DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No. 379/2018
Mr. Anil Gadodia
S/o Late Sh. Hari Ram Gadodia,
R/o TU-45 Second Floor,
Pitampura, Delhi-110034
….Complainant
Versus
- The Oriental Insurance Company Ltd.
UGF 8/11/12 & 13
Arunachal Building
19 Barakhamba Road
New Delhi-110001
- Fair Deal Insurance Brokers Pvt Ltd
Mr. O P Dua
16 Avtar Enclave First Floor
Paschim Vihar
New Delhi-110063
- E-Meditek (TPA) Services Limited
Plot No.-557, Udyog Vihar,
Phase – 5
Gurgaon, Haryana-122016
….Opposite Parties
Date of Institution : 20.12.2018
Date of Order : 06.07.2022
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Member: Sh. U.K Tyagi
1. Complainant has requested to pass an award directing (i) to set aside the repudiation letter dated 09.08.2016; (ii) to release the payment of Rs.6,00,000/- alongwith interest @18% per annum(iii) to award the compensation of Rs. 1,00,000/- towards medical agony & harassment and Rs.55,000/- as litigation charges against the opposite parties.
2. Brief facts of the case are as under:-
The Complainant is having Mediclaim Policy vide No.215600/48/2016/3510 with The Oriental Insurance Company Ltd. (hereinafter referred to as OP) Since 2010 which is still continuing with validity from 27.12.2015 to 26.12.2016 for the amount of Rs.6,00,000/-. It is also pointed out here that OP-3 is the TPA appointed by OP-1. The Notices were issued to OP-2 & OP-3 but their presence was neither found recorded on the order sheet nor their reply was on record. The Complainant got admitted to Medanta Hospital and remained hospitalized from 04.01.2016 to 09.01.2016. The Complainant requested OP-3 for authorization of cashless facility. It was told that same could not be processed & may submit his claim later. Total expenses was to the tune of Rs. 7,22,186/- and accordingly put up his claim. Many letters were issued for early process of same. All requisite documents were submitted as and when asked. OP-1 sent a letter dated 07.04.2016 rejecting the cashless claim and no mention about the claim pending with OPs. Meanwhile a mail was sent to Complainant for submission of certain documents. All efforts were made to deposit these documents but not accepted. Many letters were sent by the Complainant alongwith documents but no response was received from OPs. Ultimately, the OP-1 sent a letter dated 09.08.2016 repudiating the claim of the Complainant on the ground that heart & related diseases are excluded under the policy. The Complainant had been subscribing this policy since 24.12.2009.
3. OP, on the other hand, submitted its reply and took preliminary objections stating that the complaint is liable to be dismissed as there is no deficiency of service on the part of OP. It was submitted that since inception of the mediclaim policy i.e policy period w.e.f 2009-10, 2010-11 and all subsequent policies including policy in question issued for the period w.e.f 27.12.2015 to 26.12.2016, were issued with the pre-imposed condition, “Exclusion of Heart and related Diseases Forever”, by the OP Company. It may be seen that claim of Complainant is for treatment/surgery of heart related disease in the period 04.01.2016 to 09.01.2016 with medical history and “Patient is hypertensive , Diabetic male, is known a case of Post ICD implantation in 2007 and LV Dysfunction (EF33%)”, “Presented here with complaints of Dyspnoeaon Exertion (Since Last 7-8 years) but increased since 4-5 months and pain in bilateral legs and backache. He was admitted here for further evaluation and management” and as per the treatment records Coronary Angiography was done on 04.01.2016 and CRT-D Implantation (Medtronic) was done on 07.01.2016 as is revealed vide Discharge summary dated 09.01.2016. It is alleged that same was not endorsed by the Complainant. OP, on the receipt of the said report, rightly repudiated the claim as the Complainant was treated with heart disease which is inadmissible as per the Policy.
4. Both the parties have filed Written Submissions and evidence-in-affidavit. Written Statement is on record so is rejoinder. Oral arguments were heard & concluded.
5. This Commission has gone into material placed before us and due consideration was also given to the arguments. A serious thought was given to the features and terms & conditions of policy extended to the Complainant. The OP vide its reply enclosed the copy of Happy Family Floater Policy 2015. It is believed that the said policy was extended to the Complainant. It is noted with alacrity that the Complainant vide its replication rebutted the stand of the OPs vide which it was emphasized that since inception of the mediclaim policy i.e policy period w.e.f 2009-10, 2010-11 and in all subsequent years including the policy in question 2015-16, with the pre-imposed condition, “Exclusion of Heart and related Diseases Forever”, but the Complainant was admitted in the Hospital with complaint of back-ache & legs pain. It was only later on informed by the doctors that he requires a placement of pacemaker in his heart. The Complainant assailed the position of the OP about the exclusion of “Heart and related disease” as per previous Policy as is written in Policy of Complainant. The copy of the same is enclosed with the complaint. The Complainant further submitted that he was informed by OP- Company that the Complainant would not be initially given policy covering heart related disease but if the Complainant does not avail any claim for heart related disease for initial two years of policy, then he would be entitled for heart related claim for the third year of policy.
6. The Commission occasioned to see the Happy Family Floater Policy in detail and delved into the exclusion clause at Para 4.4.1 speaks about the pre-existing diseases etc, and same are excluded for such insured person upto 4 years of this policy being in force continuously.
7. The same is also pointedly told in Para 4.3 of the said Policy where time period of Para 4.1 is reduced to two years. It would be seen from the averments of both the parties that the Complainant had been holding the said policy since 2009-10 till 2015-16 continuously. It appears that the TPA has not considered all aspects of the said policy and complete facts were not brought before OP- Company. The Complainant also referred the case of “Hari Om Aggarwal Vs Oriental Insurance”. Whereby it is held by Hon’ble High Court, Delhi that “ It is universally known that hypertension & diabetics can lead to host of ailments such as stroke, cardiac, renal failure, liver complications, etc. depending upon varied factors”. That implies that there is probability of such ailments; equally they can arise in non-diabetics or those without hypertension. It was also held that “the object of the insurance policy is to cater to medical expenses incurred by the insured” That is the “main purpose” of contract of insurance and insurance company is trying to run away from their liability to cover the medical expenses of the Complainant.
8. Having consided the material placed before us, the Commission feels that the OPs should re-consider their decision of the repudiation of the claim of the Complainant as prayed by him in its complaint. Therefore, this Commission directs the OP to reconsider and decide the case of the Complainant on merits within a time period of three months from the date of this order. Since the matter is remanded to OPs for their reconsideration, the other requests of the Complainant are not considered here.
No Order as to cost.
File be consigned to the record room after providing copy of the order to both the parties. Order be uploaded on the website
