Delhi

North East

CC/63/2014

Sh. Ripin Kumar - Complainant(s)

Versus

The C.E.O/ Nic . Co. & Anr. - Opp.Party(s)

02 Dec 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 63/14

In the matter of:

 

	Sh. Ripin Kumar S/o Sh. Attar Singh R/0 A-11/288, Part III, Zero Pushta, Circular Road, Sonia Vihar Delhi-110094	Complainant
	Versus
1.           2.	The C.E.O/General Manager National Insurance Co. Ltd., Division Office No. XV Himalaya House, 1st Floor, 23-Kasturba Marg, New Delhi-110001 The C.E.O /General Manager East West Assist Pvt. Ltd., 97, Maneckshaw Road, Sainik Farm, New Delhi-110062	Opposite Parties

 

DATE OF INSTITUTION:                                     JUDGMENT RESERVED ON:                                                      DATE OF ORDER :

24.02.2014                  06.10.2022                  02.12.2022

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

ORDER

Anil Kumar Bamba, Member

The Complainant has filed the present complaint under Section 12 of the Consumer protection Act, 1986.

Case of the Complainant

1.  The case of the Complainant as revealed from the record is that the Complainant is the husband of deceased Priyanka and she expired on 20.04.2013 at Yashoda Hospital Kaushambi, Ghaziabad U.P during her treatment in Hospital. Deceased wife of the Complainant had taken the hospitalization benefit vide policy no. 351500/48/12/8500005071 dated 29.03.2013 policy period 29.03.2013 to mid night of 28.03.2014 after properly medical check up the authorized doctor of the Opposite Parties. After the death of the wife of the Complainant the Complainant filed the claim vide No. 186026 before the Opposite Party No. 1 along with all relevant documents with medical prescriptions and medicines bills total amounting to Rs. 85,875/- and the Complainant also provided the above said document to the Opposite Parties. Complainant also spent money for travelling and other medicines purchased from the market which was the total expenses comes to Rs. 35,000/-. The deceased wife of the Complainant taken the Hospitalization Benefit Policy on 29.03.2013 after paying the premium amount along with service tax of Rs. 2,219/- dated 29.03.2013 and accordingly deceased wife of the Complainant received the policy schedule and Hospitalization Benefit Policy as well as individual Medi-claim and the said medi-claim policy period mentioned in the above said policy form 29.03.2013 to midnight of 28.03.2014 and the above said policy accordingly was in existence at the time of under treatment and death of the deceased wife of the Complainant as such when the policy has been commenced and premium has been received by the Opposite Party No. 1 then the policy cannot be revoked by the Opposite Parties and the Opposite Parties are liable to give the benefit of the Policy and also responsible to pay the claim as per the Hospitalisation Benefit Policy to the insured person as well as the egal heirs of the insured person. The Opposite Party No. 2 on dated 24.06.2013 issued the Query letter which is also filled up by the Complainant w.r.t to the claim. On dated 21.10.2013 the Complainant issued the reminder of the claim filed by the Complainant but no action was taken by the Opposite Parties intentionally and deliberately till date. The Complainant issued a legal notice dated 18.12.2013 to the Opposite Parties and the Opposite Party No. 1 gave a false and frivolous reply dated 30.12.2013 to the Complainant and deny the claim of the Complainant without any cogent reason. The Complainant approached and visited various times the office of the Opposite Parties in reference of the claim but no fruitful result was come out.  The Complainant has prayed to direct the Opposite Parties to pay the payment of Rs. 1,20,875/- as per the terms of the policy of medi-claim, Rs. 50,000/- on account of mental harassment and Rs. 21,000 on account of legal charges.

Case of Opposite Party No. 1

2. The Opposite Party contested the case and filed written statement. It is stated by the Opposite Party that one hospitalisation benefit policy issued in the name of Ms. Priyanka W/0 Sh. Ripin Kumar, R/0 A-22/288, Part III, Zero Pushta, Circular Road, Sonia Vihar, Delhi on 29.03.2013 for a period from 29.03.2013 to 28.03.2014 and the sum insured was Rs. 2,00,000/- The  claim submitted by the Complainant was processed by the Competent Authority and expert penal doctors of TPA and it was found that the compensation can not be given to the Complainant as the insured was admitted in the hospital within the 30 days of taking of the policy which is clearly excluded under clause 4.2 of the Exclusion Clause of the terms and conditions of the Policy. Clause 4.2 of the Terms and Conditions is as under:

Clause 4 Exclusion

4.1 .........

4.2Any disease other than those stated in clause 4.3, contracted by the Insured Person during the first 30 days from the commencement date of the policy. This condition 4.2 shall not however apply in case of the insured person having been covered under this Scheme or group insurance scheme with our company for a continuous period of preceding 12 months without any break or is hospitalized due to accidental injuries suffered after inception of the policy.

3. Hence, the claim submitted by the Petitioner got repudiated.  Ms. Priyanka hospitalized on 18.04.2013 with the complaint of fever, pain abdomen, distention of abdomen, loose stools, vomiting etc. On admission she was conscious and oriented, her blood pressure was 80/50 mm hg, and her pulse rate was 110/min. She was investigated with X-ray abdomen showed multiple air fluids level. USG abdomen S/o Interior Obstruction with minimal ascites, bilateral pleural effusion. She developed VT on 20.04.2013. DC shock was given, CPR initiated and ACLs protocol followed but patient not responded to resuscitative measures and she was declared dead on 20.04.2013. The cause of the death was given by the doctors was Ventricular Tachycardia with ARDS. It is further submitted by the Opposite Party No. 2 that the document filed by the Complainant is itself clear that the deceased was suffering from the disease at the time of taking the policy and it is the reason that after taking the policy she immediately taken the treatment within 30 days which is excluded by the terms and conditions of the insurance policy. Hence, there is no deficiency in services rendered by the Opposite Party. The Opposite Party repudiated the claim file of the Complainant within the terms and conditions of the policy and after considering the opinion of the Panel Doctor of TPA. Therefore, the complainant is not entitled to any claim under the Consumer Protection Act. On this ground also the present complaint merits dismissal.
4. None has appeared on behalf of the Opposite Party No. 2 despite notice served on 20.03.2014. Hence, Opposite Party No. 2 proceeded against Ex-parte vide order dated 15.05.2014.

Rejoinder to the written statement of Opposite Party No. 1

5. The Complainant filed rejoinder to the written statements of Opposite Parties wherein the Complainant has denied the pleas raised by the Opposite Parties and has reiterated the assertion made in the complaint.

Evidence of the Parties

6. The Complainant in support of her case filed her affidavit wherein she has supported the assertions made in the complaint. In order to prove its case Opposite Party has filed affidavit of Shri. R.P Sharma, Deputy Manager, National Insurance Co. Ltd., having office at D.O No. 15, K.G Marg, New Delhi, wherein the averments made in the written statement have been supported.

Arguments and Conclusion

7. We have heard the Counsel for the Complainant. We have also perused the file and written arguments filed by the Complainant and Opposite Party No.1. The case of the Complainant is that the Complainant’s wife had taken a Hospitalization Benefit Policy dated 29.03.2013 for a period from 29.03.2013 to 28.03.2013 for sum insured Rs. 2,00,000/-. Complainant’ wife was admitted to the hospital on 18.04.2013 with the complaint of fever, pain abdomen, distension of abdomen, loose stools, vomiting etc. and she was investigated with X-ray abdomen shoed multiple air fluids level, USG abdomen s/o Interior Obstruction with minimal ascites, bilateral pleural effusion and died in the hospital on 20.04.2013. The cause of the death was given by the doctors Ventricular Tachycardia with ARDS. After death of the Complainant’s wife, Complainant filed claim under the policy to the Opposite Party No. 1 along with all relevant documents with medical prescription and medicines bills total amounting to Rs. 85,875/-. Complainant also spent Rs. 35,000/- on travelling expenses and other medicines purchased from the market. Opposite Party is admitted a fact that wife of the Complainant had taken a policy on 29.03.2013 for a period from 29.03.2013 to 28.03.2013 and the sum insured was Rs. 2,00,000/- The claim submitted by the Complainant was processed by the Competent Authority and expert penal doctors of TPA and it was found that the compensation can not be given to the Complainant as the insured was admitted in the hospital within the 30 days of taking of the policy which is clearly excluded under clause 4.2 of the Exclusion Clause of the terms and conditions of the Policy. Clause 4.2 of the Terms and Conditions is as under :

Clause 4 Exclusion

4.1 .........

4.2Any disease other than those stated in clause 4.3, contracted by the Insured Person during the first 30 days from the commencement date of the policy. This condition 4.2 shall not however apply in case of the insured person having been covered under this Scheme or group insurance scheme with our company for a continuous period of preceding 12 months without any break or is hospitalized due to accidental injuries suffered after inception of the policy.

8. Hence, the claim submitted by the Petitioner got repudiated and there is no deficiency in service rendered by the Opposite party.
9. Complainant failed to produce any material nor he submitted any medical record of his wife for suffering any disease regarding his claim is not covered under clause 4.2 of the policy. It is also admitted by the Complainant that he received the policy along with schedule.
10. In view of above, we did not see any ground to allow the complaint. The complaint is dismissed accordingly.
11. Order announced on 02.12.2022.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

 

(Anil Kumar Bamba)           Member

(Surinder Kumar Sharma) President