Chandigarh

DF-II

CC/422/2015

Sohan Singh - Complainant(s)

Versus

Paramount Health services(TPA) Pvt. Ltd. - Opp.Party(s)

In Person

11 Apr 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II U.T. CHANDIGARH Consumer Complaint No. : 422/2015 Date of Institution : 05.08.2015 Date of Decision : 11/04/2016 Sohan Singh s/o Sh.Gurdev Singh, Manager, Govt. Marketing, Dainik Bhaskar, Plot No.11-12, Sector 25-D, Chandigarh. ... Complainant. Versus 1. Paramount Health Services (TPA) Pvt. Ltd., D-39, Okhla Industrial Area, Phase-I, New Delhi-110020 through its M.D./Director. 2. Oriental Insurance Co. Ltd., 109-110-111, Surindera Building, Sector 17-D, Chandigarh. …. Opposite Parties. BEFORE: SHRI RAJAN DEWAN, PRESIDENT SHRI JASWINDER SINGH SIDHU, MEMBER SMT.PRITI MALHOTRA, MEMBER Argued by:Complainant in person. Sh.Navin Kapur, Advocate for OP No.2. OP No.1 exparte. PER RAJAN DEWAN, PRESIDENT 1. In brief, the case of the complainant is that being an employee of Dainik Bhaskar, he opted for Group Health Insurance Scheme of the Oriental Insurance Co. Ltd.(OP No.2) and the premium for the same was paid by his employer, after deducting the same from his salary, who obtained the insurance cover for its employees. As per mediclaim policy (Annexure C-1) it was for self, parents and parents-in-law and the same was valid from 21.11.2014 to 20.11.2015. It was a family floater policy. Besides the complainant, his family members including his father-Sh.Gurdev Singh and mother –Smt.Bhushan Kaur are also covered and only ID cards were issued. It has been averred that on 10.07.2015, his father complained abdomen pain, multiple episodes of vomiting and loose stools and he was taken to the Govt. Multi-Speciality Hospital, Sector 16, Chandigarh from where he was taken to Max Super Speciality Hospital, Mohali. His father got admitted on 10.07.2015 and discharged on 11.07.2015 and he incurred Rs.24,857.17 P vide receipt (Annexure C-4) on the treatment of his father at Max Hospital. He also gave due intimation to OP No.1 after the illness and admission of his father in the Max Hospital and requested it to provide the cashless benefit for the hospitalization of his father. OP no.1 vide letter dated 10.07.2015 (Annexure C-5) though admitted the receipt of the request for pre-authorization of the above mentioned hospitalization but expressed its inability to sanction cashless benefit and rejected the claim under Exclusion 4.8 (Alcohol related). It has been further averred that it was nowhere stated by the treating doctors that the sudden ailment of Sh.Gurdev Singh diagnosed as acute gastroenteritis was due to intake of alcohol or it was a chronic disease. It has been further averred that the complainant was never made know of such exclusions nor any policy conditions were ever supplied or made known to him. It has been further averred that the claim has been wrongly and illegally rejected by the OPs. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the complainant has filed the instant complaint. 2. Despite due service through registered post, Opposite Party No.1 failed to put in appearance and as a result thereof it was ordered to be proceeded against exparte vide order dated 17.09.2015. 3. In its written statement, OP No.2 while admitting the factual matrix of the case as pleaded that Sh.Gurdev Singh was intimated to have taken to Max Super Speciality Hospital, Mohali for treatment from GMSH, Sector 16, Chandigarh and a request for cashless treatment was received from the said hospital alongwith the medical record. It has been pleaded that the cashless request sent by the hospital on 14.07.2015 was rejected due to ‘issue denial under Exclusion 4.8 (alcohol related) after due application of mind and after seeking opinion from medical expert/doctor. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made. 4. The complainant filed rejoinder to the written reply of Opposite Party No.2 controverting its stand and reiterating his own. 5. We have heard the complainant, in person, learned counsel for OP No.2 and have gone through the documents on record. 6. After going through the rival submissions of the parties and evidence on record, we are of the considered view that the complaint is liable to be accepted for the reasons stated hereinafter. The main defence of OP No.2 is that the claim of the complainant was denied on account of issue denial under Exclusion 4.8 (Alcohol related). 7. However, the complainant has vehemently submitted that the sudden ailment of his father-Sh.Gurdev Singh was diagnosed as Acute Gastroenteritis and it has nowhere been stated in the medical record that it was due to intake of alcohol or it was a chronic disease. We have gone through Annexure R-2 on basis of which the Insurance Company has rejected the claim of the complainant due to issue denial under exclusion 4.8 (Alcohol related). However, we are unable to find that the disease i.e. Acute Gastroenteritis for which the patient was treated at the Max Super Speciality Hospital, Mohali was the result of the alcohol as tried to be projected by the OPs. Moreover, the OPs have failed to adduce on record the affidavit of the treating doctor of the patient (Sh.Gurdev Singh) to prove that the disease for which he was treated was the result of the alcohol. Moreover, the Insurance Company purported to have rejected the claim of the complainant after seeking the medical opinion from medical expert/ doctor but no such opinion has been placed on record to corroborate and substantiate its version. 8. It needs to be mentioned that the insurance is to provide social security to the members of the society and ordinarily, the insurance claims must be honoured by the insurance companies unless there is some case of cheating, fraud or misrepresentation. It is also important to note that insurance is a subject matter of ubberema fide whereby both the parties have to honor their commitment and to come before each other with clean hands. It is also important to mention that the Consumer Protection Act, 1986 is a social security legislation, which is based on the principle of equity, fair play and good conscious. In the present case, Sh.Gurdev Singh suddenly complained of abdomen pain, multiple episodes of vomiting and loose stool and the Insurance company has not been able to place on record any medical record to show that Sh.Gurdev Singh was suffering from any disease prior to taking the insurance policy. The Insurance Company had the total liberty to check the medical condition of the complainant/his family members at the time of granting the policy to him/them. It is, however, unfortunately not on record whether any medical examination of the complainant or his family member had been got done by the Insurance Company. It would have been prudent on the part of the Insurance Company to get the complainant/his family members medically examined prior to the insurance of the policy and in such a case, the simple tests would have indicated the state of health of the complainant/his family members with regard to the disease suffered by them prior to taking the insurance policy. If the medical examination has willingly not been done by the OPs then the insured cannot be made to suffer for the same. It is common knowledge that private insurance companies such as OP No.2 induces the customers to obtain the medical insurance policies on the assurance of granting the same without any delay or prior medical test; an act which is subsequently used against the insured at the time of payment of claims for repudiating the same. In the present case, it is on record that the complainant came to the OPs with clean hands and the OPs have not placed anything on record to prove that the complainant willfully concealed any information about his health or health of his family members from the OPs. There is also nothing on record to prove that the father of the complainant was aware of his illness prior to filling in the proposal form and that he was under any medication or treatment for the same. Thus, we are of the opinion that the Insurance Company has wrongly denied the claim to the complainant. 9. It is settled law that the insurance claims should not be repudiated on merely technical grounds and the aim of the insurance company should be to indemnify the insured unless of course, the claim is due to some misrepresentation, cheating or fraud. In this case, admittedly, the complainant had a genuine problem for which his father was operated upon and he bonafidely got the treatment of his father from the hospital and paid the bills. In this view of the matter, we have no hesitation in concluding that the genuine claim of the complainant has been rejected by the company and he must be indemnified to the extent of the expenses incurred by him on the treatment of his father at the hospital. 10. In view of the above discussion, the present complaint deserves to be allowed and the same is accordingly allowed. The Opposite Parties are directed as under ;- i) To reimburse the claim of Rs.24,857/- incurred by the complainant on the treatment of his father at Max Super Speciality Hospital, Mohali ii) To pay Rs.7,000/- as compensation for mental agony and physical harassment suffered by him at the hands of the OPs. iii) To pay Rs.2,500/- as costs of litigation. This order be complied with by the Opposite Parties, within 45 days from the date of receipt of its certified copy, failing which the amount at Sr.No.(i) and (ii) shall carry interest @9% per annum from the date of this order till actual payment besides payment of litigation costs. 11. Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. Announced 11/04/2016 Sd/- (RAJAN DEWAN) PRESIDENT Sd/- (JASWINDER SINGH SIDHU) MEMBER Sd/- (PRITI MALHOTRA) MEMBER