DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

1.                 Ravinder Kumar Rehani s/o Jai Dayal Rehani r/o H.No.1331, Sector 37B, Chandigarh 160036.

2.                 Hitesh Rehani w/o Ravinder Kumar Rehani r/o H.No.1331, Sector 37B, Chandigarh 160036.

                                  --- Complainants.

Versus

1.                 Reliance General Insurance Company, 570, Naigaum Cross Road, Next to Royal Industries Estate, Wadala (W), Mumbai-400031 through its Chairman/Director/Authorised Signatory

2.                 Reliance General Insurance Company Ltd., SCO 145-146, Top Floor, Above VLCC, Sector 9-C, Chandigarh through its Manager/Authorised Signatory.

3.                 Medi Assist India Pvt. Ltd., 3^rd Floor, No.49, First Main Road, Sarakki Industrial Layout, JP Nagar Third Stage, Bangalore 560078 through its Manager/Authorised Signatory

---Opposite Parties.

BEFORE:  SHRI LAKSHMAN SHARMA                 PRESIDENT

                   SMT. MADHU MUTNEJA                       MEMBER

                   SHRI JASWINDER SINGH SIDHU       MEMBER

Argued by: Sh. Munish Goel, Adv. for the complainants

                        Ms. Jaimini Tiwari, Proxy counsel for Sh. Rajneesh Malhotra, Adv. for OPs No.1 & 2.

                        OP No.3 already exparte

PER LAKSHMAN SHARMA, PRESIDENT

1.                           Sh. Ravinder Kumar Rehani & another have filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the Act only) praying for the following relief :-

i)                   to pay Rs.50,150/- as expenditure on treatment at Fortis Hospital alongwith interest @ 18%

ii)                to pay Rs.30,000/- for causing mental tension, harassment etc.

iii)              to pay Rs.5,500/- as costs of litigation.

2.                           In brief, the case of the complainants is that complainant No.1 purchased a Reliance Healthy Family Insurance Policy PNB Arogya Shree from the opposite parties for the period 1.1.2008 to 31.12.2008 for the sum insured of Rs.3,00,000/-.  Complainant No.2 was also covered under the policy.  According to the complainants, pre-existing diseases are also covered under the policy from the 3^rd year onwards or after two continuous renewals.  According, to the complainant, the policy was renewed for the period 1.1.2009 to 31.12.2009, from 5.1.2010 to 4.1.2011 and also from 5.1.2011 to 4.1.2012, by paying the premiums due.  It has been averred that it is duly mentioned in the policy that “insured person/s is/are entitled to continuity benefits with PNB Arogya Shree Policy No.2004392830100001”

                   According to the complainants, in the month of July 2010, complainant No.2, went to USA and during sight seeing she felt some pain in knees. On return, she consulted a doctor at the Govt. Medical College & Hospital, Chandigarh on 18.10.2010. Thereafter, she felt more discomfort during walking and, therefore, she got herself checked at the Fortis Hospital on 14.2.2011 where she was advised knee replacement.  She got herself admitted in the Fortis Hospital on 28.2.2011, she was operated upon on 1.3.2011 and was discharged from the hospital on 7.3.2011.  The Fortis Hospital charged total amount of Rs.2,06,125/- for the treatment given to complainant No.2.  Upon lodging of claim, E-Meditek Solutions Ltd. approved and paid Rs.1,70,000/- and the balance of Rs.30,625/- was paid by the complainant No.1 from his own pocket on 7.3.2011.  He also paid Rs.5,500/- in advance for the said treatment and Rs.475/- as consultation to the Fortis Hospital on 14.2.2011.  In addition, he also spent Rs.9,487.16 for the purchase of medicines, physiotherapy and various tests as advised at the time of discharge.  He thereafter lodged a claim of Rs.46,887/- on 5.4.2011 which was duly registered by Opposite Party No.3. He also lodged a claim for Rs.3,263/- for post hospitalization on 9.6.2011.  However, the claim of the complainant was repudiated vide letters dated 30.6.2011 and 25.7.2011 on the ground that the problem suffered by the complainant was pre-existing.  According to the complainants the repudiation of the claim was illegal and against the terms and conditions of the policy.

                   In these circumstances the present complaint has been filed.

3.                           Opposite parties No.2 & 3 appeared through counsel and took many dates for filing reply and evidence but they failed to do so.  Hence, vide order dated 7.8.2012, their defence was struck off.

4.                           None appeared on behalf of Opposite Party No.3 despite due service, hence it was proceeded against exparte. 

5.                           We have heard the learned counsel for the contesting parties and have gone through the documents on record.

6.                           In order to controvert the stand of the complainants, the opposite parties had to file their reply and evidence, but they failed to do so, despite taking a number of adjournments for the same.  On the other hand, Sh. Ravinder Kumar, complainant No.1 has filed his duly sworn affidavit in support of his contentions.  Hence, the stand of the complainants goes un-rebutted. 

7.                           According to the ld. Counsel for the complainants as per the terms and conditions of the policy, pre-existing diseases are also covered under the policy from the 3^rd year onwards after two continuous renewals.  In this regard he has placed reliance on clause 6 of the Reliance Healthy Family Insurance Policy – PNB Arogya Shree which reads as under :-

“6.     Pre-existing Disease

This policy covers relevant medical expenses incurred for treatment of pre-existing disease, illness or injury, from the 3^rd year of inception of this policy or after two continuous renewal of this policy as mentioned in the Schedule of this Policy.”

A bare reading of the above referred clause clearly establishes that the policy also covered relevant medical expenses incurred for treatment of pre-existing disease from the 3^rd year of inception or after two continuous renewals.  In the present case the policy was continually renewed from the date of inception i.e. 1.1.2008.  Hence, the repudiation of the claim by the opposite parties certainly amounted to deficiency in service.

8.                           In view of the above discussion, the present complaint is allowed and the opposite parties are directed to:-

i)                   release the entire claim of Rs.50,150/- (46,887 +3263) of the complainants in terms of the policy

ii)                pay Rs.15,000/- as compensation for mental and physical harassment suffered by the complainants

iii)              pay Rs.5,000/- as costs of litigation.

9.                           This order be complied with by the opposite parties, within 45 days from the date of receipt of its certified copy, failing which the amounts at (i) & (ii) shall carry interest @18% per annum from the date of this order till actual payment, besides payment of litigation costs.

10.                       Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

08.08.2012.

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER