Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 31
Instituted on : 16.01.2019
Decided on : 09.10.2023
Pushap Kanta@ Kanta Devi w/o Late Sh. Mahabir Parshad Jain R/o Aggarwal Photostate, Dara Bazar, Aggarwal Commercial College, Hansi District Hisar now at H.NO. 183/R, Model Town, Rohtak.
………..Complainant.
Vs.
- PNB Oriental Royal Mediclaim Insurance Policy registered office at Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002 through its Chairman/Director/M.D./Authorized.
- PNB Oriental Royal Mediclaim Insurance Policy, Branch Office at SCO No. 174-175, Red Square Market, Railway Road, Hisar, Haryana-125001 through its Manager/Authorized.
- M/s Raksha Health Insurance, 15/5, Mathura Road, Faridabad-121003 through its Proprietor/Partner/Manager/Authorized.
- Raksha TPA Pvt. Ltd., SCO 359-360, Ist Floor, Sector 44-D, Chandigarh-160047 through its Director/M.D./Authorized. Ph:0172-5008716. …….Opposite parties.
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT,2019.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR.VIJENDER SINGH, MEMBER.
Present: Sh. Pardeep Mittal, Advocate for complainant.
Sh. Puneet Chahal, Advocate for the opposite party No.1&2.
Opposite party no. 3 and 4 already exparte.
ORDER
NAGENDER SINGH KADIAN PRESIDENT:
1. Brief facts of the case are that the complainant had purchased a health insurance policy from opposite party no. 2 vide policy no.261500/48/2017/650 and the same was regularly got renewed by the complainant. She renewed the same on 04.10.2017 vide policy no. 261500/48/2018/749 for which she paid an amount of Rs.3487/- as amount of premium and further insured for a period of one year commencing from 06.10.2017 to 05.10.2018. It is further submitted that on 23.10.2017, the complainant was admitted in Chhotu Ram Hospital, Rohtak for treatment related to Heart and remained admitted there w.e.f. 23.10.2017 to 25.10.2017 and the complainant incurred an expenditure of Rs.11,450/-(Rs.1500/-+ Rs. 850/- + Rs.9100/-) in the aforesaid treatment out of her own pocket. Thereafter the complainant was remained admitted w.e.f.29.10.2017 to 31.10.2017 in Holy Heart Hospital, Rohtak for treatment and incurred an expense of Rs.1,72,730/- as amount of treatment. It is also submitted that complainant duly gave intimation in this regard to the opposite parties and in the month of 2017, the complainant submitted the claim form vide claim number 55651718337536 to the opposite party alongwith all requisite documents upto their satisfaction. On time to time as per the demand of opposite party no.4, the complainant submitted the required documents. But till the filing of the present complaint, the opposite parties did not pass the said claim and prolonged the matter on one pretext or the other. The complainant requested the opposite parties many a times but they did not pay any heed towards the genuine requests of the complainant. Thereafter on 05.09.2018, complainant sent a legal notice to the opposite parties. Then the opposite party no.2 sent reply to the said notice and wrongly repudiated the claim of the complainant on false and baseless ground whereas the opposite party no. 3 in their reply submitted that claim of the complainant is lying under query. It shows that opposite parties incollusion with each other intentionally, deliberately neither pass the claim nor pay the claim amount. As such, there is deficiency on the part of the opposite parties. Hence, the present complaint and it is prayed that opposite party may kindly be directed to pay Rs. 1,84,180/- alongwith interest at the rate of 18% per annum w.e.f. 23.10.2017 till actual realization to the complainant. It is further prayed that opposite parties also be directed to pay Rs.25,000/- as litigation expenses and Rs.51,000/- as compensation to complainant as explained in relief.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties No. 1 and 2 in their reply submitted that complainant intentionally concealed the fact that she was having pre-existing disease “As per treating doctor certificate patient is old case of HTN AND DIABETES and now admitted with complete heart block. This disease is chronic in nature and policy is in its third year of inception. Hence claim recommended to be not-payable as per clause 4.1 (Pre existing disease) which is as under:-
“Any ailment/disease/injuries/health condition which are preexisting (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when cover incepts for the first time, are excluded for such insured person upto 3 years of this policy being in force continuously”.
This exclusion clause will also apply to any complication arising form pre-existing ailments/diseases/injuries. The opposite party repudiated the liability under the above policy on genuine ground and complainant was informed vide letter dated 27.02.2018 under registered AD post to complainant by reproducing the above observations of TPA as well as the exclusion clause 4.1 as under:- “While going through the claim papers submitted by you in support of your claim, observation of TPA vis-à-vis policy terms and conditions, we regard to inform you that your claim is not payable. As such, you are requested to comment that why your claim should not repudiated on the above grounds. Please note that in case we have no response from you within 15 days from the receipt of this letter, we will presume that you are no longer interested in the claim and the file will be repudiated for reasons mentioned above without further advices from us”. It is further submitted that complainant sent an altogether evasive and concocted reply dated 20.03.2018(after expiry of stipulated period of 15 days) to the said letter, whereas on the expiry of the stipulated period of 15 days of the above letter dated 27.02.2018, her claim stood automatically repudiated since long. Hence, the opposite party is not liable to pay any claim. All the other contents of the complaint were stated to be wrong and denied and opposite party No.1 & 2 prayed for dismissal of complaint. Opposite party no. 3 and 4 appeared and submitted their joint reply that the case of the complainant regarding mediclaim policy which the complainant had filed, was issued by the opposite party no. 1 & 2. They registered under the Companies Act 1956 is licensed TPA under IRDA Act 2001 to act as a facilitator for the processing of the claim. The insurance contract is between the insured and the insurer i.e. opposite party no. 1 & 2 by itself or its TPA(opposite party no. 4) is obliged to process the claim as per terms and conditions of the policy. They nominated as the Third Party Administrator for arranging to process the claims of the insurance company as per the terms and conditions laid down by the opposite party no. 1 & 2. The claim stands non payable due to non submission of the necessary document by the insured required to process the claim, as per terms and conditions of the opposite party no. 1 & 2. Thereafter opposite party no. 3 & 4 not appeared. Case called several times since morning but none has appeared on behalf of opposite party no. 3 & 4. As such the opposite party no. 3 & 4 proceeded against exparte vide order dated 13.10.2021 of this Commission.
3. Complainant in her evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C46 and has closed her evidence on dated 14.10.2020. Ld. counsel for the opposite party No. 1 & 2 has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R7 and has closed her evidence on dated 29.04.2022.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case claim of the complainant has been repudiated by the insurance company on the ground that the complainant has pre-existing disease at the time of inception of the policy. They further submitted that the complainant concealed the material facts from the opposite party/insurance company at the time of purchase of policy. So the claim of the complainant has been repudiated by the opposite party as per cause 4.1 of the poicy, which is as under :
Any ailment/disease/injuries/health condition which are preexisting(treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when cover incepts for the first time, are excluded for such insured person upto 3 years of this policy being in force continuously.
It has been further submitted by the respondent that: “As per treating doctor certificate patient is old case of HTN and diabetes and now admitted with complete heart block. This disease is chronic in nature and policy is in its third year of inception. Hence claim recommended to be no payable”. We have minutely perused the documents placed on record by both the parties. After receiving the queries of the respondent insurance company, the complainant submitted the clarification with the respondent company which is Ex.C36. This clarification has been issued by the treating doctor Aditya Batra on 12.2.2218 and it has been specifically mentioned in this certificate that: “The complainant was having HTN and T2DM since 6 months. It is further submitted that the patient has presented before the treating doctor with complete heart block and there is no history of CAD”. During the treatment a pacemaker has been installed by the Holy Heart Hospital. The patient was admitted in the hospital from 29.10.2017 and 31.10.2017. After perusal of clarification we came into the conclusion that complainant have no pre existing disease at the time of purchase of the policy. We have also perused the law cited by ld. counsel for the complainant in (2004) 4 CPJ735 of Hon’ble Delhi State Commission, titled as Life Insurance Corporation of India Ltd. and Ors., Vs. A.K.Kalra whereby Hon’ble State Commission has held that “In modern times almost everyone is prone to a high tension life and, therefore, hypertension and diabetes are not such disease for which a person gets a set treatment to keep them under control that concealment of which may render the contract null and void. These are normal disease”. The claim has been wrongly and illegally repudiated by the insurance company on the false grounds. At the time of arguments it has been submitted by the respondent counsel that the insurance company demanded some documents through Ex.R6 but the same has not been provided by the complainant to the insurance company till date. As per our opinion complainant has placed on record all the required documents before this Commission and also provided the same to the respondent insurance company. As such the repudiation of claim by the opposite party is illegal and amounts to deficiency in service. Hence the complainant is entitled for the claim amount. As per bill Ex.C23 to Ex.C25, complainant has spent an amount of Rs.11450/- on her treatment in Chhotu Ram Hosptial and as per claim form Ex.C37 which is supported with the bills issued by the Holy Heart Hospital Ex.C26 to Ex.C36, she spent Rs.172730/- in Holy Heart Hospital i.e. total Rs.184180/-.
6. In view of the fact and circumstances of the case we hereby allow the compliant and direct the opposite party No.1 & 2 to pay the amount of Rs.184180/-(Rupees One lac eighty four thousand one hundred and eighty only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 16.01.2019 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant. Order shall be complied within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
09.10.2023.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
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Vijender Singh, Member
