District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.164/2020.
Date of Institution: 16.06.2020.
Date of Order: 12.09.2022.
Hari Saini son of late Shri Mawas Ram Saini r/o House No. 956, sEctor-23, Main Road, Housing Board Colony, NIT, Faridabad having email id –ksachdevaadvocae@gmail.com. …….Complainant……..
Versus
1. The Oriental Insurance Company Ltd., Office at:- 5B/4BP, 2nd floor, Neelam Railway Road, NIT, Faridabad through its Director/principal Officer/Branch Manager.
2. Health Insurance TPA of India Ltd., Office at: - Majestic Omnia Building, 2nd floor, A-110, Sector-4, Noida – 201301 (U.P) through its Director/Principal Officer/Branch Manager.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………..Member
PRESENT: Sh. Kumud Sachdeva, counsel for the complainant.
Sh. Anuj Gupta, counsel for opposite party No.1.
Opposite party No.2 exparte vide order dated 27.10.2021.
ORDER:
The facts in brief of the complaint are that the complainant obtained mediclaim policy – Happy Family floater-2015 policy schedule bearing policy No. 272400/48/2019/11678 valid form 15.01.2019 to 14.01.2019 which was obtained by the complainant from opposite party No.1 against payment of premium paid to the opposite parties for sum assured Rs.20,00,000/- silver plan. Unfortunately the complainant felt chest heaviness off and on associated with uneasiness, nausea and vomiting on 16.3.2019 and thus visited Fortis Escorts Hospital, Faridabad on the same day and was admitted by the aforesaid hospital of admission on 16.3.2019 as he was diagnosed for Acute Coronary Syndrome. The complainant was denied cashless benefit and the complainant had to deposit a sum of Rs.1,04,000/- in cash with the Fortis Escorts Hospital, Faridabad on 19.3.2019 vide reeipt No. 1105/DP/1903/228695, the complainant was also called upon to deposit a sum of Rs.7,000/- in cash which was complied on 19.03.2019 vide receipt No. 1105/DP/1903/228696 and on the same line the complainant deposited a sum of Rs.6,000/- on 19.3.2019 vide receipt No. 1105/DP/1903/228715. In this manner the complainant paid a total sum of Rs.1,27,000/- for his treatment of heart ailment since his admission in the Fortis escorts Hospital, Faridabad on 16.3.2019 and till the date of his discharge on 19.3.2019. The complainant submitted his claim to opposite parties for getting benefit of reimbursement of hefty amount of Rs.1,27,000/- on 22.03.2019 but despite getting for almost five months, the
complainant did not receive even a single panny form the opposite parties towards his claim. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) sum of Rs.1,27,000/- being the claim amount pertaining to aforesaid mediclaim policy together with interest @ 12% from the date of default and till actual realization.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) Any other relief which this Forum deems fit in the facts and circumstances of the complaint be also granted to the complainant and against the opposite parties.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant was covered under happy family floater policy 2015 Silver Plan (having co-payment of 10%) and age of the complainant entered in the policy was 55 years and incepts under policy for the first time since 15.01.2016. As per discharge summary complainant had a past history of coronary artery disease – Post PTCA to LCX/RCA (02.08.2014). The policy incepts for the first time since 15.01.2016 and insured diagnosed with CAD and underwent PTCA in 2014, present ailment/admission comes under purview of pre-existing defined in clause 4.1 which reads as under (4.1 All Pre-existing disease) (whether treated/untreated, declared or not declared in the proposal form) which were excluded upto 48 months of the policy being in force. Pre-existing diseases should be covered only after the policy had been continuously in force for 48 months. For the purpose of applying this condition, the date of inception of the first indemnity
based health policy taken should be considered, provided the renewals had been continuous and without any break in period, subject to portability condition. This exclusion should also apply to any complication(s) Arising from pre existing diseases. Such complications would be considered as part of the pre existing health condition or disease). There was misrepresentation on the part of insured/complainant, since as per policy insured age was 55 years, whereas in hospital records his age was 64 years, hence the exclusion clause 5.14 and clause 17 were comes in operation, which reads as under:-
5.14 (Fraud/Misrepresentation/concealment: Non – disclosure, concealment of misrepresentation of material facts or making false statements in the proposal form and/or in the Claim form or any other document shall render the policy null and void ab initio a d the company shall not be liable under this policy. The company shall also not be liable under the policy in respect of any claim, if such claim be in any manner intentionally or fraudulently or otherwise misrepresented or concealed or involves making false statement or submitting false bills whether by the insured person or any other person/institution/organization on his behalf. Company shall be at liberty to take suitable legal action against such insured person/institution/organization as per the laws).
17. (Disclosure to information Norm: The policy shall be void, in the event of misrepresentation, mis-description or no disclosure of any material fact).
v) On the basis of above facts the team of opposite party No.2 opined that the claim is no t payable as per clause 4.1, 5.14 and 17 of the insurance policy. The claim of the complainant was repudiated and complainant was informed vide letter dated 12.07.2019 with reason of repudiation, the decision of repudiating the claim was taken after go through treatment papers, settled norms, terms, conditions
& exclusion of the policy, the act of answering opposite part was justified one and within the purview of their contract of insurance, hence the complainant was not entitled to invoke the jurisdiction of the Hon’ble DCDRC .Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Registered notice sent to opposite party No.2 on 1.10.2021 not received back either served or unserved. Case called several times since morning but none had appeared on behalf of opposite party No.2. Therefore, opposite party No.2 was hereby proceeded against exparte vide order dated 27.10.2021.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties– The Oriental Insurance Company Limited with the prayer to: a) sum of Rs.1,27,000/- being the claim amount pertaining to aforesaid mediclaim policy together with interest @ 12% from the date of default and till actual realization. b)pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) Any other relief which this Forum deems fit in the facts and circumstances of the complaint be also granted to the complainant and against the opposite parties.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Shri Hari Saini, Ex.C1 – Happy Family Floater 2015 policy schedule, for the period 15.01.2019 to 14.01.2020, Ex.C-2 – Happy Family Floater-2015 policy schedule valid from 15.01.2018 to 14.01.2019, Ex.C-3 –
Happy Family Floater – 2015 policy schedule for the period 15.01.2017 to 14.01.2018, Ex.C-4 - Happy Family Floater – 2015 policy schedule for the period 15.01.2016 to 14.01.2017, Ex.C5 – Discharge summary,, Ex.C-6 to 9 – deposit Receipts,, Ex.C-10 – claim form, Ex.C-11 –legal notice. Ex.C-12 & 13 – postal receipts,
On the other hand counsel for the opposite party No.1 strongly
agitated and opposed. As per the evidence of the opposite party No.1, Ex.RW1/A – affidavit of Shri Ramesh Kumar, Sr. Divn. Manager of Oriental Insurance co. Ltd., NIT, Faridabad, Ex.R-1 – Discharge summary, Ex.R-2 - Happy Family Floater – 2015 policy schedule for the period 15.01.2019 to 14.01.2020,, Ex.R-3 – Terms and conditions.
7. As per discharge summary complainant had a past history of coronary artery disease – Post PTCA to LCX/RCA (02.08.2014) vide Ex.C5. The policy incepts for the first time since 15.01.2016 and insured diagnosed with CAD and underwent PTCA in 2014, present ailment/admission comes under purview of pre-existing defined in clause 4.1
8. In the repudiation letter is has been mentioned that on the day of admission complainant admitted on 16.3.2019 diagnosed with Type 2 Diabetes Mellitus (HbAIC-9.4%), Coronary artery disease – post PTCA + Stent (2014) Acute coronary syndrome – NSTEMI EF 45-50% CAG patent stent in OMI and 100% thrombotic occlusion in RCA stend LAD 90% stenosis with double vessel disease, PTCA – stent to LAD & POBA to RCA done on 18.03.2019. Post procedure patient discharged on 19.03.2019. Insured has availed cashless facility and in view of pre-existing nature of illness same was denied. As per our records policy incepts for the first time since 15.01.2016 and insured diagnosed with CAD
and underwent PTCA in 2014, present ailment/admission comes under purview of pre existing also misrepresentation noted in the age of the patient, as per policy insured age is 55 years and in hospital records 64 years hence claim is not admissible and is being recommended for repudiation under clause 4.1. As per Ex.C5 the complainant was diagnosed in October 2014. Opposite party has not placed on record any documentary evidence about his pre existing disease.
9. It is evident from the perusal of policy issued by opposite party that the fact of suffering of pre-existing disease by the complainant has not been mentioned in the policy. Had there been any pre-existing disease then same should have been mentioned in the policy but not mentioning the same go to prove that the complainant was not suffering from any pre-existing ailments.
10. Moreover, when the insured is above 45 years then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines.
11. The ground of rejection of claim does not stand to the test of scrutiny because opposite party has not placed on record any credible evidence to prove that the complainant had pre existing disease which was not disclosed by him at the time of obtaining said policy.
12. Therefore, not releasing claim of the complainant amounts to deficiency in service on the part of opposite party.
13. Resultantly, the complaint is allowed. Opposite party is directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a from the date of filing of complaint till its realization. The opposite party will also pay Rs.2200/- as compensation on account of mental tension, agony and harassment and Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on:12.09.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
