Haryana

Kaithal

CC/22/2022

Pawan Kumar Rana - Complainant(s)

Versus

The New India Assurance Co. - Opp.Party(s)

Sh.Dinesh Kumar

04 Dec 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL

 

                                                               Complaint Case No.           22 of 2022.

                                                               Date of institution:             25.01.2022.

                                                               Date of decision:       04.12.2023.

 

Pawan Kumar Rana s/o Shri Mahipal Singh, r/o Main Gali, Ward No.3, near GSS School, Kalayat, District Kaithal.

                                                                                      …Complainant.

                                                     Versus

 

1. The New India Assurance Company Ltd., First Floor, above Vijay Bank, Ambala Road, Kaithal.
2. The New India Assurance Company Ltd., Bldg, 87 MG Road, Fort, Mumbai-400001.
3. Alchemist Hospital, Registered office Sector 21, Panchkula.

...Opposite Parties

 

          Complaint under Section 35 of the Consumer Protection Act

 

CORAM:   SMT. NEELAM KASHYAP, PRESIDENT.

                   SMT. SUMAN RANA, MEMBER.

                   SHRI SUNIL MOHAN TRIKHA, MEMBER.

                  

Present:       Shri Dinesh Kumar Bhatia, Advocate, for the complainant.   

                   Shri Amit Singh Rana, Advocate for Opposite Parties No.1 & 2.

                    Opposite Party No.3 ex-parte.

                  

ORDER - NEELAM KASHYAP, PRESIDENT

        Complainant has filed this complaint under Section 35 of Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the OPs.

2.                In nutshell, the facts of present case are that the complainant got a medical insurance policy from OPs vide policy No.35440034179500000027 in the year 2017 and got renewed in the year 2018,2019,2020 and 2021 for the duration of 26.07.2021 to 25.07.2022 vide policy No.35440034212700000022 dated 26.07.2021 and paid Rs.8933/- with medical claim benefits of Rs.5 lacs. On 14.06.2021 at about 08:30 AM, he suddenly abdomen pain in his home premises and admitted at Performa respondent, where he was admitted for four days and diagnosed for abdomen and diabetes. He was duly treated in the said hospital and charged amount of Rs.81415/-. OPs advised him to fulfill all the necessary formalities to claim for sum of Rs.81,415/- vide Claim No.20210616B0090500720 and requested the OPs to pay the claim amount, but they illegally repudiated his claim on the bases of disease is specifically excluding under the first four years waiting period and issued rejection letter. The above act and conduct of OPs, amounts to gross deficiency in service, on their part, due to which, he suffered huge physical harassment, mental agony as well as financial loss, constraining him, to file the present complaint, against the OPs, before this Commission.

3.                Upon notice, OPs No.1 & 2 appeared before this Commission and filed their written statements, whereas, OP No.3 failed to appear before this Commission and was proceeded against ex-parte on 31.03.2022. OPs No.1 & 2, in their written statement admitted about issuing the policy in question to the complainant for the year 2017,2018,2019,2020 and 2021. The complainant having health problem was admitted on 14.06.2021 in Alchemist Hospital, Panchkula and was discharged on 17.06.2021. As per discharge summary, the complainant was diagnosed for diabetes mellitus with history of one episode of pancreatitis four years ago and now was again admitted in the hospital for further evaluation and management. Thus, as per discharge summary, the complainant has been suffering from old pre-existing ailment of diabetes Mellitus. While purchasing the policy, the complainant has not disclosed about his above pre-existing disease and such kind of treatment is not covered under the terms and conditions of the insurance policy and prayed for dismissal the present complaint.

4.                To prove the case, complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C6.

5.                On the other hand, OPs tendered into evidence affidavits Ex.RW1/A, Ex.RW2/A along with documents Annexure R-1 to Annexure R-7.

6.                We have heard the learned counsel for the parties and perused the record carefully.

7.                Learned counsel for the complainant has argued that the complainant got a medical insurance policy from OPs in the year 2017 and got renewed in the year 2018,2019,2020 and 2021 for the duration of 26.07.2021 to 25.07.2022 with medical claim benefits of Rs.5 lacs. He further argued that on 14.06.2021 at about 08:30 AM, the complainant suddenly abdomen pain in his home premises and admitted at Performa respondent, where he was admitted for four days and diagnosed for abdomen and diabetes. The complainant was duly treated in the said hospital and charged amount of Rs.81415/- and he fulfilled all the necessary formalities for claim of Rs.81,415/- and requested the OPs to pay the claim amount, but they illegally repudiated his claim on the bases of disease is specifically excluding under the first four years waiting period and issued rejection letter. The above act and conduct of OPs, amounts to gross deficiency in service, on their part.

8.                On the other hand, learned counsel for the OPs has argued that the OPs had issued the policy to the complainant for the year 2017,2018,2019,2020 and 2021. He further argued that the complainant having health problem was admitted on 14.06.2021 in Alchemist Hospital, Panchkula and was discharged on 17.06.2021. He further argued that as per discharge summary, the complainant was diagnosed for diabetes mellitus with history of one episode of pancreatitis four years ago and now was again admitted in the hospital for further evaluation and management. Thus, as per discharge summary, the complainant has been suffering from old pre-existing ailment of diabetes Mellitus. While purchasing the policy, the complainant has not disclosed about his above pre-existing disease and such kind of treatment is not covered under the terms and conditions of the insurance policy and prayed for dismissal the present complaint.

9.                 Admittedly, the complainant got a medical insurance policy from OPs, initially from the year 2017 and got renewed the same in the year 2018, 2019, 2020 and 2021 for the duration of 26.07.2021 to 25.07.2022 vide policy No.35440034202700000028 dated 26.07.2021, with medical claim benefits of Rs.5 lacs, vide policies documents Annexure C-1. It is admitted fact that on 14.06.2021, the complainant admitted in Alchemist Hospital, Panchkula and discharged on 17.06.2021, vide Discharge Summary Annexure C-2.

10.              As per complainant, he spent Rs.81415/- for his above treatment and approached the OPs for claim amount by submitting the requisite documents, but they repudiated his claim, vide repudiation letter dated 16.06.2021 Annexure C-5.

11.              On the other hand, the OPs contended that as per Discharge Summary, the complainant has been suffering from old pre-existing ailment of diabetes Mellitus and while purchasing the policy, the complainant has not disclosed about his above pre-existing disease and such kind of treatment is not covered under the terms and conditions of the insurance policy.

12.              It is pertinent to mention here that the OPs had repudiated the claim of the complainant on the ground of Discharge Summary Annexure C-3, which was prepared by the treating doctor of complainant namely Dr. Daksh Khurana. The complainant produced a document as Annexure C-3, on the case file, vide which, the said Dr. Daksh Khurana (who treated him) has undertaken that “Patient name Pawan Kumar Rana (Complainant) has been suffering from Diabetes Mellitus since 2018 onwards. It was wrongly mentioned in our records, earlier. Meaning thereby, the complainant was not suffering from Diabetes Mellitus, rather as per Discharge Summary Annexure C-2, he was admitted in the hospital with “Epigastric pain radiating to back x 10/06/21 onwards”. As such, the OPs have wrongly repudiated the claim of complainant, on this very ground. Moreover, the OPs cannot be used the “diabetes mellitus” as concealment of pre-existing disease for repudiation of the insurance claims. In this regard, we can rely upon the case law titled Life Insurance Corporation of India Vs. Sudha Jain 2007(2) CLT 423, the Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has drawn conclusions in para 9 of the order and the relevant clause is 9(iii), which is reproduced as under:-

                   "9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease."

14.              Keeping in view the ratio of the case laws laid down by the superior Fora in the aforesaid cases and the facts & circumstances of the present case, we are of the considered opinion that the OPs has not been able to prove the allegations, on the basis of which, they had repudiated/rejected the claims of the complainant. Thus, the repudiation/rejection of the claims, done by the OPs, is held to be unjustified and amounts to deficiency in services on the part of OPs.

15.              Now the question which arises for consideration is what should be the quantum of indemnification? In the complaint, complainant has alleged that he had spent Rs.81415/- on his said treatment. To prove the same, complainant produced bills on the case file for total Rs.81415/- as Annexure C-3 (60012+ 10,000+ 900+ 1000+ 7133+2149.43+221), and the OPs are liable to pay the same to the complainant, along with compensation amount and litigation expenses.

16.              In view of our above discussion, we accept the present complaint and direct the OPs, jointly and severally, to make the payment of total claim amount of Rs.81415/-, to the complainant, along with compensation amount of Rs.5,000/- + litigation expenses of Rs.5,000/-, within a period of 45 days, from the date of preparation of certified copy of this order, failing which, the award amount shall carry interest @6% per annum, from the date of this order, till its realization.

17.              In default of compliance of this order, proceedings shall be initiated under Section 72 of Consumer Protection Act, 2019, as non-compliance of Court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. File be consigned to the records, after due compliance.     

Announced in open Commission:

Dt.:04.12.2023.

                                                                                       (Neelam Kashyap)

                                                                                       President.

 

(Sunil Mohan Trikha).             (Suman Rana).              

Member.                                  Member.

 

 

 

Typed by: Sham Kalra, Stenographer.