Chandigarh

DF-II

CC/228/2014

Suresh Kumar Bhatia - Complainant(s)

Versus

The Indian Bank - Opp.Party(s)

Gaurav Bhardwaj,Adv

23 Oct 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	228 of 2014
Date  of  Institution	:	01.05.2014
Date   of   Decision	:	23.10.2015

 

 

 

 

 

Suresh Kumar Bhatia s/o Sh.K.L.Bhatia, R/o H.No.1589, Sector 18-D, Chandigarh.  

 

             …..Complainant

Versus

 

1]  The Indian Bank through its Branch Manager, SCO No.38, Sector 7, Madhya Marg, Chandigarh

 

2]  United India Insurance Co. Ltd., through its Managing Director, Divisional Office, Catholic Centre, 64, ARMENIAN STREET, Chennai 600001.

 

3]  Vidal Health TPA Pvt. Ltd., (Formerly TTK Healthcare), through its authorised representative, First Floor, SJR-1 Park, EPIP Road, White Field, Bangalore

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      :     Sh.Gaurav Bhardwaj, Advocate

 

For Opposite Party(s)   :     Sh.Sumit Batra, Adv. for OP-1.

Sh.Sukaam Gupta, Adv. for OP-2.

OP-3 exparte.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant is maintaining a bank account with Opposite Party No.1 and on its advice, he had availed a medical insurance policy namely “Indian Bank Arogya Raksha Plan” launched by Opposite Party No.2 effective from 31.3.2010 to 30.3.2011, thereby insuring the complainant and his wife for a total sum of Rs.3.00 lacs (Ann.C-1 & C-2).  It is averred that the said Mediclaim insurance policy was renewed from time to time upto 30.3.2014 (Ann.C-3) and then upto 28.2.2015 having sum insured of Rs.3.60 lacs (Ann.C-4). It is also averred that the complainant did not make any claim towards the reimbursement of any medical expenses in the first three policy years. 

         It is submitted that the complainant in Jan., 2014 had complained of Palpitation, and as such, approached Medanta Medicity, Gurgaon and was diagnosed to undergo the surgery i.e. ‘Alcoholic Septal Abaltion’, which involved surgery of heart in which some growth in the heart was to be treated through the above said procedure.  Thus, the complainant lodged claim with Opposite Party No.3 and the pre-authorization approval letter was generated and Opposite Party No.3 also issued a cashless facility vide letter dated 28.1.2014 (Ann.C-5).  However, after having been treated upon for the said disease at the said hospital, the cashless facility was rejected by Opposite Party No.3 vide letter dated 31.1.2014 (Ann.C-7) on the ground of pre-existing disease.  As such, the complainant had to make payment of the bills issued by the Hospital to the tune of Rs.2,07,444/- (Ann.C-8 to C-12).  The complainant also received repudiation letter dated 24.3.2014 mentioning the Condition No.4.1.  It is pleaded that the complainant was never informed that the condition of three consecutive renewals has been replaced with a new condition of four consecutive renewals for making the complainant eligible for the coverage of pre-existing disease nor any terms & conditions containing said clause has been supplied to the complainant. Therefore, alleging the said repudiation as illegal and deficiency in service on the part of the OPs, this compliant has been filed.

 

2]       The Opposite Party No.1 has filed reply stating therein that the complainant himself approached the answering Opposite Party for the issuance of said policy.  It is admitted that the policy was renewed from time to time.  It is asserted that the question of terms & conditions of the policy are to be answered by Opposite Party No.2.  It is also asserted that OPs No.2 & 3 are to verify and settle the claim and the answering Opposite Party No.1 has no role to play in the said process. Rest of the allegations have been denied with a prayer to dismiss the claim. 

 

         The Opposite Party No.2 (United India Insurance) has filed the reply and admitted the issuance of Mediclaim policy to the complainant and its renewal from time to time.  It is stated that the policy was issued for a term of one year and the terms & conditions issued were also valid for one year only.  It is also stated that the terms & conditions of the policy were changed in the year 2013 and fresh terms & conditions were duly conveyed to Opposite Party NO.1 on 7.5.2013, hence the same are applicable in the present case as claim was reported in the year 2014 (Annexure R2-C).  It is further stated that the condition of three consecutive renewals was deleted and a new condition of four consecutive renewals was added in terms and conditions of the said policy and all the old clauses were overruled by the fresh terms & clauses and said clauses were also applicable on the policies as issued prior to year 2013 also. It is submitted that while scrutinizing the claim papers, it was observed that the complainant was a known case of “HCM WITH ALCOHOLIC SEPTAL ABLATION DONE” since year 2000 and the commencement period of the policy is 2010 and date of admission is 29.1.2014, hence being pre-existing disease, the claim of complainant came under exclusion Clause NO.4.1, so it was rejected and intimated to the complainant on 24.3.2014.  It is further submitted that as per policy, consumable items for which Rs.63,000/- (Ann.C-8) had been charged, are not covered under the scope of present policy and even the charges like admission fee/registration charges/service charges/ surcharges, luxury tax and similar charges levied by the Hospital are also not covered under the policy. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

         Opposite Party No.3 did not turn up despite service of notice, hence it was proceeded against exparte vide order dated 11.6.2014.

 

3]       The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Party No.2 made in the reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the record.

 

6]       It is proved on record that the complainant through Opposite Party No.1 obtained Mediclaim insurance policy, namely, “Indian Bank Arogya Raksha Plan” launched by OP No.2 bearing Policy No.2010/48410000062/4 for the period from 31.3.2010 to 30.3.2011 for a total sum of Rs.3.00 lacs.  Further, it was renewed for the period from 31.3.2011 to 30.3.2012, from 31.3.2012 to 30.3.2013; from 31.3.2013 to 30.3.2014 and then from 31.3.2014 to 28.2.2015 having sum insured of Rs.3.60 lacs and well admitted by the OPs.  There is no denial that the complainant suffered Palpitation in 3^rd week of Jan., 2014 and was diagnosed to undergo surgery i.e. Alcoholic Septal Abaltion, recommended by hospital Medanta Medicity, Gurgaon. Accordingly, the complainant underwent the said procedure and admittedly the pre-authorization request for cashless facility approved earlier vide letter dated 28.01.2014 (Ann.C-5) was declined by Opposite Party No.2 vide letter dated 31.1.2014 (Ann.C-7) on the ground that pre-existing disease and its complication are not payable by insurance. 

 

7]       It is also not disputed that the complainant had to pay all the medical expenses incurred on the above said treatment at Medanta The Medicity Global health (P) Ltd., Gurgaon i.e. to the tune of Rs.2,07,444/.- (Ann.C-8 to C-10).  Ann.C-13 establishes that the claim lodged for the reimbursement of the above said amount was repudiated by the Opposite Party No.2 i.e. Insurance Company on the ground detailed as under:-

“On Scrutiny of the claim documents, we observed that the claim is for ‘HCM WITH ALCOHOLIC SEPTAL ABLATION DONE’.  Further, we noticed that the patient is a known case of HCM since 2000.  The policy is effective from 31/3/2013 and the hospitalization was on 29/1/2014.  Hence this falls under pre-existing disease.  As per policy condition P.E.D. is paid after four claim free years.  So the claim is medically repudiated under the clause 4.1 as per the policy condition.

Clause-4.1: All diseases/injuries which are pre-existing when the cover incepts for the first time.  For the purpose of applying this condition, the date of inception of the initial Mediclaim Policy taken from any of the Indian Insurance Companies shall be taken, provided the renewals have been continuous and without any break, However, this exclusion will be deleted after 4 consecutive continuous claim free policy years, provided, there was no claim for hospitalization of the pre-existing ailment during these 4 years of Insurance. 

          Hence the claim stands repudiated.”

 

8]       In addition to the above, it is submitted by the ld.Counsel for the Opposite Party No.2 that the terms & conditions of the policy is subject to the time period of the policy and submitted further that the terms & conditions of the policy in question i.e. Indian Bank Arogya Raksha Plan were changed in the year 2013 and fresh terms & conditions were duly conveyed to Opposite Party No.1. Claimed further that as per the new terms & conditions, the condition of three consecutive renewals was deleted and a new condition of four consecutive renewals was added in the terms & conditions of the said policy and all the old clauses were overruled by the fresh terms & conditions, which were also applicable on the policies issued prior to the year 2013 also.   Claimed further that since the complainant obtained first policy in the year 2010, so the existing terms & conditions of the policy covers the case of the complainant and also claimed that the complainant’s case is thus, covered under Clause No.4.1. 

 

9]       The ground so furnished by Opposite Party No.2 to justify the repudiation of the claim of the complainant, is not sustainable.  Firstly, there is no proof on record to show that the changed terms & conditions had ever been supplied to the complainant for the claim period or for the period when they became applicable. The acknowledgement receipt  Annexure R-C, placed on record by Opposite Party NO.2 claiming that new terms & conditions were duly conveyed to Opposite Party No.1, is not cogent proof to establish that the complainant was duly informed or conveyed the new terms & conditions of the Indian Bank Arogya Raksha Plan opted by him.  Also there is no proof that what was conveyed under the said acknowledgement receipt. Furthermore, there is no fresh proposal form got filled from the complainant and the policy in question was got renewed on the basis of proposal form filled in the year 2010 only, so the terms & conditions which bears application in the present complaint, are the one which were issued to the complainant in the year 2010 and it is clearly evident in those terms & conditions, placed on record, vide Ann.C-2 that under the Exclusion Clause No.3 that “All pre-existing diseases/injuries will get covered only after three continuous claim free policy years (i.e. from 4^th year onwards) (4.1)” and accordingly, the claim in question for the reimbursement is duly covered under this provision. Admittedly, the claim of the complainant was filed under the 4^th year of the policy after three claim free renewals. Further, there is no such record placed by the Opposite Party No.2 wherefrom they observed that complainant is known case of HCM since 2000, so the averment of pre-existing disease goes unproved.  It concludes that reimbursement of the claim of the complainant is completely payable under the terms & conditions supplied to him at the time of availing the policy in question for the first time in the year 2010.

 

10]     In view of the above observations, the deficiency in service on the part of the Opposite Party No.2 is proved. Therefore, the complaint stands allowed against Opposite Party No.2 & 3.  The Opposite Party No.2 & 3 are jointly & severally directed as under:-

a]  To pay Rs.2,07,444/-, incurred by the complainant on his treatment, along with interest @9% p.a. from 24.3.2014 i.e. the date of repudiation of the claim (Ann.C-13), till it is paid.

b]  To pay an amount of Rs.15,000/- to the complainant towards compensation for causing him mental & physical harassment;

c]  To pay litigation expenses to the tune of Rs.7000/-

 

         This order shall be complied with by the Opposite party No.2 within a period of 30 days from the date of receipt of its copy, failing which it shall be liable to pay interest @18% per annum, on the amount of Rs.2,07,444/- from 24.3.2014 i.e. the date of repudiation of the claim (Ann.C-13), till it is paid and also on the compensation of Rs.15,000/- from the date of filing this complaint till it is paid, apart from paying litigation expenses.

 

11]      However, the complaint qua OPs No.1 stands dismissed.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

23^rd October, 2015                                                        Sd/-                                                                                                   

 (RAJAN DEWAN)

PRESIDENT

 

 

          Sd/-

(JASWINDER SINGH SIDHU)

MEMBER

 

 

          Sd/-

 (PRITI MALHOTRA)

MEMBER

Om                                                                                                                       

 

 

DISTRICT FORUM – II

CONSUMER COMPLAINT NO.228 OF 2014

PRESENT:   None   Dated the 23rd day of October, 2015

O R D E R                        Vide our detailed order of even date, recorded separately, the complaint has been allowed against Opposite Party No.2 & 3 and dismissed qua Opposite Party No.1.                    After compliance, file be consigned to record room.

 

(Priti Malhotra)	(Rajan Dewan)	(Jaswinder Singh Sidhu)
Member	President	Member