Haryana

Karnal

CC/309/2018

Jai Chand - Complainant(s)

Versus

The Manager Oriental Insurance Company Limited - Opp.Party(s)

B.R. Dahiya

02 May 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No.309 of 2018

                                                         Date of instt. 13.11.2018

                                                         Date of decision:02.05.2019

 

Jai Chand son of Shri Tirth Dass House no.330-Sector-14, Urban Estate, Karnal.

                                                                   …….Complainant

                                        Versus

 

1. The Manager Oriental Insurance Company Ltd. Meera Ghati Chowk, Karnal-132001.

2. The Manager Raksha T.P.A Private Ltd. SCO no.359-360, First Floor, Sector-44-D, Chandigarh-160047.

3. The Manager Raksha Health Insurance TPA Private Ltd. c/o Escort Corporate Central 15/5, Mathura Road, Faridabad (Haryana), 121003.

                                                                   …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.    

       

Before   Sh. Jaswant Singh……President.       

              Sh. Vineet Kaushik………Member

              Dr. Rekha Chaudhary……Member

 

 Present:  Shri B.R.Dahiya Advocate for complainant.

                 Ms. Saroj Bala Jain Advocate for OP no.1

                 Opposite parties no.2 and 3 exparte.

                               

                (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant had got insured for mediclaim policy of insurance from OP no.1, vide policy no.261301/48/2018/2893, which was valid from 19.12.2017 to 18.12.2018 and there is no break in the policy, being enforce continuously. The said policy was health insurance of the complainant under which the complainant was fully covered and at the time of issuing the said policy the authorized agent of OPs had assured the complainant by saying that in case of any mis-happening regarding health of complainant as well as all kinds of hospital expenses and other expenses incurred on the treatment of the insured person i.e. the complainant will be paid by the OPs. There was no cardiac problem to the complainant in the past. On 09.04.2018 the complainant had gone for check up to Dr. R.I. Singh of Arpna Hospital Karnal and thereafter on his advise, he had also gone for checkup to Cygnus Hospital Karnal and on 10.04.2018 the concern Doctor of the said Hospital advised to contact Raksha TPA for proposed Hospitalization of the complainant. Thereafter, complainant had gone to Civil Hospital Jagadhari Road Ambala Cantt. Haryana where he was diagnosed and treated there and the concerned doctor had recommended for  PTCA+stent to LAD and he was operated upon for the same and stent to LAD was done and complainant remained as indoor patient from 21.04.2018 to 23.04.2018. The complainant has also informed the OPs in this regard within time and the said hospital has charged Rs.1,43,064/-for the aforesaid treatment. Thereafter, the complainant has submitted mediclaim form alongwith hospital bills and necessary documents as required by the OP no.1 to 3, vide reference no.55651819068321/24 dated 25.05.2018 and the same were sent to the OPs through couriers  but inspite of that the OPs did not pay any heed to it and kept mum for a period of about 5 months and during the aforesaid period the complainant has also sent many letters of request through registered post to the OPs. Complainant submitted the required document to the OPs for reimbursement of the claim but OPs did not pay any claim and repudiated the same, vide letter dated 12.10.2018 without any cogent reason. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, OP no.1 appeared and filed written version raising preliminary objections with regard to maintainability; locus standi; cause of action and concealment of true and material facts. On merits, it is pleaded that the complainant had having pre-existing disease and first policy was issued on 19.12.2016 and treating doctors had endorsed in the treatment of complainant that the present case is the case history of HTN, CAD. So, the present disease is covered after two years of the policy as per exclusion clause 4.2 sub clause xvii. Though the duration of the treatment and amount of the expenses is admitted. Letters dated 25.05.2018, 13.06.2018 were issued to the complainant by the OP no.2 and final reminder dated 3.7.2018 was also issued to the complainant, but no reply of these letters were given by the complainant. After that the OP no.2 also issued a letter dated 9.7.2018 to the OP no.1, recommending for non-payment of the claim to the complainant. Then a dasti letter dated 12.10.2018 was given to the complainant regarding denial of the claim of policy no.261301/48/2018/2893 as per exclusion clause of terms and condition of the policy. Hence there is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied by the OP no.1 and prayed for dismissal of the complaint.

3.             OPs no.2 and 3 did not appear and proceeded against exparte vide order dated 24.12.2018.

5.             Complainant tendered into evidence his affidavit Ex.C1 and documents Ex.C2 to Ex.C15 and closed the evidence on 21.02.2019.

6.             On the other hand, OPs tendered into evidence affidavit of Dinesh Kumar Jain Ex.RW1/A and documents Ex.R1 to Ex.R9 and closed the evidence on 23.04.2019.

7.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

8.             The case of the complainant is that the complainant had got insured for mediclaim policy of insurance from OP no.1, which was valid from 19.12.2017 to 18.12.2018 and there is no break in the policy being in force, continuously. On 09.04.2018 the complainant had gone for check to Dr. R.I. Singh of Arpana Hospital Karnal and thereafter on his advise, he had also gone for checkup to Cygnus Hospital Karnal. Thereafter, complainant had gone to Civil Hospital Jagadhari Road Ambala Cantt. Haryana where he was diagnosed and treated there and the concerned doctor was recommended him for PTCA+stent to LAD and he was operated up on for the same and stent to LAD was done and complainant remained as indoor patient from 21.04.2018 to 23.04.2018. The complainant has also intimated to the OPs and said hospital has charged Rs.1,43,064/- for the treatment. Complainant submitted his mediclaim form alongwith hospital bills and necessary documents to the OPs but the mediclaim was repudiated by the OPs without any cogent report. The learned counsel for complainant relied upon a authority cited in 2016(4)CLT page 372 of U.T. Chandigarh titled as SBI General Insurance Company Limited Versus Balwinder Singh Jolly & Anr.

9.             On the other hand the case of the OP no.1 is that the complainant has suppressed the true and material facts as prior to obtaining the policy from the OP, he was suffering from heart problem. So, he is not entitled to get any claim from the OPs. Moreover, the complainant has not submitted the relevant documents for releasing the mediclaim. The OPs has rightly repudiated the claim of the complainant as per clause 4.2 of the terms and conditions of the policy which is being reproduced as below:

        “4.2- -  - -   The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable, if contracted and/or manifested during the currency of the policy.

xvii -  Hypertension-2 years

10.           Admittedly, complainant got insured for mediclaim policy of insurance from OP no.1 and the said policy was valid from 19.12.2017 to 18.12.2018. It is also admitted the complainant was admitted in Civil Hospital, Jagadhari Road, Ambala Cantt. The complainant was operated and stent to LAD was done. The said hospital has charged Rs.1,43,064/- for the treatment of the complainant. The mediclaim of the complainant was repudiated by the OPs on the ground that he was suffering from Hypertension  prior to obtaining the medical policy and he violated the terms and conditions of the mediclaim insurance policy. During the course of argument, the counsel for the OP relied upon Oriental Bank Mediclaim Policy Ex.R9 and as per the terms and condition of 4.1, if the insured was suffering from Hypertension prior to 2 years of purchasing the policy then he is not entitled for mediclaim.

11.           It is proved on the record that at the time of purchasing of mediclaim insurance policy, complainant was of 68 years old. As per the instructions issued by Insurance Regularly and Development Authority of India (IRDAI), if the insured was above 45 years than it was duty of the insurer to put insured to through medical examination. There is nothing on the record to show that before insurance policy was issued to complainant, the OP got him medically examined, which as per instruction issued by the Insurance Regularly and Development Authority of India (IRDAI) is must in such like cases. The claim of the complainant was repudiated only on the ground that complainant was suffering from pre-existing diseases i.e. Hypertension  prior to purchase the mediclaim policy. As per IRDAI instructions it is mandatory in case of issue of mediclaim policy in the favour of a person more than 45 years of age, to get him thoroughly examined. Similarly, view was taken by Hon’ble State Commission, Punjab in the case of M/s Max Bupa Health Insurance Co. Ltd. Versus Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016 wherein it was held that if contrary to the instructions issued b IRDAI, an insured above the age of 45 years, was not put to through 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 the policy was obtained. The case law cited by the complainant is fully applicable to the present case. The claim of the complainant cannot be repudiated on account of non-disclosure of the fact of pre-existing disease when policy was obtained. Thus, we are of the considered view that the claim of the complainant wrongly repudiated by the OPs and the act of the OPs are amounts to deficiency in service.

12.           Thus, as a sequel to above discussion, we allow the present complaint and direct the OPs to pay mediclaim of Rs.1,43,064/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization. We further direct the OPs to pay Rs.15,000/-to the complainant for mental agony, harassment and towards litigation expenses. This order shall be complied with within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 02.05.2019

                                                                        President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

                  

      

  (Vineet Kaushik)     (Dr. Rekha Chaudhary) 

                        Member                       Member