BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.377 of 2014

Date of Instt. 27.10.2014

Date of Decision :29.09.2015

Rakesh Kumar Arora son of Jiwan Lal R/o H.No.393-R, Model Town, Jalandhar.

..........Complainant Versus

1. The Oriental Insurance Co.Ltd, Branch Office-II, Ground Floor, Jeevan Rakshak Building, S.C.O.50, Puda Complex, Jalandhar through its Branch Manager.

2. E-MEDTTEK Service Limited, Corporate Office, Plot No.577, Udyog Vihar, Phase-V, Gurgaon (Haryana)-122016 through its Director.

.........Opposite parties.

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.KC Malhotra Adv., counsel for complainant.

Sh.Brijesh Bakshi Adv., counsel for opposite party No.1.

Notice to OP No.2 dispensed with.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that law abiding citizen complainant above named obtained Happy Family Floater under the silver plan insurance policy hospitalization benefit covering risk to reimburse/indemnify expenses for any disease or suffer from any illness/ailments, disease or injury sustained from opposite party No.1 through its authorized agent for the period stated in cover note No.783532 dated 18.6.2012 by renewal effective from the period 28.6.2012 to 27.6.2013. The complainant has been continuously and un-interruptly insured himself, his wife Smt.Sudesh Arora and son Sunil Arora since the year 2008 without any gap/break and stings by opposite party No.1. The policy number 233108/48/2013/759 was allotted. Person insured by H.F.F.Policy for medical benefit insurance policy are complainant and his wife Sudesh Arora and son Sunil Arora each for sum insured Rs.2 Lacs under silver plan. The cover note and policy schedule HFF policy were issued in the name of complainant. The total amount of renewal premium of Rs.6922/- as consideration was paid to the opposite party No.1 through its authorized agent/representative which was accepted after satisfying the continued insurability and without questioning the credentials of the insured person without any demur and strings. The opposite party No.1 issued/delivered to the complainant cover note and policy schedule of HFF Policy only from the inception of the risk coverage under the mediclaim insurance policy and on its renewal. The policy document was not issued/delivered to the complainant by opposite party No.1 during the whole of the period of the policy. Complainant, insured with opposite party No.1 complained chest pain and on examination diagnosed as a case of inferior valve MI and was admitted on 10.3.2013 and discharged on 12.3.2013 by Tagore Hospital and Care Centre Private Limited, Jalandhar. He underwent successful primary PTCA + Stent on 10.3.2013 and discharged in a stable condition. Dr.Nipun Mahajan, Senior Cardiologist and Interventionist performed surgery. The complainant was charged and paid Rs.2,01,000/- to the hospital besides Rs.2720-20/- incurred on medicine. After discharge from the hospital, the complainant made a claim for PTCA for Rs.2,01,000/- and Rs.2720/- on account of medicine for reimbursement to opposite party No.1 duly completed claim on prescribed form, bills and receipts and discharge certificate alongwith the clinical test reports etc were submitted. All the formalities and the requirements whichever asked for, were completed and complied with for settlement and reimbursement of medical claim for an amount of Rs.2,01,000/- and Rs.2720/- on account of medicine. Opposite party No.1 forwarded claim to opposite party No.2. The claim was registered under No.103031300140. To utter surprise and to dismay of the complainant opposite party No.2, vide letter dated 5.7.2014 unilaterally, arbitrarily on whims and fancy intimated that the claim is not payable. The disease has two years of waiting period so can not be paid and that opposite party No.1 insurance company not liable to make payment under section 4-Exclusions, and clause No.4.3, inter-alia, advised opposite party No.1 to repudiate the claim on the basis of opinion obtained by TPA from its panel doctor. However, opposite party No.1 had not issued any repudiation letter to the complainant regardless of the advise of opposite party No.2 providing specimen of draft repudiation letter. On such like averments, complainant has prayed for directing the opposite party No.1 insurance company to pay him the claim amount of Rs.2 Lacs alongwith interest. He has also claimed compensation and litigation expenses.

2. Notice to opposite party No.2 was dispensed with.

3. Upon notice, opposite party No.1 appeared and filed a written reply, inter-alia, pleading that the medical claim policy issued to the complainant is matter of record and subject to terms and conditions therein. The claim reimbursement is subject to the policy conditions and exclusions. The claim of the complainant was rightly repudiated and intimation thereof conveyed to the complainant. The fact of the matter is that on scrutiny of the claim form and documents submitted by the complainant, it was found that he was admitted in Tagore Hospital & Heart Care Centre, diagnosed for Acute Coronary Syndrome, Mild LV Dysfunction PTCA stent to RCA done. The disease has two years waiting period so can not be paid because there is no policy prior to 28.6.2011. It is pertinent to mention that it was specifically noted that despite raising queries copies not received. Thus, on valid grounds the claim stood finally repudiated after acquiescence of the opposite party No.1 to the proposal of the opposite party No.2. It denied other material averments of the complainant.

4. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavits Ex.CA and Ex.CB alongwith copies of documents Ex.C1 to Ex.C23 and closed evidence.

5. On the other hand, learned counsel for the opposite party No.1 has tendered affidavit Ex.OPA alongwith copies of documents Ex.O1 to Ex.O8 and closed evidence.

6. We have carefully gone through the record and also heard the learned counsels for the parties.

7. It is not disputed that the complainant had obtained mediclaim insurance policy from opposite party No.1 insurance company for Rs.2 Lacs. It was also not disputed that complainant was admitted in Tagore Hospital on 10.3.2013 with complaint of chest pain and underwent PTCA + Stent on 10.3.2013 and was discharged after surgery. The complainant made claim with opposite party insurance company but opposite party insurance company repudiated his claim on the ground that the above said disease has two years of waiting period and complainant has no policy before 26.6.2011. Ex.C1 is repudiation letter issued by opposite party No.2. The claim was repudiated under section 4 containing exclusions. Clause 4.3 of the exclusions provide as under:-

"4.3. 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. If these diseases are pre-existing at the time of proposal the exclusion No.4.1 for pre-existing condition shall be applicable in such cases.

7. Counsel for opposite party No.1 contended that as per discharge summary Ex.C9, the complainant was suffering from HTN i.e hypertension and the disease i.e Inferior wall MI is the direct consequence of the hypertension. We have carefully considered the contentions advanced by learned counsel for the opposite party No.1. As per medical literature, hypertension is one of the risk factor of heart problem. There are many other risk factors for heart problem. The complainant was suffering from Inferior wall MI and this disease is not mentioned in clause 4.3 of the terms and conditions of the mediclaim policy (section 4 relating to exclusions). There is no medical or expert evidence on record to prove that in the present case, the aliment from which the complainant suffered i.e Inferior wall MI was the direct consequence of hypertension. When the aliment or disease Inferior wall MI is not mentioned in the clause 4.3, therefore, the opposite parties could not have invoke the exclusion clause for repudiating the claim of the complainant. In the above circumstances, we are of the view that the opposite party insurance company was not justified in repudiating the claim of the complainant on the above said ground.

8. In view of above discussion, the present complaint is accepted and opposite party No.1 insurance company is directed to pay Rs.2 Lacs to the complainant alongwith interest @ 9% per annum from the date of repudiating of his claim till the date of payment. It is clarified that interest amount is being granted by way of compensation. The complainant is also awarded Rs.3000/- on account of litigation expenses. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

29.09.2015 Member Member President