Haryana

Karnal

CC/268/2017

Ram Karan Goyal - Complainant(s)

Versus

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

B.R. Dahiya

28 Jan 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No.268 of 2017

                                                         Date of instt. 17.08.2017

                                                         Date of decision:28.01.2019

 

 

Ram Karan Goyal son of Shri Kashmiri Lal, House no.26, Chaudhary House Colony, Railway Road 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.

                 Shri Karamvir Mandhan Advocate for OP no.1.

                 Mr. Deep Chand Rep. of OP no.2.

                 OP no.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.261301/48/2017/1685, which was valid from 26.08.2016 to 25.08.2017 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. The complainant felt acute retrostenal and abdominal pain on the night of 17.01.2017 and on 18.01.2017 and then he was admitted in Kalayani Hospital CHD Sector-45, Karnal where he was diagnose and treated and the concerned doctor of said hospital was recommended him 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 18.01.2017 to 20.01.2017. The complainant has also informed the OPs in this regard within time and the said hospital has charged Rs.1,28,000/-for the aforesaid treatment. Thereafter, the complainant has submitted mediclaim form alongwith hospital bills and necessary documents as required by the OP no.1, vide reference no.556221617475934/21 dated 21.03.2017 and the same were sent to the OPs through couriers on 30.01.2017, 1.4.2017 and 4.4.2017 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 4.7.2017 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 prior to obtaining the policy from the OPs, complainant was suffering from Hypertension & Diabetes and he did not disclose this fact to the OPs. So, he is not entitled to any relief. It is further pleaded that OPs had been consistently pursuing the complainant for submission of deficit documents, vide letter dated 17.02.2017, 4.2.2017 and 21.03.2017. However, the insured/complainant has not submitted the relevant documents till date. It is further pleaded that after considering all the relevant documents the OP no.1 has rightly repudiated the claim of the complainant as per the clause 4.2 of the terms and conditions of the policy. Hence there is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied by the OPs and prayed for dismissal of the complaint.

3.             OP No.2 vide his statement dated 29.01.2018 stated that written statement filed by the OP no.1 be read as statement of OP no.2.

4.             OP no.3 did not appear and proceeded against exparte vide order dated 30.10.2018.

5.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C45 and closed the evidence on 15.05.2018.

6.             On the other hand, OPs tendered into evidence affidavit of Manraj Kaur Virk Ex.RW1/A and documents Ex.R1 to Ex.R8 and closed the evidence on 14.11.2018.

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 26.08.2016 to 25.08.2017 and there is no break in the policy being in force, continuously. On 17.01.2017 complainant felt acute retrosternal and abdominal pain and he was admitted in Kalyani Hospital Chandigarh, sector-45, Karnal 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 18.01.2017 to 20.01.2017. The complainant has also intimated to the OPs and said hospital has charged Rs.1,28,000/- 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 OPs no.1 and 2 is that th complainant has suppressed the true and material facts as prior to obtaining the policy from the OP, he was suffering from Hypertension and Diabetes. 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

xviii -  Diabetes-2 years.”

10.           Admittedly, complainant got insured for mediclaim policy of insurance from OP no.1 and the said policy was valid from 26.08.2016 to 25.08.2017. It is also admitted the complainant was admitted in Kalyani Hospital, CHD, Sector-45, Karnal. The complainant was operated and stent to LAD was done. The said hospital has charged Rs.1,28,000/- 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 and Diabetes 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 produce the Oriental Bank Mediclaim Policy and as per the terms and condition of 4.2, if the insured was suffering from Hypertension and Diabetes 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 57 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 pre-existing diseases i.e. Hypertension and Diabetes prior to purchase the mediclaim policy. The complainant and his wife both are older than the age of 45 years. 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.1,28,000/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization. We further direct the OPs to pay Rs.10,000/-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: 28.01.2019

                                                                        President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

 

                     (Vineet Kaushik)     (Dr. Rekha Chaudhary) 

                        Member                       Member