| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA (PUNJAB)
CC No. 366 of 26-07-2011 Decided on : 11-01-2012
Dharam Paul Singla aged about 57 years S/o Tej Ram R/o M/s. Tej Ram Dharam Paul, Maur Mandi, District Bathinda. .... Complainant Versus The New India Assurance Co. Ltd., Mall Godown Road, Rampura Phul, through its Branch Manager M/s. Raksha TPA Pvt. Ltd., R/o 15/5 Mathura Road, Faridabad (Haryana) 121003 through its Branch Manager/Director ..... Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM Smt. Vikramjit Kaur Soni, President Sh. Amarjeet Paul, Member Smt. Sukhwinder Kaur, Member
For the Complainant : Sh. Lovenish Garg, counsel for the complainant For the Opposite parties : Sh. Sunder Gupta, counsel for opposite party No. 1. Opposite party No. 2 exparte.
O R D E R
VIKRAMJIT KAUR SONI, PRESIDENT
The instant complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended upto date (here-in-after referred to as 'Act'). Briefly stated the case of the complainant is that she had obtained a Medi Claim Insurance Policy (Hospitalization Benefit Policy) from opposite party No. 1 bearing Cover Note No. 287162 valid from 11-04-2007 to 10-04-2008 for sum insured of Rs. 3,00,000/- for himself, his wife Nirmala Singla, and his two sons namely Neeraj Kumar Singla and Nutesh Kumar Singla and paid a premium of Rs. 12,196/- to opposite party No. 1. After expiry of the said policy, the same has been renewed by the agent/employee of opposite party No. 1 vide policy No. 360604/34/08/11/00000017 valid from 17-06-2008 to 16-06-2009 after making the payment of premium of Rs. 22,015/ with all benefits which were available with previous policy. The policy was again renewed with all previous benefits vide No. 360604/34/09/11/00000026 valid from 17-06-2009 to 16-06-2010 and the premium of Rs. 22,940/- was paid. During the subsistence of policy on 5-1-2010, the complainant Dharam Paul Singla suffered some vision problem and contacted Dr. Mahipal Singh Sachdev, who got conducted some routine test and advised him Cataract surgery and asked him to visit again. On 20-01-2010, the complainant again approached the said doctor and he performed Cataract surgery and discharged the complainant on the same day with instruction to come again on 21-01-2010 for the status of surgery. The complainant alleged that he spent Rs. 50,000/- on his treatment. The complainant intimated opposite party No. 1 and submitted his all original medical reports, bills and completed other formalities. The complainant approached opposite party No. 1 and requested them to release his claim, but the opposite party No. 1 told him that his claim would be settled and paid by Raksha TPA Pvt. Ltd., Faridabad, i.e. opposite party No. 2. The complainant alleged that he obtained the Insurance policy from opposite party No. 1 and paid the premium to opposite party No. 1, but they sent the matter to opposite party No. 2 for harassing the complainant. The opposite parties vide letter dated 12-08-2010, repudiated the claim of the complainant without any reason except that the policy is running under 2nd year. The opposite parties vide their letter dated 18-08-2010 in reply to letter dated 14-08-2010 of the complainant, has admitted the version of the complainant regarding the policy in question running in the third year. The complainant visited the office of opposite party No. 1 and requested them repeatedly to release his claim, but to no effect. Hence, the complainant has filed the present complaint. The opposite parties filed their joint written reply and admitted that the complainant obtained medi-claim policy vide Cover Note No. 287162 effective from 11-04-2007 to 10-04-2008 but denied that opposite party No. 1 agreed to reimburse any expenses and hospitalization of the first year of Insurance policy as any medi-claim is payable as per terms and conditions of the policy. It has been pleaded that complainant was fully aware that he was suffering from cataract of the eyes which is a pre existing disease and when he learnt about the same, he obtained first medi-claim policy on 11-04-2007 which was discontinued. He obtained fresh Insurance Policy bearing No. 360604/34/08/11/00000017 effective from 17-06-2008 to 16-06-2009 with capital sum insured Rs. 3.00 Lacs and said policy was again renewed vide Policy No. 36-6-4/374/09/11/00000026 effective from 17-06-2009 to 16-06-2010 and in this way, the policy is in second year of inception. After receipt of intimation regarding the treatment/operation obtained by the complainant from Center of Sight Hospital carried on 20-01-2010, opposite party No. 1 sent the documents to opposite party No. 2 to assess the lawfull claim of the complainant but the same was repudiated by them as per exclusion clause 4.3 of the standard medi-claim policy vide letter dated 18-08-2010. It has been pleaded that contract of insurance is contract of “Uberima Fides” i.e. utmost good faith where both the parties are supposed to disclose each and every fact correctly and since the complainant has concealed the true and material fact regarding his pre-existing disease, which was within his knowledge, his claim is not payable. Parties have led their evidence in support of their respective pleadings. Arguments heard. Record alongwith written submissions submitted by the parties perused. It is the admitted fact of the opposite parties that complainant obtained medi-claim Insurance policy vide Cover Note No. 287162 valid from 11-04-2007 to 10-04-2008 for the sum insured of Rs. 3,00,000/- for himself, his wife and two sons. The version of the complainant is that the said policy has been renewed by opposite party No. 1 vide policy No. 360604/34/08/11/00000017 valid from 17-06-2008 to 16-06-2009 whereas the plea of the opposite parties is that the said policy is a fresh policy. The copy of the first Insurance policy valid for the period from 11-04-2007 to 10-04-2008 has not been placed on file, but the complainant has himself deposed in para No. 2 of his affidavit Ex. C-41 that :- “ ...initially the complainant had obtained a Medi claim insurance policy (Hospitalization Benefit Policy) from opposite party No. 1 bearing Cover Note No. 287162 (Policy No. 3606043407200000004 ) valid from 11-04-2007 to 10-04-2008.” However, in para No. 3 of affidavit Ex. C-41 he has deposed :- “After expiry of policy No. 3606043407200000004, the same has been renewed by the agent/employee of opposite party No. 1 vide Policy No. 360604/34/08/11/00000017 valid from 17-06-2008 to 16-06-2009 after making the payment of premium of Rs. 22,015/-.” The version of the complainant itself proves that policy No. 3606043407200000004 was valid from 11-04-2007 to 10-04-2008 meaning thereby that the policy expired on 10-04-2008 then how can the complainant say that policy No. 360604/34/08/11/00000017 valid from 17-06-2008 to 16-06-2009 is the renewal of the policy of first policy. Moreover, the complainant himself got renewed the policy, got issued on 17-06-2008 and expired on 16-06-2009 and it was renewed in continuity vide policy No. 360604/34/09/11/00000026 for the period from 17-06-2009 to 16-06-2010. It is not the version of the complainant that any grace period in depositing the premium in getting renewed the medi claim policy was provided by the opposite parties. The contention of the complainant that in the policy Ex. C-4 the date of issuance of first policy is mentioned as 11-04-2007 is not tenable because the complainant actually obtained first policy on 12-04-2007 which was not got renewed. Thus, it stands proved that policy No. 360604/34/08/11/00000017 is the fresh medi claim policy. A perusal of Medi-claim Insurance policy Ex. C-2 bearing No. 360604/34/09/11/00000026 reveals that complainant is insured for Rs. 3,00,000/- and the period of policy is valid from 17-06-2009 to 16-06-2009. The complainant was admitted in the hospital Centre for Sight, New Delhi, as a case of Cataract Lt. Eye on 20-01-2010 and went under surgery and Phaco+IOL implanted. He submitted his claim with the opposite party No. 1. The opposite party No. 2 has repudiated the claim of the complainant vide letter dated 18-08-2010 Ex. C-14, the relevant portion of the said letter is reproduced hereunder :- “Member ID: N9010275019, Policy No. 360604/34/09/11/00000026, Development Officer Code : 18/22060, Policy Period : 17 Jun-2009 to 16 June-2010, Claim No. 90510116806, Claimant : Dharam Pal Singla. Claim in respect of : Dharm Pal Singla (Self), Hospital Name: Others NA, Period of Hospitalization : 20 Jan-2010 to 20 Jan-2010. ...This is to inform you that the claim has been made NON-TENABLE for the following reason. Observation and Opinion Patient admitted and diagnosed Cataract Lt. Eye. Phaco+IOL Implantation done. Since the policy is in 2nd year of inception and cataract surgery comes under two year exclusion. Hence claim is non payable Cataract Lt. Eye for Phaco+IOL.” After receipt of said letter of opposite party No. 2, the complainant wrote a letter Ex. C-15 to opposite party No. 1 intimating them that the policy in question has been issued subject to Mediclaim Policy 2007; the date of issuance of first Policy 12-04-2007 and the claim is payable as the policy is in third year. In response to this letter, the opposite opposite party No. 1 vide letter Ex. C-17 clarified as under :- “....We have scrutinized the policy record and found that your medi claim policy which was in operation in the year 2007 was expired on 11-04-2008. Then you had got a fresh Medi claim policy (2007) in the year 2008, which was commenced from 17-06-2008 to 16-06-2009 and the same is renewed in the year 2009 for the period 17-06-2009 to 16-06-2010. Hence this was the second year of operation of policy and the claim falls in the second year of the policy and was under the exclusion as per terms and conditions of the policy.” A perusal of clause 4.3 of the Medi-claim policy reads as under :- “During the first year of the operation of insurance cover, the expenses on treatment of diseases such as Cataract, Benign, Prostatic Hypertrophy, Hysterectomy for Menomhagia or Fibromyoma, Hernia, Hydrocele, Congenital, Internal diseases, Fistula in arms, Piles, Sinustis and related disorders are not payable. If these diseases are pre existing at the time of proposal, they will not be covered even during the subsequent period of renewal too.” Clause 4.3 Medi-claim Policy 2007 Ex. R-3 reads as under : “4.3 Waiting period of specified diseases/ailments/conditions : From the time of inception of the cover, the policy will not cover the following diseases/ailments/conditions for the duration shown below. This exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with our Company without break. .....5. Catract & age related eye ailments .... Two years” As discussed above, the complainant obtained medi claim policy No. 360604/34/08/11/00000017 valid from 17-06-2008 to 16-06-2009 which was got renewed by him vide policy No. 360604/34/09/11/00000026 valid from 17-06-2009 to 16-06-2010. His cataract surgery was done on 21-01-2010. Since the complainant has undergone operation of Catract of left eye on 21-01-2010 which is within the second year of inception of the policy, his claim falls under exclusion clause 4.3 of policy and accordingly, the opposite parties rightly repudiated the claim of the complainant and there is no deficiency in service on their part. In view of what has been discussed above, this complaint fails and is hereby dismissed with no order as to costs. Copy of this order be sent to the parties concerned free of cost and the file be consigned to record.
Pronounced 11-01-2012 (Vikramjit Kaur Soni) President (Amarjeet Paul) Member
(Sukhwinder Kaur) Member
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