MA/33/2022 in CC/179/2022

Order Date: 28/12/2023

Order on application for condonation of delay filed by the Complainant

1. Heard both the parties on the delay application and perused the record of the complaint.
2. The Respondent no.2 has duly served with the notice of the delay condonation application, but absented, hence the application proceeded ex-parte on 12/12/2023.
3. The Complainant has taken Mediclaim insurance policy no.121500/48/2020/1316 for the period 12/09/2019 to 11/09/2020 from the Respondents.
4. The Complainant has taken Mediclaim Policy in the year 2016 has taken Medi claim Policy no.121500/48/2017/1621 for sum insured of Rs.5,00,000/-. In the year 2019 the Complainant has made enhancement in the sum insured from Rs.5,00,000/- to Rs.10,00,000/- of the same renewal policy.
5. In month January 2020 the Complainant suffered unconsciousness and sudden fall. Therefore, she has consulted their family doctor who after examination suggests some medical tests. After examination of the said medical reports, doctor referred to Neuro Surgeon at Breach Candy Hospital and it was diagnosed with her Right Carotid Artery which supplies blood to the head, face and brain had 95% blockage. Therefore, immediate surgery for stenting Right ICA-CCA Angioplasty stenting was conducted on 04/02/2020 and discharged on 08/02/2020. She incurred total expenditure of Rs.9,26,682/- towards above said surgery. Therefore, lodged the claim for Rs.9,26,682/-, out of that only Rs.5,00,000/- was paid to the Complainant. The Respondent no.2 i.e. agent of Respondent no.1 by their claim settlement Advice dt.07/04/2020 deducted the claim amount Rs.4,26,682/- on the ground that, excess of defined amount/ Ailment Limit.
6. The Complainant made all her attempts to get the claim; but the Respondent did not pay heed. Thus, the Complainant has sent legal notice to Respondent on 13/06/2022, to consider the valid and legal claim of the Complainant; but in vain.
7. Thereafter the Complainant had approached to the office of the Insurance Ombudsman by the letter dt.14/04/2021 for the consideration of the claim which was rejected by the Respondent no.1. The Ombudsman by its award dt.05/01/2022 did not consider or rejected the claim of the Complainant.
8. Therefore, approaching to the Ombudsman and due to Pandemic Covid-19 situation, the Complainant has not filed the present complaint within time. Therefore, she has prayed, to condone the delay of 109 days in filing the present complaint.
9.  The Respondent has strongly opposed the application on the following grounds:
   1. The Complainant has obtained Medi claim Insurance Policy-PNB Oriental Medi claim Policy-2017 Group Health Insurance Product wherein the Policy was for Bank Account Holders of PNB only.
   2. The Complainant has a parallel Medi-claim Insurance Policy with National Insurance Co. Therefore, National Insurance Co is necessary party to this proceeding to rule out that the amount of Rs.4, 26,682/- has not been obtained through the said Insurer and their TPA.
   3. The Complainant has nowhere assured that he has not filed any parallel proceedings in any other court of law for the said ailment and hospitalization.Therefore the National Insurance Co. is essential party in the matter unless they are made a party to the proceedings, the matter be held in abeyance.
   4. The Complainant has lodged a claim with the Respondent for the admission and treatment taken by her at Breach Candy Hospital from 04/02/2020 to 08/02/2020 for Hypertension and IHD. The Complainant is known case of IHD-PTCA and LAD since 2007 and PTCA in 2016. She has lodged the claim of Rs.9,26,682/- out of that Rs.5,00,000/- was sanctioned and transferred in her account by electronically. The claim was restricted to Rs.5,00,000/- since the ailment was a complication of IHD and Hypertension and there is three years waiting period applicable or the which the Complainant was hospitalized. It is pertinent to note that the claim arose during the first year of the enhancement. The amount was restricted to Rs.5,00,000/- as the claim fell within Policy clause 4.1 and 4.2 of the policy terms and condition.
   5. The claim settlement voucher was forwarded to the Complainant on 07/04/2020. The Complainant has belatedly raised an objection and approached to Ombudsman conveyed their order towards the grievance of the Complainant vide letter dt.03/02/2022 wherein the Ombudsman had decided the matter on 05/01/2022.
   6. The delay is quantified by the Complainant as109 day which is completely erroneous. The Complainant has raised a grievance towards alleged balance amount after a period of 26 ½ months. There is no justification for this inordinate delay.
   7. It is pertinent to note that the diagnosis was discovered sometime prior to the renewal and enhancement of the sum insured. The ailments for which the Complainant was allegedly treated were by triggered by pre-existing ailments.
   8. The Complainant cannot take refuge of Covid-19 Pandamic as the lockdown was relaxed for long period wherein she could have filed her complaint.
   9. On all the grounds, it has prayed for dismissal of the said application with costs.
10. Considering the contention and the arguments of both the parties, the following point arises for our determination.

6. The Complainant has policy holder since 2016 and renewed the same year to year for the sum assured of Rs.5,00,000/-. In the Septmeber 2019, she has enhanced the sum assured up to Rs.10,00,000/-.  Thereafter, she was operated for Right ICA-CCA Angioplasty stenting on 04/02/2020 and was discharged on 08/02/2020. Therefore she has lodged the claim of Rs.9,26,682/- for reimbursement of medical expense. The said claim was settled by the Respondent to the tune of Rs.5,00,000/- on 07/04/2020 and partially repudiated the claim on the ground of pre-existing disease(enhanced sum insured). Therefore, she was approached to the Ombudsman on12/04/2021 and the said complaint was disposed off by the Ombudsman and award was passed on 05/01/2022.
7. Therefore, according to the Complainant, there is 109 days of delay in the filling of present complaint on the ground of Ombudsman proceeding and Pandamic situation. According to the Respondent there is delay of 26 ½ months in the matter.

The partial claim was allowed to Rs.5,00,000/- on 07/04/2020. Then within reasonable time doors of ombudsman should have been knocked. However, complaint to Ombudsman appears to be made on dt.12/04/2021. The same came to be rejected by order dt. 05/01/2022. In such a fashion the delay in between allowing claim partially, till that order uphold by Ombudsman stands condoned as Ombudsman has not raised any objection thereto.

8. Now we have to deal delay from the date of order of Ombudsman i.e. 05/01/2022 till the filing of complaint i.e. on 21/07/2022. The delay calculated in such manner comes to 6 months 17days. Thus, Complainant was duty bound to assign sufficient and satisfactory grounds thereto. She has taken shelter of Covid-19 which indeed over when claim has been rejected by Ombudsman. On this plight evidence of Respondent needs consideration. In such manner only one conclusion arises that no sufficient ground has been made out to condone the alarming delay.

9. Therefore, under such circumstances, the condonation of delay will amount to misuse of the judicial process. Hence, there is no sufficient ground to condone the delay; consequently, the delay application deserves to be rejected. Hence, we record the finding on the point accordingly and proceed to pass the following order.

Final Order

1. The condonation of delay application no.33/2022is hereby dismissed without costs.
2. As the delay condonation application ended in dismissal the Consumer case no.179/2022 stand hereby dismissed.