BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.377 of 2017

Date of Instt. 04.10.2017

Date of Decision: 19.12.2018

Parveen Rai S/o Mr. Jagjit Rai, Flat No.504, B-Block, 24 Carrat Gold Apartment, Raminder Nagar, Mithapur Road, Jalandhar.

..........Complainant

Versus

The Oriental Insurance Company Ltd., Through its Senior Divisional Manager, 32, G. T. Road, Opp. Narinder Cinema, Jalandhar.

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Harvimal Dogra (Member)

Present: Sh. Umesh Dhingra, Adv Counsel for the Complainant.

Sh. A. K. Arora, Adv Counsel for the OP.

Order

Karnail Singh (President)

1. This complaint has been filed by the complainant, wherein alleged that he got medical insurance policy from the OP bearing policy No.233100/48/2014/209 for the period 17.06.2013 to 16.06.2014 after making the payment of the premium which covered the complainant as well as his family members including spouse and two dependent children. After the expiry of the above said policy period, the complainant obtained medical insurance policy for the subsequent period from 17.06.2014 to 16.06.2015 for the insured amount of Rs.3,00,000/- which also covered the complainant and his family members. The complainant also paid insurance premium for obtaining medical health insurance policy to the OP.

2. The complainant suffered sudden chest pain associated with sweating in the mid-night of 28/29-12-2014 and the complainant was brought to BBC Heart Care at Pruthi Hospital, Lajpat Nagar, Jalandhar. The complainant was admitted in the hospital, where after the examination and diagnostic test by the consultant Cardiologist Dr. Lalit Garg, M. D., the complainant was diagnosed to have suffered Coronary Artery Disease, Triple Vessel Disease. Accordingly, Coronary Angiography and Coronary Angioplasty was done and the stent was placed in the artery. The complainant remained admitted in the hospital from 29.12.2014 to 31.12.2014 and the complainant paid a sum of Rs.2,45,000/- to Pruthi Hospital, vide their Invoice No.4286 dated 31.12.2014 towards hospitalization expenses for the medical treatment. The complainant submitted claim to the OP after the discharge from the hospital and submitted all the documents to the OP, whichever are required by the OP, but till date the OP has not settled the claim of the complainant, despite repeated approach to the OP several times for making the payment of the claim amount as the complainant is duly covered under the insurance policy, but the OP has failed to give any response to the request of the complainant. No intimation has been sent by the OP to the complainant regarding the claim of the complainant, which is clear cut deficiency in service on the part of the OP and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OP be directed to settle and pay the claim amount of Rs.2,45,000/- to the complainant along with interest @ 18% per annum from the date of claim till payment and further OP be directed to pay Rs.1,00,000/- towards compensation and damages for causing mental agony, inconvenience and harassment etc. and be also directed to pay litigation cost.

3. Notice of the complaint was given to the OP, who filed reply and contested the complaint by taking preliminary objections that the complaint of the complainant is time barred because the period for filing the complaint is two years from the date of occurring cause of action as well as the date of the repudiation letter and in the instant complaint, repudiation letter is dated 04.03.2015, whereas the instant complaint filed after the period of two years, therefore, the complaint is time barred and the same may be dismissed and further submitted that the insurance claim of the complainant has been already repudiated, vide letter dated 04.03.2015 because the ailment of the complainant is not covered under the terms and conditions i.e. Exclusion Clause 4 and 4.3 and accordingly, the claim of the complainant has been already repudiated on the basis of terms and conditions. It is further averred that there is no deficiency of service or unfair trade practice on the part of the answering OP, therefore the complaint is not maintainable. On merits, it is admitted that the complainant got insurance policy and also submitted a medical insurance claim, but it is alleged that the said claim has been rightly repudiated. The other averments as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

4. In order to prove the case of the complainant, the complainant himself tendered into evidence his own affidavit Ex.CA alongwith some documents Ex.C-1 Copy of Invoice, Ex.C-2 Copy of Discharge Summary, Ex.C-3 & Ex.C-4 Copy of Insurance Policy, Ex.C-5 Legal Notice and Ex.C-6 Postal Receipt and closed the evidence.

5. Similarly, counsel for the OP tendered into evidence affidavit Ex.OA along with Repudiation Letter Ex.O-1 and closed the evidence.

6. We have heard the argument of learned counsel for the respective parties and also gone through the file very minutely.

7. Precisely, the case of the complainant to the effect that the complainant purchased insurance policy from the complainant initially on 17.06.2013 to 16.06.2014 and the same was got renewed from 17.06.2014 to 16.06.2015 for an insured amount of Rs.3,00,000/- and thereafter, the complainant submitted an insurance claim, but the same has not been paid by the OP for one excuse or the other and to this extent, there is no dispute.

8. The dispute raised by the OP first time in this complaint is that the complaint of the complainant is time barred because the medi-claim of the complainant was repudiated on 04.03.2015, vide letter Ex.O-1 and the period for filing complaint is two year from the date of repudiation of letter that the complainant can file complaint on or before 04.03.2017, but the instant complaint filed by the complainant on 04.10.2017, which is apparently after the lapse of two years, therefore, complaint is not maintainable being time barred.

9. We have considered the above submission of learned counsel for the OP and also glanced the file and find that the complainant alleged in the complaint that he submitted an insurance claim, but the same was not paid by the OP nor any intimation has been given by the OP to the complainant regarding the claim of the complainant, but the OP alleged that the claim has been repudiated, vide letter dated 04.03.2015, if the claim has been repudiated by the OP on 04.03.2015, then its intimation must be given to the complainant either on email message or by telephonically or by registered letter, but the OP has not elaborated the procedure, whereby intimation in regard to repudiation of the claim, has been given to the complainant, simply preparing a letter of any date and took a plea that the claim has been already repudiated, is not sufficient to prove that the intimation has been given to the complainant. So, in view of the above discussion, we are of the considered opinion that the plea taken by the OP in regard to limitation is not proved.

10. Coming to the main controversy between the parties, it is admitted that the complainant has submitted medical insurance claim for an amount of Rs.2,45,000/-, but as per the version of the OP, the same has been repudiated, vide letter Ex.O-1 dated 04.03.2015 and now we have to glance the condition on which the medical insurance claim of the complainant has been repudiated, the mainly said claim has been repudiated by referring Section 4 Exclusion Clause read with Section 4.3. Mainly, we find that the OP has repudiated the claim on the basis of Section 4.3 of the terms and conditions, wherein some ailments/diseases are not covered for payment of the insurance claim, if the same occurred prior to the period of two years from the date of inception of the policy and accordingly, the claim of the complainant has been repudiated by the OP on the ground that the insurance policy was obtained by the complainant on 17.06.2013 and he got treatment on 29.12.2014, which is beyond the period of two years as mentioned in Section 4.3 of the terms and conditions.

11. In order to meet the above query and allegation of the OP, we find that the complainant was not originally admitted for treatment of the Hypertension and Diabetes rather as per Discharge Summary, the complainant was admitted for the treatment of Coronary Artery Disease and the same is mentioned in the Discharge Summary under the heading 'Case Summary' as under:-

“54 years old, Mr. Parveen Rai, presented with sudden chest pain associated with sweating.”

and the treatment of the above chest pain was given by the BBC Heart Care Centre and during the investigation, while the complainant was admitted in the hospital and ailment of Hypertension and diabetes was also detected, but it is categorically mentioned in the Discharge Summary that these diseases are newly detected, if the complainant mainly got treatment of the heart problem and as the ancillary got treatment of some ailment, which is covered under Section 4.3 of the terms and conditions, then the OP cannot decline the insurance claim of the complainant in lump sum if did so the same is illegal and accordingly, we find that the claim of the complainant has been repudiated by the OP not on a solid ground rather the ground taken by the OP is taking just for to decline the insurance claim. So, accordingly the repudiation letter Ex.O-1 dated 04.03.2015 is hereby set-aside and further hold that the complainant is entitled for the relief claimed.

12. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OP is directed to pay the claim amount of Rs.2,45,000/- to the complainant along with interest @ 12% per annum from the date of repudiation i.e. 04.03.2015, till realization and further OP is directed to pay compensation to the complainant, to the tune of Rs.25,000/- for causing mental agony, inconvenience and harassment and further OP is directed to pay litigation expenses of Rs.7000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Harvimal Dogra Karnail Singh

19.12.2018 Member President