Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 18/29.01.2013
Naresh Kumar s/o Sh. Jaswant Singh
R/o 8365, Arya Nagar, Paharganj,
New Delhi-110055 …Complainant
Versus
OP1- National Insurance Company Ltd.
50, Janpath, New Delhi-110001
Regd. Office at: 3, Middleton Street,
Post Pox No. 9229, Kolkata-700071
OP2- M/s Park Mediclaim (through its Director)
702, Vikrant Tower, Rajender Place
Delhi-110008 ...Opposite Parties
Date of filing 29.01.2013
Date of Order: 03.11.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
ORDER [ex-parte]
Inder Jeet Singh , President
1.1 Complainant Sh. Naresh Kumar bought medi-claim policy no. 354502/46 /12 / 8500000623 w.e.f. 07.06.2012 to 06.06.2013, from OP1/National Insurance Co. Ltd. for the covering the complainant Sh. Naresh Kumar himself, Ms. Rani, Ms. Anamika & Manish being members of the family. However, in the month of August 2012, complainant’s daughter Ms. Anamika visited Indraprasth Apollo Hospital having painful swelling in her right leg for treatment, where various tests were performed.
On the advices of doctor she was hospitalized in Indraprasth Apollo Hospital on 20.08.2012 for treatment of painful swelling in the right leg, she was operated on 21.12.2012 and discharge on 25.12.2012 by issuing discharge summary. The complainant incurred an amount of Rs. 1,44,783/- on the medical treatment of his daughter as per prescriptions and bills paid. The complainant lodged claim with original bills and treatment record for reimbursement of Rs. 1,44,783/- but it was flatly refused by the OP, whereas, the OP was liable to pay the amount. Thus, complainant sent and served legal notice dated 10.12.2012, (which was addressed to OP2-Park Medi-claim Consultant TPA Pvt. Limited), which was responded by reply dated 05.01.2013 by OP2. The complainant has been visiting the office of OPs several times but there was no heed to the claim. The complainant had suffered mental pain and agony because of want of reimbursement of valid claim, that is why the complaint for reimbursement of amount of Rs. 1,44,783/-. This is the case as put by the complainant in single page complaint with support of documents, then detailed evidence and written arguments argument were with further plea of interest besides medical treatment expenses of Rs. 40,000/- on lodging food-cum-special diet, compensation of Rs. 50,000/- and also Rs. 50,000/- for pain and mental agony.
1.2 The complaint is accompanied with the documentary record of proof/cards of persons insured being family of complainant, copy of medi-claim policy letter, prescriptions letter dated 02.08.2012 by Dr. Rakesh Mahajan, clinical report conducted at Indraprasth Apollo Hospital, discharges summary dated 25.08.2012, in-patient bills and other cash memos, claim form, the queries responded by the complainant, inadmissibility of claim by OP1 vide letter dated 01.11.2012, legal notice dated 10.12.2012 and its reply dated 05.01.2013 by OP2.
Initially the complaint was filed against M/s Park medi-claim (since OP2), however, the name of National Insurance Co. Ltd (since OP1) was impleaded pursuant to order dated 03.07.2015 on the application of complainant.
2.1 The OP1 does not dispute that complainant was issued the subject medi-claim policy w.e.f. 07.06.2012 to 06.06.2013. The liability of OP1 is subject to terms and conditions of the policy.
However, the complaint is opposed by OP1 vehemently on other plea that there is no cause of action in favour of the complainant for want of deficiency in services. The complainant came without clean hands and the complaint was filed to make unlawful gain. The case needs detailed examination of evidence and cross-examination, therefore, it could be adjudicated by appropriate civil court, the complaint is not maintainable in the Consumer Forum.
When the OP1 had received claim of complainant and scrutinized the papers, it was discovered that patient was hospitalized on 20.08.2012 because of complained of painful swelling in the right leg for many months. She had large area of fibro-vascular malformation involving the dorsum of right foot and entire lower leg. However, the patient was covered under the Baroda Health Policy since 07.06.2012 and policy was commenced just 2 months 13 days prior to her hospitalization. As per condition no. 4.1 the claim is not payable since policy does not cover the expenses on treatment of pre-existing disease and also as per another condition no. 4.3 of the policy, it does not cover internal congenital defects for one year after the inception of the policy. Thus, by considering the record and also applying judicious mind to the claim of complainant, it was repudiated and the complainant was informed by letter dated 05.01.2013, which was received by the complainant. The complainant is not entitled for any claim and complaint is liable to be dismissed.
2.2 There is no reply by the OP2 (i.e. TPA). However, when initially complaint was filed, it was against TPA exclusively, it failed to appear and it was proceeded ex-parte. That is why, before impleadment of the National Insurance Co. Ltd., the complainant had led ex-parte evidence against TPA. But on the eve of impleading the National Insurance Co. Ltd., it was arrayed as OP1 in the memo of parties subsequent to order dated 03.07.2015. There is no reply by the OP2. The matter proceeded further as per procedure laid down.
3. The complainant filed replication/rejoinder to the reply of OP1 and it denies the allegations of written statement of OP1/National Insurance Co. Ltd. by reaffirming the complaint correct. The complainant also denies allegations of pre-existing disease to insured patient. However, the OP1 in its preliminary objections as well as in reply on merits vehemently emphasized conditions of the clause 4.1 (pre-existing disease) and condition no. .3 (exclusions) of the policy but the rejoinder/replication does not respond about exclusion condition no. 4.3 but denial of clause of no.4.1.
4. The complainant Sh. Naresh Kumar led his evidence and it is supplemented with the documentary record filed with the complaint. On the other side, OP1 led evidence by filing affidavit of Sh. A. K. Lal, Deputy Manager of OP1, which is on the pattern of written statement.
5. At the stage of final arguments, the complainant has filed written arguments. Since the parties were not appearing, the Commission felt it appropriate to issue notice to them, the general notices issued were served on the complainant, the OP1 and the OP2, however, none had appeared. The case was also adjourned for arguments, so that the parties may make it convenient and to have opportunity for oral submissions, however, they failed to appear. Therefore, the material on record will be considered.
5.1 (Findings)- The case of complainant and the case of OP1 are considered keeping in view their pleadings, evidence led and the written argument which highlights rival contentions.
The OP1 has an objection that the present case needs detailed examination and cross-examination of witnesses, which could be in the civil court, which was denied by the complainant.
However, this reason is misplaced since not a single fact or other matrix has been suggested which may warrant that adjudication is required by the civil court. Therefore, by considering the material on record, which is sufficient that the dispute may be determined in summary way by the present consumer Forum/Commission, it is held that the present Consumer Commission is competent and has jurisdiction to decide the issues involved. Now it can be further proceeded.
5.2 By taking into account totality of circumstances, the following conclusions are drawn:-
(i) There is no dispute in respect of issue of medi-claim insurance policy no. 354502/46/ 12/8500000623 w.e.f. 07.06.2012 to 06.06.2013 by OP1 in favour of insured persons namely Sh. Naresh Kumar, Ms. Rani, Ms. Anamika & Manish being members of a family. There is also no dispute about the dates of treatment, date of admission and discharge for the ailment of Anamika from Indraprasth Apollo Hospital.
(ii) The dispute is in respect of pre-existing disease. As per discharge summary Ms. Anamika had swelling in right leg for many months and complainant has also proved prescription/consultancy dated 02.08.2012 by Dr. Rakesh Mahajan, therefore, it spells out that Ms. Anamika had pain in her right leg when she went to doctor on 02.08.2012. Subsequently, she had undergone treatment at Apollo Hospital. To say, there is no evidence on behalf of OP1 that this ailment was existing prior to taking the medi-claim policy w.e.f. 07.06.2012. The clause 4.1 does not apply.
(iii) The other dispute is in respect of applicability of the pre-existing clause no.4.1 and exclusion clause 4.3, which was mentioned in OP2’s letter dated 01.11.2012 proved by complainant (but OP2 refers letter dated 5.1.2013, which is factually reply to legal notice).
(iv) The OP1 has specifically narrated policy condition no. 4.3 in the written statement (in preliminary objections and also in reply on merits) as well as in evidence that policy does not cover internal congenital defects for one year after the inception of the policy. Ms. Anamika was examined after 2 months and 13 days after policy w.e.f. 07.06.2012, it is within 1 year from the inception of the policy.
However, the complainant has not replied the preliminary objection nor on merits about exclusion clause no. 4.3 nor he disputes that his daughter was treated after 2 months and 13 days from inception of policy on 07.06.2012, which is within one year period of inception of policy. Thus, exclusion clause of 4.3 is not disputed by the complainant.
(v) The parties are bound by terms and conditions of policy, thus when admitted exclusion clause 4.3 applies to situation of insured Ms.Anamika, it cannot be construed to be deficiency of services.
5.3. In view of above analysis and conclusions, the complaint fails. The complaint is dismissed. No order as to costs.
6. Announced on this 3rd November, 2023 [कार्तिक 12, साका 1945].
7. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances.
[Vyas Muni Rai] [Shahina] [Inder Jeet Singh]
Member Member (Female) President
