DISTRICT CONSUMER DISPUTES REDRESSAL FORUM II
Udyog Sadan C 22 & 23 Qutub Institutional Area
(Behind Qutub Hotel) New Delhi 110016.
Case No.815/2007
Sh. N. B. Singh
S/o Shri Singh
R/o D 192 Westend Heights
DLF City Phase V Gurgaon
Haryana 122002 ….Complainant
Versus
1. M/s The New India Assurance Co. Ltd.
(through its Divisional Manager)
Branch office: 311502 2nd Floor
Mother House 22 Yusuf Sarai
Commercial Complex
Gulmohar Enclave New Delhi 110024
2. M/s Raksha TPA Pvt. Ltd.
(through its Managing Director)
15/5 Mathura Road
Faridabad Haryana 121003 ……Opposite Parties
Date of Institution : 25.07.07 Date of Order : 27.09.16
Coram:
Sh. N.K. Goel President
Ms. Naina Bakshi Member
O R D E R
Briefly stated the case of the Complainant is that the Complainant alongwith his wife Mrs. Geeta Singh had taken a policy Individual Medi claim for the period from 21.07.06 to 20.07.07 vide policy No.311502/48/06/20/70000787 dated 12.07.06 from OP No.1. On 27.12.06 Complainant felt pain in his stomach/abdomen and visited Dr. R. Tandon for consultancy who told that the Complainant s had severe and total intestinal blockage and referred to Pushpawati Singhania Research Institute Press Enclave Marg New Delhi 17 where he was admitted and they pumped out the stomach and took X rays and CT Scan was also done. Report showed a total intestinal blockage and when efforts to remove the blockage failed then a surgery was advised to be done after consulting Dr. K. K. Pandey Chief Surgeon of Rockland Hospital and on 28.12.06 he was shifted to Rockland Hospital to undergo surgery of intestinal blockage on 29.12.06 surgery was done on 29. 12 2006 and he remained in hospital for about 13 days and discharged on 08.11.07. He submitted claim form alongwith discharge summary and all original bills for reimbursement of the medical expenses incurred during the hospitalization and claimed a total amount of Rs.1 93 012/ from the OPs. The OPs from the day one tried to delay the claim and demanded useless informations which were not at all required for passing the claim. He received a letter dated 12.06.07 from OP No.2 in which it was stated that kindly en route your request from your underwriting office of the New India Assurance Co. Ltd. i.e. Opposite Party No.1 to enable us to change the same in our records. When he approached OP No.1 for change of the address the Divisional Manager rudely informed him that his claim is not tenable as observed by OP No.2 and the claim had been rejected and the rejection letter was already received by him as per their record and hence there was no need of change of address letter. According to the complainant the OPs rejected the claim on frivolous pleas and taken more than 180 days to reject the genuine claim from which it is evident that there is a deficiency in service on the part of OPs. Hence pleading deficiency in service on the part of OPs the complaint has been filed for the following reliefs:
- Direct the OPs to pay jointly and severally a sum of Rs.1 93 012/ on account of Mediclaim compensation
- Direct the OPs to pay jointly and severally a sum of Rs.50 000/ towards compensation for causing mental agony and physical agony to the Complainant
- Direct the OPs to pay jointly and severally pay a sum of Rs.11 000/ as litigation charges.
OP No.1 in the written statement has inter alia stated that the complaint is not maintainable as the same is beyond the purview of the insurance contract on account of the exclusion clauses of the insurance policy issued to the Complainant and especially undertaking/declaration being signed by the person while entering into the contact with the OP No.1 which reads as under:
I hereby declare and warrant that the above statements are true and complete. I consent and authorize the insurers to seek medical information from any Hospital/Medical Practitioner who has at any time attended or may attend concerning any disease or illness which affects my physical or mental health. I agreed that this proposal shall from thee basis of the contract should the insurance be effected. If after the insurance is effected it is found that the statements answers or particulars stated in the Proposal form and its questionnaires (sic) are incorrect or untrue in any respect the insurance company shall incur no liability under this insurance.
I have read the Prospectus and am willing to accept the coverage Subject to the terms conditions and exceptions prescribed by the Insurance Company therein. Sd/
The printed proposal specifically excludes the pre existing diseases. The clause 4 of the Insurance contract speaks as under:
4.0 The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of
4.1 Such diseases which have been in existence at the time of proposing this insurance. Pre existing conditions means any injury which existed prior to the effective date of this insurance. Pre existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance whether or not the insured person had knowledge that the symptoms were relating to the sickness. Complications arising from pre existing disease will be considered part of that pre existing condition.
OP No.1 has further stated that the disease was pre existing disease as per the discharge summary of Rockland Hospital in which it was inter alia stated as under:
PRIMARY DIAGNOSIS : FUC CA RECTUM AND CA OESOPHAGUS (POST SURGERY) WITH ACUTE INTESTINAL OBSTRUCTION.
Associated ailments : Nil
PROCEDURE : EXPLORATORY LAPAROTOMY DONE ON 29.12.2006
BLOOD GROUP : O POSITIVE
BRIEF CASE SUMMARY
Mr. N. B. Singh 68 years old nondiabetic normotensive male an old known & operated case of Ca esophagus (2003) & Ca rectum ( Oct 2006) was admitted on 28.12.2006 with clinical features of acute intestinal obstructions. X ray abdomen erect and supine related multiple and fluid levels & small intestinal dilation level of obstruction suspected at mid ileum. CECT whole abdomen revealed at same. He was resuscitated & taken up for emergency exploratory laparotomy on 29.12.2006 when he was found to have adhesive obstruction and the feeding jejunostomy was also released and stapled stricteroplasty done. His post operative recovery was uneventful. He is being discharged on 08.01.2007 with healthy suture line and on oral feeds.
It is stated that vide the insurance policy in question the complainant and his wife had got them insured for Rs. 1 50 000/ each and hence according to the said benefits the policy covers total benefits amounting to Rs. 1 50 000/ which is the maximum liability of the OP 1 at any point of time during the pendency of the policy. It is further submitted that the complainant had submitted a cash memo for Rs. 50/ deposit receipts for Rs. 29950/ Rs. 1071 Rs. 209 Rs. 256/ Rs. 149/ and Rs. 174/ from Pushpawati Singhania Research Institute and PSRI Drugstore totaling to Rs. 31 859/ only as against the alleged amount of Rs. 1 93 021/ . It is prayed that the complaint be dismissed.
We must say at once here that OP 1 has not specifically denied the fact that individual policy had been being taken by the complainant and his wife for the last one year.
OP No.2 has been proceeded exparte vide order dated 13.02.2008 passed by our predecessors.
Complainant has filed his own affidavit in evidence while affidavit of Sh. Surinder Bhatoa Regional Manager has been filed in evidence on behalf of the OP No. 1.
Written arguments have been filed on behalf of the parties.
We have heard the arguments on behalf of the parties and have also gone through the file very carefully.
It is not in dispute that the Complainant had taken a policy Individual Medi claim for the period from 21.07.06 to 20.07.07 vide policy No.311502/48/06/20/70000787 dated 12.07.06 from OP No.1. As stated hereinabove OP 1 has not denied the fact that the policy in question was in continuation of earlier policies taken by the complainant and his wife. Moreover in insurance policy in question (copy Annexure P1) previous policy Year/No. have been mentioned as 2005/312500480575504 by the OP No. 1 Branch. Hence the policy in question was in continuation of earlier policy/policies. Complainant was admitted in Pushpawati Singhania Research Institute New Delhi on 27.12.2006 and was shifted to Rockland hospital on 28.12.2006. He underwent surgery of intestinal blockage on 29.12.2006 and remained hospitalized for about 13 days and was discharged on 08.01.07. The Complainant has filed the copy of insurance policy valid from 21.07.06 to 20.07.07 (copy Annexure P 1) copy of the discharge summary issued by Rockland Hospital (copy Annexure P 3). The Complainant filed the claim with OP No.2 (copy Annexure P 5). Relevant portion of the said documents reads as under:
Some bills relating to Doctors fees medicines etc. have been misplaced due to the nature of the emergency but that cannot be helped. If found later I will forward them to you for consideration.
The OP No.2 vide letter dated 12.02.07 repudiated the claim of the Complainant on the ground that the Complainant was suffering from pre existing disease.
As stated hereinabove the policy in question was in continuation of earlier policy/policies being taken by the complainant from OP 1. Therefore the claim of the complainant ought not to have been repudiated on this ground. Therefore the repudiation of the claim by the OPs was totally unjustified and done with malafide intentions.
However according to the complainant he spent Rs. 1 93 012/ on his medical treatment in PRSI Saket New Delhi and Rockland Hospital New Delhi. However to our utter surprise he has not filed the copies of the medical bills/final medical bills issued by the Rockland Hospital New Delhi though he has filed the copy of discharge summary issued by the Rockland Hospital New Delhi. While stating so we are not unmindful of the fact that according to the complainant he had filed original medical papers including original discharge summary and medical bills with the OPs. However according to the OPs the OPs received total bills for Rs. 31 859/ from the complainant. According to the complainant himself he had lost some bills of the doctors fee medicines etc. Complainant has filed the copy of the details of the expenditure incurred by him on his treatment as Annex. P 4. This is a statement of expenses. It has neither been signed by the complainant nor anybody on his behalf. The figure has been written on a plain paper which has no evidentially value. Therefore we are not inclined to believe that the complainant had infact spent Rs. 1 93 012/ on his medical treatment.
In view of the above discussion we allow the complaint in part and direct the OP 1 to pay Rs. 31 859/ to the complainant towards medical expenses along with interest @ Rs. 6% p.a. from the date of filing of the complainant till realization and Rs. 15 000/ in lumpsum towards harassment mental agony and cost of litigation within one month of receipt of copy of this order failing which OP 1 shall become liable to pay interest @ Rs. 9% per annum on the amount of Rs. 31 859/ from the date of filing of the complaint till the date of realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL)
MEMBER PRESIDENT
Announced on 27.09.16.
Case No. 815/07
27.9.2016
Present – None.
Vide our separate order of even date pronounced the complaint is allowed in part. OP 1 is directed to pay Rs. 31 859/ to the complainant towards medical expenses along with interest @ Rs. 6% p.a. from the date of filing of the complainant till realization and Rs. 15 000/ in lumpsum towards harassment mental agony and cost of litigation within one month of receipt of copy of this order failing which OP 1 shall become liable to pay interest @ Rs. 9% per annum on the amount of Rs. 31 859/ from the date of filing of the complaint till the date of realization. Let the file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL)
MEMBER PRESIDENT
