Chandigarh

DF-II

CC/669/2018

Mrs. Neelam Dhingra - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

Durga Dutt Sharma Adv. & Chandan Dhingra Adv.

17 Feb 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	669/2018
Date of Institution	:	27.11.2018
Date of Decision	:	17.02.2020

 

                                       

                                               

Mrs.Neelam Dhingra w/o Sh.Sham Sunder Dhingra r/o H.No.980, Sector 10, Panchkula, Haryana.

                                ...  Complainant.

Versus

1. The Oriental Insurance Company Ltd., through its Regional Manager, Regional Office, SCO No.109-110-111, Surendra Building, Sector 17-D, Chandigarh 160017.
2. M/s Raksha TPA Pvt. Ltd., through its Authorized Signatory/Representative, # 15/5, Mathura Road, Faridabad, Haryana -121003.
3. Max Super Speciality Hospital, SAS Nagar, Mohali, Punjab through its Authorized Signatory/Representative, Near Civil Hospital, Phase -6, SAS Nagar, Mohali Punjab.

…. Opposite Parties.

BEFORE:

              SHRI RAJAN DEWAN, PRESIDENT

SMT.PRITI MALHOTRA, MEMBER

 

Argued by :

Sh.Chandan Dhingra, Adv. for the complainant

Sh.J.P.Nahar, Adv. for OPs No.1 & 2.

                Ms.Neetu Singh, Adv. for  OP No.3.    

 

PER RAJAN DEWAN, PRESIDENT

1.         Briefly stated, the complainant along with her son  took a Medi-Claim Policy i.e. Happy Family Floaters Policy from OP No.1 against the premium of Rs.12,517/-, which was valid from 20.02.2014 to 19.02.2015 and thereafter for the years 2015-16, 2016-17 and 2017-18.  It has been averred that neither any policy was issued nor any terms and conditions were sent or details of that were explained to the complainant anytime from the day one.  In June/July 2017, she suffered from high fever and remained admitted for three days in Civil Hospital, Chandigarh where she was treated on the basis of liver abscess and UTI with Inj. pippracillin plus tazobactum and metrogyti later on the basis of urine culture.  Subsequently, she had approached Max Super Specialty Hospital, Mohali and undergone RCP with stent exchange with prior dilatation of the dominant biliary stricture.  In the evening, she had a bout of vomiting with pain in the epigstum radiating to the back for which she was brought to ER.  Investigations showed e/o pancreatitis and hence she was managed as past ERCP pancreatitis with relief in vomiting. Thereafter, she has submitted the claim with OP No.1 which was proposed to be repudiated vide letter dated 13.10.2017 (Annexure C-8) on the ground of pre-existing disease. She was given 10 days time to substantiate the claim in view of the grounds of repudiation before the final decision. She submitted the  representation dated 13.10.2017 (Annexure C-9) to OP No.1 for reviewing the claim. In reply to the said letter, she was informed vide letter dated 19.09.2018 (Annexure C-10) that the claim was repudiated.  It has further been averred that the claim was rejected on the ground of terms and conditions of the policy which were not applicable to the case.  Alleging that the aforesaid acts of commission and omission amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the complainant has filed the instant complaint.
2.         In their written statement, OPs No.1 and 2 while admitting the factual matrix of the case have pleaded  that Annexure C-4 is not print out taken from the internet but a signed policy duly stamped by the Policy Issuing Office and consists of three pages. However, the complainant has annexed only one page of the insurance policy.  It has been admitted that the complainant was insured for Rs.4 lakhs but the claim was subject to the terms and conditions of the Insurance Policy. It has further been pleaded that the complainant is paying the premium every year since 02/2014 and it is unthinkable that the policies terms and conditions were not provided to her.  It has further been pleaded that she did not lodge the claim pertaining to her hospitalization from 14.07.2017 to 17.07.2017 for her admission at CMC Chandigarh. However, she is a known case of hypertension for four years and idiopathic ulcerative colitis for 5 years as per the discharge summary of CMC, Chandigarh.   It has further been stated that the opinion given by the doctor Annexure C-8 is an afterthought and was issued just to help the complainant. It has further been pleaded that the claim was rightly repudiated as per the terms and conditions of the insurance policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, a prayer for dismissal of the complaint has been made.
3.         In its separate written statement, OP No.3 has submitted that the complainant has not claimed any relief qua it and the grievance, if any, is against OPs No.1 and 2.  Therefore, it is prayed that the complaint qua it be dismissed.
4.         The complainant filed rejoinder to the written reply of the Opposite Parties No.1 and 2 controverting their stand and reiterating her own.              
5.         We have heard the learned counsel for the parties and have gone through the documents on record.
6.         It is admitted fact on record that the complainant  along with her family members had obtained Medi-Claim Policy i.e. Happy Family Floaters Policy  from the Opposite Parties commencing from 20.02.2014 to 19.02.2015 and thereafter for the year 2015 to 2018 as is evident from the cover notes/policy (Annexure C-1 to C-4).
7.         The grouse of the complainant is that the claim  was wrongly repudiated by the OPs vide letter dated 19.09.2018 (Annexure C-10) on the ground that she was suffering from pre-existing disease by relying upon the Clause 4.1 of the terms and conditions of the insurance policy .
8.         On the contrary, the contention of the OPs is that since the complainant was suffering from pre-existing disease and, therefore, the claim was rightly repudiated in view of Clause No.4.1 of the terms and conditions of the insurance policy.
9.         It is established from the discharge summary  (Annexure C-6) issued by the Max Super Specialty Hospital, Mohali that she was admitted in the said hospital on 04.09.2017 and discharged on 05.09.2017.  She was diagnosed to be suffering from ulcerative colitis, primary scilerosing cholangitis, dominant stricture left ductal system, prior secondary bacterial cholangitis E.coli related, ERCP with stenting done (2 procedures 3 days apart one month back), patient had a fever with anorexia and hence ERCP done for cholangitis (4/9/17) and post ERCP Pancreatitis: Clinically Mild.  Under the column of history of the discharge summary, it was also mentioned that she had a history of hypertension for 5 years and ulcerative colitis for 5 years.  
10.         Moreover, it is also evident from the discharge and follow card issued by the CMC, Chandigarh (Annexure C-5) that the complainant remained admitted in the hospital on 14.07.2017 and discharged on 17.07.2017. Under the column of History & Physical Examination, it was clearly mentioned that the complainant was a known case of hypertension for 4 years and ulcerative colitis for 5 years. In the said hospital, the complainant was diagnosed to be suffering from Liver Abcess, Urinary Tract Infection, Idiopathic with  ulcerative colitis.  We have no hesitation in our mind to conclude that the complainant had pre-existing disease for which she was treated, which was a “material fact” in regard to her health but she had suppressed it at the time of taking the mediclaim policy in question, and thus, breached the terms and conditions of the policy in question. Consequently, no fault could be found in repudiation of the claim by the Insurance Company                                                           
11.         Keeping in view the facts and circumstances of the present, we are of the considered view that the claim of the complainant was rightly repudiated by the OPs vide its letter dated 19.09.2018 (Annexure C-10) on the grounds stated therein as per the terms and conditions of the insurance policy.  
12.         As regards, the plea of the complainant that the OPs have not supplied the terms and conditions of the policy is concerned,  we find not no substance in this plea  because she was paying the premium since 20.02.2014 to the OPs and at the bottom of the said cover notes (Annexure C-1 to C-3) itself, it was clearly stated that “the insured named above having this day proposed to effect the above insured and having paid/made a deposit/furnished a bank guarantee for the premium stated above the risk is hereby insured subject to the usual terms and conditions of the company’s Standard policy.  In case, the complainant had not received the terms and conditions of the insurance policy, it was her duty to immediately inform the OPs by writing any letter/email about the same at the time of renewal of the policy or thereafter, but she did not do so and as such ignorance of the terms and conditions of the policy is no excuse and the complainant cannot take stand that she has not received or supplied terms and conditions.
13. .  Here our view is bolstered from the judgment of the Hon’ble National Commission passed in R.P.No.429/2017 titled as Aman Kapoor Vs. National Insurance Company Ltd. and Others wherein it was held that when there seems to be no effort on the part of the complainant to obtain a copy of the terms and conditions of the policy, the ignorance of the terms and conditions of the policy is no excuse and provides no shelter to the complainant.
14.         For the reasons record above, the complaint is dismissed with no order as to costs. 
15.         Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Sd/-                         sd/-

Announced		[RAJAN DEWAN]	(PRITI MALHOTRA)
17.02.2020		PRESIDENT	MEMBER