BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no.184 of 2015
Date of Institution : 19.10.2015
Date of Decision : 25.10.2016.
Smt. Rukmani wife of Sh. Bhup Singh, resident of H.No. B/20/1253, Near Hanuman Mandir, Patel Basti, Begu Road, Sirsa, Tehsil and District, Sirsa, Haryana.
….Complainant.
Versus
1. Reliance Life Insurance Company Ltd., H-Block, Ist. Floor Dhirubhai Ambani Knowledge City, Navi Mumbai (Maharastra)- 400710, through its President or Executive Director.
2. The Branch Manager, Reliance Life Insurance, Dabwali Road, Sirsa (Haryana) 125055.
3. The Manager, Medicare TPA Services (I) Pvt. Ltd. 6B, Bishop Lefroy Road, Kolkata 700020
..…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI S.B.LOHIA…………………PRESIDENT
SHRI RANBIR SINGH PANGHAL ……….……MEMBER.
Present: Sh. S.S. Kathuria, Advocate for the complainant.
Sh. S.S. Mandia, Advocate for opposite parties no.1 & 2.
Opposite party no.3 exparte.
ORDER
Case of complainant, in brief, is that on the advertisement of Medical Insurance policy of op no.1, on 28.12.2011 complainant and her son Kapil Sharma had purchased ‘Reliance Care For You Plan’ policy for the sum assured of Rs.2,00,000/- through agent/ broker Sh. Chetan Sharma for three years and had paid Rs.5328.58/- as first premium. The office of ops had also issued a policy in their favour. The complainant suddenly fell ill and she suffered with the problem of irregularity of menses upon which she contacted with the doctors of Janta Maternity and General Hospital, Sirsa on 20.3.2014 and after check-up doctors provided treatment to her but she was not cured. Thereafter, she went to Apex Hospital and Research Centre, Sirsa where the doctors advised her different tests from Diagnosis Centers which were got conducted and on 21.4.2014, the doctors advised her for surgery. Then she took advice and got conducted medical tests on 7.6.2014 at Sarvodya Hospital, Faridabad which was on the penal of ops, and there surgery was conducted and she had remained under treatment for three months from 20.3.2014. She was admitted to Sarvodya Hospital, Faridabad for surgery on 12.6.2014 and was discharged on 13.6.2014 and she had incurred Rs.27,556/- there. The complainant as per instructions of ops submitted all the relevant original documents including bill alongwith claim form on 25.6.2014 to op no.2 and thereafter submitted many requests to disburse her claim through her husband by sending mails etc. but ops did not pay any heed and they refused to pay the claim of complainant without any reason. She also got served a legal notice upon ops on 21.5.2015, but to no effect. Hence, this complaint.
2. Upon notice, opposite parties No.1 & 2 appeared and filed reply wherein issuance of policy to the complainant has been admitted. It is submitted that claim form alongwith documents were received in the office of ops, wherein complainant alleged to have remain admitted with Sarvodya Hospital, Faridabad for the period 12.6.2014 to 13.6.2014 with Diagnosis for irregular bleeding P/B with heavy flow x 6 months and submitted a final claim bill amounting to Rs.27,556/-. On receipt of the claim documents, same were forwarded to an independent TPA (Third party arbitrator) duly licensed and registered from IRDA for adjudication of claim on merits and
being an expert, op no.3 after going through the terms and conditions of the policy repudiated the claim of the claimant as patient was diagnosed to have disease within waiting period. Hence, claim was not payable. The claim of the complainant was repudiated as expenses related to hospitalization and treatment following the diagnoses within the certain period are not covered under the scope of policy and prayer for dismissal of complaint has been made.
3. Op no.3 did not appear despite notice sent through registered post and due acknowledgment and was proceeded against exparte.
4. In evidence, the complainant has tendered her affidavit Ex.C1, copy of policy Ex.C2, repudiation letter Ex.C3, application dated 25.6.2014 Ex.C4, details of medical expenses Ex.C5, verification of Sarvodya Hospital Ex.C6, treatment record from Ex.C7 to Ex.C14, bill of Shree Gopal Medicos Ex.C15, final bill Ex.C16, detail of final bill Ex.C17, discharge summary Ex.C18, receipt of Rs.10,000/- Ex.C19, receipt of Rs.14,400/- Ex.C20 and other documents Ex.C21 to Ex.C28. On the other hand, ops no.1 & 2 tendered affidavit of Ms. Sujata Kapoor, Authorized Signatory Ex.R1 and copy of discharge summary Ex.R2, policy Ex.RW1/A with documents Ex.R2/A and claim repudiation letter Ex.R3.
5. We have heard learned counsel for the parties and have gone through the case file carefully.
6. There is no dispute that complainant and her son had obtained medi-claim insurance policy from the opposite parties on 28.12.2011. The claim of the complainant has been repudiated on the ground that as patient was diagnosed to have disease within waiting period, hence claim was not payable. The complainant Smt. Rukmani for the first time suffered problem of irregular bleeding in the month of March, 2014 for which firstly she went to Janta Maternity and General Hospital, Sirsa on 20.3.2014 and finally she was operated upon on 12.6.2014 in Sarvodya Hospital, Faridabad and was discharged on 13.6.2014. The Clause 5.4 of the policy in question provides two year waiting period for the under mentioned diseases and same is reproduced as under:-
Clause 5.4: Two year waiting Period: Kidney Stone/ Ureteric Stone/ Lithotripsy, Cataract, Hysterectomy, Cholelithiasis, Choledocholithiasis, surgery of Gall bladder and Bile ducts excluding Malignancy, surgery of Benign Prostatic Hypertrophy, Hernia (Inguinal), Hemorrhoids, Anal Fissure, Fistula-in-anus, Exploratory, Laparotomy, Lapcholecystectomy, diagnostic Laparoscopy, any gynecological disease, Hydrocoele, Fibroids.
7. From the above said clause, it is clear that there was two years waiting period for any gynecological disease. But the complainant suffered the problem of irregular bleeding in the month of March, 2014 i.e. after two years of waiting period from the purchase of policy in question which was purchased on 28.12.2011. In the certificate of Dr. Seema Manuja of Sarvodya Hospital, Faridabad Ex.C6 which was given on 21.6.2014 it is mentioned that irregular bleeding since six months approximately and same also goes to show that complainant suffered the said problem after two years of purchase of policy in question. Therefore, the opposite parties have wrongly and illegally repudiated the claim of the complainant. The repudiation of the claim of the complainant is not justified and is set aside.
8. The complainant has claimed that she has spent an amount of Rs.27,556/- on her treatment of said disease and have placed on file various bills in this regard and therefore, she is entitled to the above said amount of Rs.27,556/- spent by her on her treatment. Hence, we allow the present complaint and direct the opposite parties to pay the said amount of Rs.27,556/- alongwith interest @9% per annum from the date of filing of present complaint i.e. 19.10.2015 till actual realization. We also direct the opposite parties to pay a sum of Rs.10,000/- to the complainant as compensation for harassment including litigation expenses. This order should be complied by the opposite parties jointly and severally within a period of 45 days from today. Copy of the order be supplied to the parties free of costs. File be consigned to the record room after due compliance.
Announced in open Forum. President,
Dated: 25.10.2016. District Consumer Disputes
Redressal Forum, Sirsa.
Member.
