discharge summary and above documents that the complainant was having hypertension for last 15-20 years and diabetes from 7-8 years and was taking medicines. Therefore, the OP was perfectly justified in repudiating the claim of the complainant as per exclusion clause 4.1 of the terms and conditions of the policy which inter-alia exempts the OP No.1 Co. from making any payment whatsoever incurred by an insured person in connection with or in respect of Diabetes & Hypertension/ Coronary Artery disease upto 4 years in case the disease is pre-existing.
The complainant has not given the details of treatment received by him at Max Hospital in his complaint and has made an unsuccessful attempt to mislead this Forum. He has not even filed the replication to the reply of OP No.1.
In view of the above discussion, we hold that the complainant has failed to prove any deficiency in service on the part of the OPs. Accordingly, we dismiss the complaint with no order as to costs.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 29.01.18.
