Delhi

West Delhi

CC/18/3

NAVEEN MAHAJAN - Complainant(s)

Versus

RAKSHA HEALTH INSURANCE - Opp.Party(s)

12 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-III: WEST

GOVT. OF NCT OF DELHI

C-BLOCK, COMMUNITY CENTRE, PANKHA ROAD, JANAK PURI

NEW DELHI-110058

 

Complaint Case No. 03/2018

 

In the matter of:

 

	Naveen Mahajan son of late Shri Ram Lal,    r/o 2738, Gali No.13,    Ranjit Nagar, New Delhi-110008	.....Complainant
	Versus

Raksha Health Insurance

TPA Pvt. Ltd., Care: Oriental Insurance Co.

through its Manager/ Principal Officer

DO -101, LSC, 1st Floor, H Block, Vikaspuri,

New Delhi-110018                                                                     …………..Opposite party

 

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                      DATE OF DECISION:

04.01.2018 12.10.2022 12.11.2022

 

 

CORAM

Ms. Sonica Mehrotra, President

Ms. Richa Jindal, Member

Mr. Anil Kumar Koushal, Member

Present: Complainant in person.

  

                                                            ORDER

 

 

 

Per: Anil Kumar Koushal, Member

          Succinctly put,  facts leading to filing of the present complaint are as follows:

1.       Complainant states that he was having Individual Mediclaim Policy of OP since 2008  and has been uninterruptedly getting it renewed  year after year.  The last policy NO.212200/48/2016/921 was valid from 27.09.2015 to 26.09.2016 for a total sum assured of Rs.3 lakhs (Rs.1 lakh each for the complainant, his wife and minor son. The said policy was thereafter renewed as Happy Family Floater Mediclaim Policy No.212200/48/2017/1018, valid from 27.09.2016 to 26.09.2017 for a total sum assured of Rs.6 lakhs  for all the persons on payment of premium of Rs.16,325/- paid by complainant to OP.     

2.       Complainant submits that during the tenure of the said policy, his wife  suffered from gynecological endometrial polyp  with abnormal uterine bleeding  and she was admitted in Kailash Nursing Home, 49, South Patel Nagar Market, New Delhi on 20.3.2017 where she underwent emergency Hysteroscopic Polypectomy and was discharged on 21.3.2017. The complainant had also given the intimation to the Opposite party about the said ailment and the OP gave the approval of the same vide their letter dated 20th March, 2017  for the room @ Rs.6000/- per day including Nursing Care & ICU charges @ Rs.12000/- per day. The total bill of the said nursing home came  to be Rs.35,218/- vide Bill No.35175 dated 21.3.2017 in the name of  wife of the complainant Ms. Dimple.  As per complainant, out of the said total expenditure of Rs.35,218/-, the opposite party paid only the meagre sum of Rs.10,900/- and  did not pay the balance amount of  mediclaim bill  of Rs.24,309/- (Rs.Twenty four thousand three hundred and nine only) which the OP  is liable to pay to complainant  along with interest thereon @ 18% per annum.

3.       Complainant contends that vide several letters w.e.f. March, 2017 to July, 2017,  he requested the opposite party to make  payment of  balance amount of R.24,309/- and also sent  reminders to the office of the Opposite party but to no use. The complainant and his wife have suffered mental agony and torture due to the said wrong acts and failures on the part of the Opposite party to  clear the balance payment. The complainant got sent a notice dated 25.9.2017 through his Advocate  and the same has been served upon the OP. By virtue of the said notice, the complainant required the Opposite party to make the payment of the balance medical amount of Rs.24,309/- along with interest thereon @ 18% per annum till the date of realisation of the said amount within 15 days from the date of receipt of this notice. However, the OP  neither replied nor complied with the terms of the said notice. Complainant accordingly was forced to file the present complaint and due to harassment, mental agony, tension as well as deficiency of service on the part of the officials of the opposite party claims a sum of Rs.50,000/- as damages/compensation in addition to the payment of  the balance amount of Rs.24,309/-  as aforementioned, total amounting to Rs. 74,309/- with interest.

          By way of the present complaint, the following prayers are made:

1. OP be directed/ordered to pay the amount of Rs. 24,309/- (Rs. twenty four thousand three hundred and nine only) along with interest thereon to the complainant @ 18% p.a. till the date of realisation of the said amount.
2. To award Damages/compensation  of Rs.50,000/-
3. Costs of the proceedings throughout may also be granted to the complainant.

4. Complainant filed along with the complaint, copies of  mediclaim insurance policy of Oriental Insurance Co.Ltd., copy of letter dated 20.03.2017 written by the complainant to TPA/OP for approving the mediclaim, copy of letter dated 20.03.2017 issued by the TPA/OP to the Kailash Nursing Home where the wife of complainant was admitted, stating that  though the cashless hospitalization is denied in terms of instructions as notified  on the website of OP but the treatment is not denied and the Hospital concerned can raise the claim  for reimbursement inclusive of room rent @Rs.6000/- per day copy of letter dated 22.5.2017 written by the complainant to Insurer/OP for approving balance amount of Rs.24,309/- towards mediclaim, , copy of  receipt dated 21.3.2017 issued by the Kailash Nursing Home to complainant in the sum of Rs.35,218/- towards the treatment of his wife Mrs. Dimple along with the treatment details and  copy of discharge summary report, copy of claim form submitted by the complainant to Insureer/OP, copy of letter dated 24.07.2017 written by the complainant to TPA/OP to reconsider the mediclaim amount in respect of treatment of his wife, copy of legal notice dated 25.09.2017 sent by the complainant’s counsel to OP and Oriental Insurance Co. Ltd.
5. Upon admission of the complaint on 6^th March, 2018, notice was issued to OP. A joint reply  was filed by the TPA and the Insurer/OP.
6. OP submitted that the  complainant has not approached this Commission with clean hands and has suppressed the true and material facts from the  scrutiny of this Commission and as such, is not entitled for any relief and accordingly, the present complaint  is not maintainable and  liable to be dismissed with costs.
7. It is submitted by the OP that the present complaint is not maintainable as the opposite party has already awarded entitled claim for a sum of Rs.10,900/- to the complainant/beneficiary in terms of the policy. The beneficiary was admitted as a case of Endometrial Polyp with abnormal Uterine bleeding and underwent Hysteroscopic Polypectomy. According to the terms of the policy clause 9(iv) & 4.3, the treatment for Hysterectomy, for the extended sum insured is covered after continuous coverage of two years policy. The complainant was holding a policy since 2008-2009 to 2009-2016 for three members wherein sum insured for each member was Rs.1,00,000/- respectively. However in the financial year 2016-2017, the complainant had opted Happy Family Floater Policy wherein the sum insured was Rs 6,00,000/-. Since the treatment for Hysterectomy is covered only after continuous coverage of two years policy. Therefore the beneficiary was entitled to the benefits of the previous policy wherein sum insured was Rs.1,00,000/- for each member. Hence the sum insured applicable is Rs.1,00,000/-. The complainant/beneficiary was entitled for Rs.1000/- as room rent per day being 1% of sum insured of Rs.1,00,000/-. The other entitlement benefits would be applicable according to Room rent entitlement. The opposite party has already provided such benefits to the complainant.
8. According to OP,  the complainant has no cause of action to file and maintain the present complaint against the answering OP  and therefore, the present complaint is liable to be rejected. There is no deficiency in service on the part of the OPs in providing the service to the complainant and as such, the present complaint is not maintainable and the same is liable to be dismissed with costs.
9. OP admitted that Happy Family Floater Mediclaim policy bearing no. 212200/48/2017/1018, for a period from 27/09/2016 to 26/09/2017 was issued to the complainant subject to certain terms and conditions. Before that the complainant was holding an Individual policy since 2008-2009 to 2009-2016 for three members wherein sum insured for each member was Rs.100,000/- respectively. The room rent of Rs.6000/- an mentioned in the approval letter was typographical error whereas it was Rs.1,000/- per day based on 1% of the sum insured of Rs.1,00,000/-. The OP has  already provided such entitlement benefits according to the terms of the policy to the complainant.
10. OP denied that it is liable to pay the balance mediclaim bill amount of             Rs.24,309/- or any interest on such amount.  The other entitlement benefits would be applicable according to Room rent entitlement. Hence the deductions were made in order proportionately on every charges as per room rent entitlement except medication charges. Accordingly the OPs have paid Rs.1000/- as room rent out of Rs.4000/-,       Rs.375 was paid as Doctor fee/charges out of 1500/-, Rs 1250/- was paid as Anaesthesia charges out of Rs.5000/-, Rs.3750/- was paid as Surgeon fees out of    Rs.15000/-. Rs 2214/- was fully paid as medication charges, Rs.1250/- was paid as Operation Theatre charges out of Rs.5000/-, Rs 470/- was paid as Consumables charges out of 1004/- and Rs. 600/- fully paid as Hospital. The lab charges were not paid as Histopathology report was not attached. Hence the opposite parties have paid Rs 10,900/- according to room rent entitlement out of Rs 35,218/-.
11. OPs denied having received the legal notice from the complainant as alleged. Therefore, there is no question of reply to the same. Therefore, the complainant is not entitled to any relief from this Commission and the present complaint  being false, frivolous and not maintainable, is liable to be dismissed with costs.
12. OP enclosed with  its reply, copies of insurance policies issued to the complainant from time to time with terms and conditions of the present Happty Family Floater Policy, 2015.
13. After going through the contentions raised in the written statement, the complainant preferred filing a replication to the reply of OPs and denied the averments made therein. Complainant  denied that the opposite party has already provided entitled claim for a sum of Rs.10,900/- to the complainant/beneficiary in terms of the policy. The allegations of the opposite party regarding treatment and terms of the alleged policy etc. are false and fabricated. The insurance policy of the complainant and his family members are matter of record. The complainant’s wife  suffered from the said ailment during the policy period and the total bill of the said nursing home came  to be Rs.35,218/-. Out of the said total expenditure of Rs.35,218/- the opposite party paid only the meagre payment of Rs.10,900/- and they did not pay the balance amount and  are liable to pay the balance mediclaim bill amount of Rs.24,309/- along with interest thereon @ 18% per annum to the complainant. Complainant contended that many a time he requested the opposite party to make the payment of the balance amount and also sent  reminders to the office of the Opposite party but to no use.  It is false and misleading on the part of the OP  that since the treatment for Hysterectomy is covered only after continuous period of two years, therefore the beneficiary was entitled to the benefits of mediclaim under the previous policy wherein the sum insured was Rs.1,00,000/- for each member. It is further wrong and denied that the sum insured applicable is Rs.1,00,000/ and it is further wrong and denied that the complainant/ beneficiary was entitled for Rs.1000/- as room rent per day.  It is submitted that the approval was given by the opposite party for the said treatment including room charges and only after  that, the claimant went under treatment and he is entitled to the amounts claimed in the complaint. The opposite party is trying to twist the real facts.
14. Complainant submits that he has legal and valid cause of action to maintain the present complaint  against the OPs.  The complaint is bonafide, correct and the complainant has claimed the genuine reliefs and  entitled to the reliefs prayed.
15. Complainant submitted that there is clear deficiency of service on the part of the OPs in providing service to the complainant. Complainant denied that the room rent of Rs.6000/- as mentioned in the approval letter was typographical error. Complainant further  denied that the opposite party has already provided such entitlement benefits according to the terms of the policy to the complainant. It is stated by the complainant that in no hospital, the room is provided @ Rs.1000/- per day. The approval was given by the opposite party and the total bill has been mentioned, out of which  meagre amount has been paid by the opposite party which is highly insufficient and the complainant is entitled to the actual expenditure amount incurred on the treatment of his wife as explained in the complaint.  It is further denied by the complainant that the other entitlement benefits would be applicable according to Room Rent entitlement approved by OP. The alleged payment of Rs. 10,900/- is highly insufficient and is not as per the entitlement of the claimant. It is submitted that the complainant is entitled to the reliefs prayed.
16. Evidence by way of evidence was filed by the complainant and he exhibited the documents as Ex. C.W.1/A to C.W.1/K.  The OP  also filed evidence by way of affidavit and exhibited the documents filed on record as Ex. OP.2/1 to 2/3.
17. Written arguments were also filed by the parties.  Oral arguments were heard on 12^th October, 2022 when only the complainant advanced his arguments. There was no appearance on behalf of OP.  The orders were reserved.  Accordingly, based on the written documents submitted by both the parties and the oral arguments advanced by the complainant, we proceed to decide the complaint in terms of Section 38(2)(C) of the CP Act, 2019.
18. The contention of the OP was  that it was a case of Endometrial Polyp with abnormal Uterine bleeding and  the wife of complainant underwent Hysteroscopic Polypectomy.  Further in terms of clauses 9.iv and 4.3 of the Happy Family Floater Policy taken by the complainant, full claim could not be given till two years of  completion of the present policy and accordingly the claim of the complainant was settled as per the earlier  individual mediclaim policy taken by the complainant and his family. 
19. Endometrial Polyp is usually a  non-cancerous  growth attached to the inner wall of the womb(Uterus) of a woman.  Endometrial polyps  are common in woman who are undergoing or have completed  menopause.  As per common knowledge there are 1 million cases per year in India.  Hysteroscopic Polypectomy  is a surgical procedure in which the uterine polyps are removed.  These are the non-cancerous overgrowth of cells in the lining or the inner wall of the uterus. It is a routine procedure that not only is used for elimination of polyps and its symptoms but is also a test for cancer.  The idea to interpret the above disease is just to  bring to the fore the fact that this is a common ailment being suffered by womenfolk, due to  hormonal changes in the body as they grow old. It can occur at any stage/age after menopause. Hysteroscopic Polypectomy is not Hysterectomy which is removal of uterus but is a minimally invasive procedure to detect/diagnose/treat dysfunctional bleeding polyps etc. in uterus and removal of polyps.  It cannot be termed as a pre-existing disease of which before hand knowledge can be drawn.  If we go by the interpretation of OP, it appears to be a pre-existing disease and therefore, full treatment charges including room rent are admissible only after taking  the policy continuously for two years.   Complainant in the complaint clearly mentioned that the ailment was contracted by  his wife only after taking the existing policy and the same was not known to him earlier.  Therefore, there was no ground to deny the claim as per the  approval letter dated 20 March, 2017.
20. It is nowhere the case of the OP that the disease contracted by the wife of complainant was pre-existing.  This fact is apparent from the present policy papers submitted on record by the OP and the complainant.  In the column “pre-existing disease” it is  left blank  just to show that there was no existing disease.  Further there is no mention in the new policy of any claim ever been taken by the complainant towards mediclaim in the past.  
21. In the case of Hari Om Agarwal vs. Oriental Insurance Co. Ltd, decided by the Hon’ble High Court of Delhi on 17.09.2007 in which, relying on the judgment of the Apex Court in the case of Life Insurance Corporation of India vs. Consumer Education and Research Centre, 1995(4) SCC 482,  it was observed that  actions of the State, its instrumentalities and public authorities or of persons whose actions bear insignia of public law element or public character are amenable to judicial review  and that legality of such actions would be tested upon the anvil of Article 14.  Fairness and non-arbitrariness are considered as two immutable pillars supporting the equality principle, an unshakable threshold of state and public behaviour.  Every action, policy or even change of policy in the realm of State activity should be informed, fair and non-arbitrary. Further the exclusion clause  in the context of a contract of insurance, which is an assurance whose main purpose has to be given prominence, should be construed strictly.  The primacy given to the “main purpose” notwithstanding that contracting parties agreed to certain exclusions, is founded on the principle of interpretation that if contracting parties seek to achieve  a certain purpose by entering into an agreement, the existence of exclusion clauses should be strictly interpreted and if it tends to defeat the main purpose, should be read down by the Court and if that is not possible, the Court should altogether ignore it.
22.   We may observe that the object of the insurance policy  is to cater to medical expenses incurred by the insured.  That is the “main purpose” of the contract of insurance. If the insurer accepted the proposal  and issued the insurance cover, what for the said cover  would be if such  clauses  which permit taking treatment only after two years of issue of  the policy, are allowed to impede.  Giving textual effect to such  clauses  would in most cases render the mediclaim cover meaningless; the policy would be reduced to a contract with no content in the event of happening of a contingency.  Such clauses cannot be allowed to override the insurer’s primary liability to indemnify the insured.  If we go by the proposition of the OP, the insured, on detection of any sudden illness would be compelled to continue to suffer the pain  and pend taking the treatment for the ailment till such time the clauses of the policy are complied with.  As noted above, there  was not even a whispher of such ailment having been contracted by the complainant’s wife at the time of taking the policy.  No where in the discharge summary issued by the Nursing home, the pre-existence of such an ailment finds mention. Had the complainant been aware of such ailment, he would have accordingly taken the mediclaim policy as suited to his requirement.
23. In Manmohan Nanda vs. United India Assurance Company Limited, (Civil Appeal No8386/2015), decided on 6^th December, 2021, the Hon’ble Supreme Court on the question of disclosure and non-disclosure of the pre-existing disease at the time of taking the mediclaim policy and after going through the law laid down on the said question,  held as under:

“The object of seeking a mediclaim policy is to seek indemnification  in respect of a sudden illness or sickness which is not expected or imminent and which may occur overseas.  If the insured suffers sickness or ailment which is not expressly excluded  under  the policy, a duty is cast on the insurer to indemnify the insured for the expenses incurred thereunder”

24. The upshot of the above analysis is that  in the present case the ailment which was contracted by wife of the complainant  was also not known to her at the time of taking the policy.  The OP by taking a myopic view and misinterpreting the disease and treatment of Hysteroscopic Polypectomy for Hysterectomy, had  restricted the claim  filed by the complainant. The OP is wrong in claiming that  the letter dated 20.03.2017 issued by it  while approving the room rent of Rs.6000/- per day  was due to typographical mistake. It was  rather  an afterthough to deny the legitimate claim. Therefore, clauses 4.3 and 9.iv of the Happy Family Floater  Policy  taken by the complainant are held to be arbitrary, one sided  and not applicable to the facts of the case.  Accordingly, the complaint is allowed and the OP is directed to pay to the complainant the remaining amount of Rs.24,309/-  along with interest @ 6% p.a. from the date of filing of the complaint till realization. For the harassment and mental agony faced by the complainant while dealing with the OP in getting his claim approved and being forced to file the present complaint, the OP is directed  to pay a sum of Rs.10,000/- as compensation.  Let this order be complied with within 30 days of receipt of copy of this order.

A copy of this order shall be supplied to parties to the dispute free of cost on a written requisition being made in the name of President of the Commission in terms of Regulation 21 of the CPR, 2020.

     File be consigned to record room.

 

(Richa Jindal)                    (Anil Kumar Koushal)                 (Sonica Mehrotra)

Member                                          Member                               President