DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 563/2016
Date of Institution : 17.06.2016
Date of Decision : 08.06.2017
Sohan Lal son of Saroop Chand H. No. B-XI/683, Street No. 6, Bharat Nagar, K.C. Road, Barnala, Tehsil and District Barnala. …Complainant
Versus
1. Tata AIG Insurance Limited Company Ltd., Peninsula Business Park Tower A, 15th Floor, Ganpatrao Kadam Marg, Lower Parel, Mumbai-400013 Through its Managing Director/Authorized Signatory.
2. TPA, Family Health Plan Ltd., Srinilaya-Cyber Spazio Suite # 101, 102, 109 and 110, Ground Floor, Road No. 2, Banjara Hills, Hyderabad-500034, Through its Managing Director/Authorized Signatory.
3. Axis Bank, Branch Barnala, Near Aggarsain Chownk Barnala, Tehsil Tapa and District Barnala, Through its Managing Director/Authorized Signatory.
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. Gagandeep Garg counsel for the complainant.
Sh. Varinder Kumar Goyal counsel for opposite party No. 1
Opposite parties No. 2 and 3 exparte.
Quorum.-
1. Shri S.K. Goel : President
2. Ms. Vandna Sidhu : Member
3. Shri Tejinder Singh Bhangu : Member
ORDER
(SHRI S.K. GOEL PRESIDENT):
The complainant Sohan Lal has filed the present complaint against Tata AIG Insurance Limited Company Limited, Mumbai opposite party No. 1, TPA Family Health Plan Ltd., Hyderabad opposite party No. 2 and Axis Bank, Barnala opposite party No. 3 under Consumer Protection Act 1986 (In short the Act).
2. The facts leading to the present case as pleaded by the complainant are that the complainant has one joint salary/saving Account bearing No. 910010044741898 with opposite party No. 3. The complainant regularly operates his account by visiting the branch office. In the month of July 2013 the complainant visited the branch office of opposite party No. 3 for doing transaction. However, Manager of opposite party No. 3 informed the complainant that opposite party No. 3 being an Agent of opposite parties No. 1 and 2 had started various insurance schemes for their Account holders customers. After that, Manager of opposite party No. 3 being an Agent of opposite parties No. 1 and 2 told the complainant that he will have to pay one single installment of premium of Rs. 10,054/- only for next one year and complainant will get one Family Floter Plan cashless policy and the said policy will cover all the risks of health for next one year for complainant and his wife without paying a single penny. It is alleged that on believing these words the complainant agreed to purchase the said plan and paid an amount of Rs. 10,054/- on 31.7.2013 through his account which was maintained with the opposite party No. 3. Opposite parties medically examined the complainant and his wife and have satisfied that both were not suffering from any ailment then they issued policy No. 0200230206 named Medi Prime which was valid from 31.7.2013 to 30.7.2014 and also issued Member Identity card for complainant having its No. ZZZZ424793301049 and complainant's wife having its No. ZZZZ424793302045.
3. It is further alleged that on 19.7.2014 the complainant suffered from heart problem. Therefore, he admitted to Naresh Hospital and Heart Center, KC Road, Barnala and the said hospital falls within the list of the network hospital under the said policy. The doctor diagnosed the complainant and found that the complainant is suffering from CAD (ACS) Coronary Artery Disease and Acute Coronary Syndrome, which means sudden heart attack. The complainant remained admitted for 4/5 days from 19.7.2014 to 23.7.2014. Policy was cashless so doctor send the pre-authorization letter to the opposite party No. 2 for payment of treatment charges. All documents which were necessary for claim were also sent by the doctor immediately. But on 22.7.2014 opposite party No. 2 send one letter and denied to pay the bills of the treatment charges on the ground of pre-existing disease. It is alleged that an expenditure of Rs. 25,638/- was charged by the above said hospital for the treatment including laboratory tests, ECG Report and other tests and complainant paid it from his own pocket in spite of valid insurance.
4. It is further alleged that thereafter the complainant contacted the opposite parties No. 1 and 2 and submitted all the documents and the opposite parties assured that the matter was under consideration but no claim was paid. Thereafter, on 14.8.2016 complainant sent one email to the opposite party No. 2 then on 20.8.2016 again sent one letter for completion of documents by the opposite party No. 2 to the complainant. In reply to the said letter complainant sent all the documents. However, in spite of that the opposite party failed to pay the said expenses. Hence, the present complaint is filed seeking the following reliefs.-
1) The opposite parties may be directed to pay Rs. 25,638/- alongwith interest at the rate of 12% from July 2014 till realization.
2) To pay Rs. 40,000/- as compensation for mental agony and harassment.
3) To pay Rs. 10,000/- as litigation expenses.
5. Upon notice of this complaint, opposite party No. 1 filed written version taking legal objections interalia on the grounds of maintainability, locus standi, cause of action, jurisdiction and frivlous litigation.
6. On merits, it is submitted that the complainant is insured with the opposite party through opposite party No. 3. However, the insurance is subject to the policy conditions. It is further submitted that complainant had given good health declaration while filling the proposal form. It is also submitted that Coronary Artery disease is caused by deposition of plaque in the arteries which lead to narrowing of arteries. This situation does not arise in a day and develop slowly. They have also submitted that the payment was declined on the ground of pre-existing disease. It is further submitted that the policy was issued by concealing the pre-existing disease and therefore the complainant is not entitled to any benefit from the policy. It is also alleged that there is no deficiency in service on the part of the opposite party and prayed for the dismissal of the complaint.
7. The opposite parties No. 2 and 3 not appeared before this Forum despite service, so the opposite parties No. 2 and 3 were proceeded against exparte.
8. In order to prove his case, the complainant has tendered into evidence his own affidavit Ex.C-1, copy of policy schedule Ex.C-2, copies of membership cards Ex.C-3 and Ex.C-4, copy of pre-authorization form Ex.C-5, copy of additional information form Ex.C-6, copy of denial of cashless service Ex.C-7, copies of bills Ex.C-8 to Ex.C-15, copy of authority letter Ex.C-16, copy of courier slip Ex.C-17, copy of reminder letter Ex.C-18, account statement Ex.C-19, list of hospitals Ex.C-20, copy of admission slip Ex.C-21 and Ex.C-22, tests Ex.C-23 to Ex.C-25, copies of treatment chart Ex.C-26 to Ex.C-28, copy of prescription slip Ex.C-29, copy of discharge slip Ex.C-30, copy of bill Ex.C-31 and closed the evidence.
9. To rebut the case of the complainant, opposite party No. 1 tendered in evidence affidavit of Mohd. Azhar Wasi Ex.OP-1/1, copies of letters Ex.OP-1/2 to Ex.OP-1/6 and closed the evidence.
10. We have heard the learned counsel for the parties and have gone through the record.
11. There is no dispute that the complainant got the policy from the opposite party No. 1 through opposite party No. 3. Ex.C-2 is the said policy in favour of the complainant and his wife which shows that they were insured for a sum of Rs. 2,00,000/- and premium paid is shown as Rs. 10,054/- for the period from 31.7.2013 to 30.7.2014 and the policy number is 0200230206. Firstly it is to be determined whether the complainant has undergone medical treatment and incurred expenses as alleged. The complainant has placed on record his affidavit Ex.C-1 wherein he has specifically stated that on 19.7.2014 he suffered from heart problem so he was admitted in Naresh Hospital and Hear Center, KC Road, Barnala and the said hospital falls within the list of network hospitals under the said policy. The complainant further stated that he remained admitted there from 19.7.2014 to 23.7.2014. He also stated that the policy was cashless so doctor sent the pre-authorization letter to opposite party No. 2 for payment of treatment charges wherein it was mentioned by the doctor the attack was sudden. However, opposite party No. 2 denied to pay the bills of the treatment on the ground of pre-existing disease. The complainant has reiterated his case as mentioned in the complaint. Ex.C-5 is the pre-authorization form sent by Dr. Naresh to opposite party No. 2 Third Party Administrator. Vide letter dated 21.7.2014 Ex.C-6 the opposite party sought further information from the said doctor. Ex.C-7 is the letter issued by the opposite party to show that the cashless facility was denied on the ground that pre-existing disease cannot be ruled out. Ex.C-8 is the bill dated 23.7.2014 issued by Dr. Naresh Hospital and Heart Center, Barnala for Rs. 16,542/-, Ex.C-9 is the bill of Rs. 2,180/- of the Laboratory Investigations, Ex.C-10 is the receipt showing the receipt of Rs. 2,000/- charged by the said hospital, Ex.C-11 to Ex.C-15 are the other various receipts which shows that the complainant was diagnosed by the said Dr. Naresh Kumar. Ex.C-21 shows that the complainant is admitted on 19.7.2014 and have undergone various tests. Ex.C-23 is the Echocardiography report. Ex.C-24 is the Morphological Data, Ex.C-25 to Ex.C-28 are the various examinations done by Dr. Naresh Hospital and Heart Center, Ex.C-29 is the medical certificate and Ex.C-30 is the discharge certificate dated 23.7.2014. Ex.C-31 is the bill of Rs. 16,542/-. On the basis of the above said evidence the learned counsel for the complainant contended that the opposite party failed to pay the said amount and therefore the complainant is entitled for the reimbursement of the said amount alongwith compensation and interest.
12. On the other hand the opposite party No. 1 has taken an objection that the disease in question was pre-existing disease and the policy was taken by the complainant without disclosing the said disease and therefore the company is not liable to make the payment.
13. It is worth mentioning here that the opposite party No. 2 the Independent Third Party Administrator and the insurance company are bound by the decisions of the TPA. However, in the present case the opposite party No. 2 TPA has failed to appear despite his service. This show that the opposite party No. 2 has opted to uncontest the case.
14. The onus to prove that the complainant was suffering from pre-existing disease was upon the opposite party. Perusal of the record shows that the opposite party No. 1 insurance company has not placed on record any expert report or document to prove that the complainant was having the pre-existing disease and due to that the claim was not payable. The opposite party No. 1 only placed on record certain letters Ex.OP-1/2 to Ex.OP-6/2 written to the complainant for asking some documents. However, no report of any medical specialist or any previous medical record of the complainant has been placed on record to indicate that previously the complainant was suffering from the disease in question.
15. In LIC of India and Anr Versus Chawali Devi reported in 2016(1) CLT-114 it was observed by the Hon'ble National Commission that no affidavit of concerned doctor who recorded history to prove that this history was given by deceased himself. Only on the basis of recorded history of deceased, it cannot be held that deceased was suffering from breathlessness, cough c expectoration etc. since last 10 years and had taken any treatment.
16. In SBI General Insurance Company Limited Versus Balwinder Singh Jolly and Anr reported in 2016 (4) CLT-372 the Hon'ble Chandigarh State Commission observed that it was a case of hypertension. Pre-existing disease. Age of insured when mediclaim insurance policy was issued was more than 45 years. In that even as per instructions issued by Insurance Regulatory and Development Authority of India (IRDA), it was duty of the insurer to put insured to thorough medical examination. Claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.
17. As a result of the above discussion there is merit in the present complaint and therefore the same is allowed against opposite parties No. 1 and 2. The opposite parties No. 1 and 2 are directed to pay Rs. 23,458/- which was the claim bill submitted to the opposite parties, to the complainant alongwith interest at the rate of 8% per annum from the date of submission of bill till realization. The opposite parties No. 1 and 2 are further directed to pay Rs. 1,100/- as litigation expenses. This order shall be complied with within 30 days from the date of the receipt of the copy of this order. Copy of this order be supplied to the parties free of costs. The file be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
8th Day of June 2017
(S.K. Goel)
President
(Vandna Sidhu)
Member
(Tejinder Singh Bhangu)
Member
