BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 37 of 2011
Date of Institution : 7.2.2011
Date of Decision : 25.5.2016
Yogesh Modi son of Sh.Nem Chand Modi, r/o Bhadra Bazar, Karnanian Street, Sirsa.
….Complainant.
Versus
- The General Manager, Reliance General Insurance Company Office at Delhi-Hisar Road at Hisar.
- Reliance General Insurance Company Ltd., 570-Naigaon, Cross Road, next to Royal Industrial Estate, Wadala (West Mumbai)-400031 through its authorized signatory/person.
- Dipesh Jain s/o Sh.Mohan Lal Jain, Agent of Reliance General Insurance Company Office at Delhi-Hisar Road at Hisar, r/o near Parshu Ram Chowk, Subhash Basti Begu Road, Sirsa.
..…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI S.B.LOHIA…………………PRESIDENT
SHRI RAJIV MEHTA……….……MEMBER.
Present: Sh.Sandeep Kamboj, Advocate for the complainant.
Sh.H.S.Raghav, Advocate for opposite parties no.1&2.
Opposite party no.3 exparte
ORDER
Case of complainant, in brief, is that he purchased a Health Policy no. 2015792825000137 from ops no.1 and 2 through Op no.3 for a sum assured for Hospitalization at Rs.3,00,000/- and Domiciliary expenses at Rs.30,000/- as detailed in the policy in the name of his family members, for a period of one year from 29.9.2009 to 28.9.2010, after completing all the conditions as required. Thereafter, the complainant deposited premium amount against proper receipt issued by the Ops. But, after few months of the purchase of insurance policy, Vanya Modi, d/o complainant suffered from heart problem and she was undergone Heart operation from Fortis Escort Heart Institute/Centre New Delhi and the complainant incurred a sum of Rs.144738/- as medical expenses including fee of doctors, tests etc. As the policy was cashless policy, so the complainant forwarded the medical expenses bills to the Ops directly through E.mail, but the Ops repudiated the claim of the complainant without any reason, despite repeated requests and legal notices sent to them. Hence, the present complaint.
2. Upon notice, opposite parties no.1 and 2 contested the case by
filing reply. It is pleaded that the complainant never made/lodged any claim with them or with their TPA. The cashless facility is an extra facility and is provided if insured lodges the claim for reimbursement of expenditure with supporting documents and if the claim is found admissible as per terms and conditions and exceptions of the policy and payable amount of claim is directly paid to the authorized and approved hospitals. It is further pleaded that as per Exclusion Clause 4.3 of the contract, “during the first year of operation of the insurance cover, expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Myomectomy, Hysterectomy or Menorrhagia or Fibromyoma unless because of malignancy Dilation and Curettage, Hernia, Hydrocele, Congenital Internal disease, fistula in annus, Sinusitis and related disorders are not payable. If these diseases are pre-existing at the time of proposal, they will not be covered even during period of subsequent renewals”. The claim of complainant falls under the said Exclusion Clause as the complainant himself alleged that after few months of the purchase of insurance policy, his daughter suffered from problem of Heart Disease, which is a Congenital Internal Disease occurred during the first year of operation of insurance policy. Thus, there is no deficiency in service on their part.
3. As none appeared on behalf of Op no.3 despite service of notice, thus, he was proceeded against exparte vide order dt. 10.10.2011.
4. In order to make out his case, the complainant has placed on record Ex.PW1/A-his own supporting affidavit; Ex.P1 and Ex.P20-insurance policy Cover note; Ex.P3-OPD record; Ex.P4 and Ex.P5-correspondences between TPA and Medical Director, Escorts Heart Institute & Research Centre, Delhi; Ex.P6 to Ex.P7/A-postal receipts; Ex.P8-legal notice; Ex.P9-to Ex.P11-receipts of payment issued by said hospital; Ex.P12 & ExP14 to Ex.P17 -bill details; Ex.P13-Escort Surgery Procedures-Paediatric slip, whereas opposite parties have placed on record Ex.R1-affidavit of Abhilesh Chander, Asstt. Legal Manager; Ex.R2-policy schedule; Ex.R3 to Ex.R5-correspondences.
5. We have gone through the record of the case carefully and have heard learned counsel for both the parties.
6. Learned counsel for complainant has argued that as the policy purchased by the complainant from opposite parties no.1 and 2 was cashless policy, therefore, the complainant submitted all the documents duly attested by the Medical Officer of the Institution to the opposite parties through e.mail, but, the amount of hospital expenses incurred by him on the treatment of his daughter were not disbursed to the complainant despite repeated requests.
7. On the other hand, learned counsel for opposite parties has argued that the cashless policy is provided if insured lodges the claim for reimbursement of expenditure with supporting documents and if the claim is also found admissible as per terms and conditions and Exclusion Clause of the policy, but the complainant failed to abide by the said terms and conditions of the policy and his case does not fall under Exclusion Clause 4.3 of the policy.
8. After hearing the learned counsel for both the parties and going through the record carefully, we are of the view that there is no dispute between the parties regarding the Health policy. It is admitted fact that the daughter of the complainant suffered heart disease, for which operation was got conducted by the complainant. The point for discussion is that whether the said problem of Heart Disease falls under Exclusion Clause 4.3 of the policy or not? In this regard, we reproduced here the Exclusion Clause 4.3. of the policy which has been mentioned by the opposite parties in their reply:-
“During the first year of operation of the insurance cover, expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Myomectomy, Hysterectomy or Menorrhagia or Fibromyoma unless because of malignancy Dilation and Curettage, Hernia, Hydrocele, Congenital Internal disease, fistula in annus, Sinusitis and related disorders are not payable. If these diseases are pre-existing at the time of proposal, they will not be covered even during period of subsequent renewals”.
9. From the perusal of said Exclusion Clause, it is clear that the daughter of the complainant was not suffering from said diseases rather she was suffering from the problem of heart disease. As per the plea of the opposite parties, the heart disease is a Congenital Internal disease, but the opposite parties have failed to prove that the said heart disease of daughter of the complainant was Congenital Internal disease. There is also no medical certificate of any doctor to prove or to presume that heart problem was from birth. Thus, it is clear that the claim of the complainant does not fall under the Exclusion Clause 4.3 of the contract.
10. Keeping in view the abovesaid discussion, we reached at the conclusion that the complainant is entitled for the said hospital expenses incurred by him for the treatment of his daughter.
11. Resultantly, this complaint is hereby allowed, with a direction to insurance company i.e. to the opposite parties, to pay hospitalization expenses i.e. Rs.1,44,738/- incurred by the complainant, with upto date interest @ 9% per annum, from the date of complaint i.e. 7.2.2011, till payment. The complainant is also hereby allowed compensation of Rs.10,000/- for his harassment, humiliation, mental agony etc. and litigation expenses of Rs.2200/-. Compliance of this order shall be made within 30 days from the date of receipt of copy of this order. File be consigned to record room after due compliance
Announced in open Forum. President,
Dated: District Consumer Disputes
Redressal Forum, Sirsa.
Member.
