CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
ISBT KASHMERE GATE DELHI
CC/38/2017
Sh. Jairam
S/o Late Sh. Ratan Singh,
R/o Vilage Dallupura, Harijan Basti,
Near Navdit Public School, Delhi. …..COMPLAINANT
VERSUS
Park MediclaimTPA Pvt. Ltd.
702, Vikrant Tower, Rajendra Place,
New Delhi-110008.
National Insurance Company Pvt. Ltd.
Through its Branch Manager,
101-106, 1st Floor, N-1, BMC House,
Connaught Place, New Delhi-110001. …..OPPOSITE PARTIES
Coram : Ms. Rekha Rani, President
Ms. Manju Bala Sharma, Member
Dr. R.C. Meena, Member
ORDER
Ms. Rekha Rani, President
Instant complaint was filed by Sh. Jairam (in short complainant) under Section 12 of the Consumer Protection Act, 1986 as amended inter-alia pleading therein that wife of the complainant namely Mrs. Rajesh was medi-claim/policy holder of Park Mediclaim TPA Pvt. Ltd. vide policy no. 39040148168500001198, TPA Card No. 071615668. Wife of the complainant was admitted in Rajiv Gandhi Cancer Institute & Research Centre on 14.06.2016 and was discharged on 03.09.2016. The hospital raised a total bill of Rs. 3,79,071/- on her treatment.
As condition of his wife was not stable, the complainant was busy looking after her and could not inform insurer about the refusal of the hospital to honor the health policy. Wife of the complainant expired on 17.09.2016. Thereafter complainant approached insurer for reimbursement of the bill amount and submitted requisite documents. Insurer did not release the amount. Complainant sent legal notice dated 12.01.2017 to insurer. Insurer neither complied with the notice nor replied to the same. Hence instant complaint was filed seeking direction to insurer to reimburse to the complainant hospital bill of Rs.3,79,017/-, Rs.1,00,000/- as compensation for causing mental agony and Rs.11,000/- as litigation expenses.
On application of complainant, National Insurance Company Limited was impleaded as a party vide order dated 29.03.2017. On receipt of notice, National Insurance Company Limited (in short OP2) appeared and contested the claim vide its reply. OP2 in its reply has pleaded that complainant is guilty of violating the terms and conditions of the policy, that he failed to submit the claim documents within 15 days after discharge from the hospital and that he failed to inform TPA and the insurer 3 days before hospitalization and also failed to give any justification for violation of terms and conditions of the insurance policy and that even in his legal notice dated 12.01.2017complainant admitted that he failed to inform OP for about 3 months. Further it is pleaded that TPA issued a letter dated 15.07.2016 clearly informing the complainant that in case of happening of an event, which may give rise to a claim under the policy, notice of the claim be sent within 7 days from the date of hospitalization. It is also stated that complainant concealed pre-existing disease of his wife at the time of taking of policy, which is clear from discharge summary of the deceased wife of the complainant. It is pleaded that wife of the complainant was diagnosed suffering from Carcinoma Gall Bladder in 2015 i.e. before the policy period.
Parties filed evidence by way of affidavits. We have heard Sh. B.P. Singh, counsel for complainant and Sh. Jitender Mehta, counsel for OP2.
Complainant has not disputed that there was delay in submission of his claim to insurer. Claim is primarily repudiated on the ground that there is concealment of pre-existing disease and that the policy was taken with this concealment and true facts were not disclosed by the complainant. It is pleaded in Para 8, Page 13 of the reply of OP2 that:
“Mrs. Rajesh was hospitalized from 14/06/2016 to 15/06/2016. She was hospitalized with diagnosis Carcinoma Gall Bladder incidentally detected in the year 2015. She was again hospitalized from 26/07/2016 to 27/07/2016, 19/08/2016 to 22/08/2016, 05/07/2016 to 07/07/2016 and 01/09/2016 to 03/09/2016. She underwent Chemotherapy Sessions. As per the available information, the patient is covered under Baroda Health Policy since 13/06/2016 only. Baroda Health Policy does not cover the expenses incurred on treatment of all diseases which are pre-existing (the insured was detected to have carcinoma Breast in the year 2015) when the cover incepts for the first time vide exclusion clause 4.1 and hospitalization within first 30 days vide exclusion clause 4.2
Exclusions Clause claim 4.1:All diseases/injuries, which are pre-existing when the cover incepts for the first time. This exclusion will be deleted after three consecutive continuous claims policy years in respect of all diseases, provided there was no hospitalization for pre-existing ailment during such three years of insurance. For this purpose policy/policies issued by other insurance companies for last three continuous consecutive years will be considered, provided there was no hospitalization for pre-existing ailment during such three years of insurance.)
Exclusions Clause claim 4.2: Any hospitalization expenses incurred in the first 30 days from the commencement of insurance cover except in case of injury arising out of accident.
Hence, the claim file is being closed as “No Claim.”
Reference may be made to the copy of discharge summary issued by Rajiv Gandhi Cancer Institute & Research Centre dated 03.09.2016. Under the head brief summary of the case it is written:
“Mrs. Rajesh, 44 yrs. Old female, came as incidentally detected Carcinoma GB in 2015. She underwent Lap Cholecystectomy on 07.05.15 HPE: carcinoma: GB (Adenocarcinoma).”
Instant policy was effective for the period 13.06.2016 to 12.06.2017. Apart from there being delay in submission of claim documents to the insurer by the complainant, the claim is not maintainable as per terms and conditions of the policy. OP2 has clearly pleaded in Para 8, Page 13 of its reply that complainant’s wife was detected with Carcinoma Gall Bladder in 2015. Complaint has not disputed the same that his wife was detected with Carcinoma Gall Bladder in 2015. He was directed to file rejoinder but he stated on 08.02.2018 that he did not want to file rejoinder. Complainant has not disputed either in his complaint or by filing rejoinder that his wife was detected with Carcinoma Gall Bladder in 2015. So, allegations made by OP2 in Para 8, Page 13 as reproduced above wherein it is pleaded that wife of complainant was diagnosed as suffering from Carcinoma Gall Bladder in 2015 stand unrebutted. The treatment was taken in 2016 and as such the claim is barred under exclusion clause 4.1 of the policy.
The complainant is dismissed. Copy of this order be sent to the parties as statutorily required. File be consigned to record room.
Announced this day of 2019.
(REKHA RANI) (MANJU BALA SHARMA) (R.C. MEENA)
PRESIDENT MEMBER MEMBER
