Haryana

Yamunanagar

CC/247/2010

Rakesh Kumar s/o Sh.Rajinder Kumar - Complainant(s)

Versus

The Oriental Insurance company Ltd. - Opp.Party(s)

Tarun Rohilla

06 Jul 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

                                                                                    Complaint No.  247  of 2010.

                                                                                    Date of institution: 19.3.2010

                                                                                    Date of decision: 6.7.2015

Rakesh Kumar son of Sh. Rajinder Kumar resident of H. No. 1238, Gomti Street, Jagadhri, Tehsil Jagadhri, Distt. Yamuna Nagar. 

 

                                                                                                                                                                          …Complainant.

                                                                                          Versus

 

The Oriental Insurance Company, Ltd. Opposite Madhu Hotel, Jagtadhri Road, Yamuna Nagar, Tehsil Jagadhri, District Yamuna nagar through its Branch Manager.                                                                                                                                           

                                                                                                                                                                         …Opposite party.   

           

CORAM:          SH. ASHOK KUMAR GARG, PRESIDENT,

                        SH. S.C.SHARMA, MEMBER.

 

Present: Sh. Tarun Rohila, Advocate, counsel for complainant.     

              Sh. Rajiv Gupta, Advocate, counsel for OP.  

ORDER

 

                        Complainant has filed the present complaint under section 12 of the consumer Protection Act 1986 praying that the OP be directed to pay the claim of Rs. 17000/- on account of hospitalization alongwith interest at the rate of 18% per annum from September 2009 till its realization and further to pay Rs. 50,000/- on account of mental agony and physical harassment alongwith Rs. 11,000/- on account of cost of proceedings.

2.                     Brief facts as alleged in the complaint are that the complainant took a Medical Insurance Policy namely MEDICLAIM POLICY from the OP in the year 2007 which was valid up to 2008 and thereafter complainant continued his said policy further for the period from 2008 to 2009 and in the year 2009, the complainant again got his said medical policy renewed for the period from 6.3.2009 to 5.3.2010 vide bearing policy No. 261700/48/2009/3014 against payment of one year premium of Rs. 1435/- covering the medical insurance of complainant himself and his wife Smt. Balesh. It has been further stated that complainant has again got his medical policy renewed from the period 6.3.2010 to 5.3.2011. It has been further mentioned that in the month of August 2009 the complainant felt pain in his throat and on checkup, there was Cyst problem found in the Vocal Cord of the complainant and for the diagnose of his said problem, the complainant had undergone an operation of his throat from Garg Hospital, Dehradun on 5.9.2009 and spent a sum of Rs. 17000/- on his entire treatment and intimation thereof was duly given to the OP by the wife of the complainant. It has been further stated that a claim was lodged under said Medi-claim policy with the OP and supplied all the necessary documents and requested for the payment of his claim but the OP failed to make the payment of his genuine claim and the complainant is running from pillar to post but the OP is kept on putting of the matter with one pretext or the other  and till today no intimation regarding the claim of the complainant has been given to him by the OP. It has been further stated that the complainant is getting the said policy for the last about 3 years and has not claimed any amount from the OP. And it  has been further stated that as per the latest guidelines of the IRDA the delay in the renewal of the health insurance policy is condonable up to maximum period of 15 days from the renewal due date despite all this the genuine claim of the complainant has not been paid by the OP. So, there is a great negligence and deficiency in service on the part of OP. Hence this complaint.

3.                     Upon notice, OP appeared and filed its written statement by taking some preliminary objections such as maintainability and on merit, it has been stated that Rakesh Kumar had obtained one medi claim policy valid from 6.3.2009 to 5.3.2010 and a claim under the said policy was lodged on 5.9.2009 by the complainant. It has been further stated that insured vide his letter dated 23.10.2009 submitted treatment bills of Rs. 17000/- and discharge summary of the said hospital. On receipt of the claim papers, the case in question was duly processed and it was found that insured was diagnosed as a case of Cyst Right Vocal Cord and he underwent Micro Laryngeal surgery. It was a case of benign neoplasm of mouth and pharynx. It has been further stated that previous medical claim policy bearing No. 260700/48/20082895 was valid for the period from 23.2.2008 to 22.2.2009 whereas the current insurance policy bearing No. 261700/48/2009/3014 was valid from 6.3.2009 to 5.3.2010. Meaning, that there is a gap of 12 days between the inception insurance policy under which the claim has been lodged and previous policy for the period from 23.2.2008 to 22.2.2009. Therefore, there is no continuity of the insurance policy.  Hence, the policy for the period from .w.e.f. 6.3.2009 to 5.3.2010 is a fresh policy and as per terms and conditions of the insurance policy, the disease for which diagnoses was taken by the insured is not covered under the policy in question being afresh in nature. Therefore, the OP company vide its letter dated 7.12.2009 repudiated the claim of the complainant being not payable under the fresh policy. It has been further stated that even otherwise as per the latest guidelines of the IRDA the delay in the renewal of the health insurance policy is condonable up to maximum period of 15 days from the renewal due date and the said provision is applicable to the policies issued or renewed after 1.6.2009 and the policy in question is not covered under the circular of IRDA. Hence, there is no deficiency in service on the part of OP and complaint deserves dismissal.

4.                     As the complainant failed to lead any evidence, hence his evidence was closed by court order. However some documents such as insurance policy valid from 6.3.2009 to 5.3.2010 Annexure-1, Intimation letter Annexure-2, Another intimation letter dated 5.9.2009 Annexure-3, Discharge summary of Garg Ear Nose Throat hospital Annexure4, Cashless card issued by TPA Annexure-5, Bill issued by Garg Hospital of amounting to Rs. 17000/- Annexure-6, Copy of provisional cover note valid from 6.3.2010 to 5.3.2011 Annexure-7 has been filed by the complainant with the complaint.

5.                     On the other hand, counsel for the OP tendered into evidence affidavit of Sh. R.S.Kalra Divisional Manager as Annexure RX and documents as Annexure R-1 Photo copy of letter for submitting medical bills and discharge summary of hospital, Annexure R-2 Insurance policy valid from 23.2.2008 to 22.2.2009, Annexure R-3 Insurance policy valid from 6.3.2009 to 5.3.2010, Annexure R-4 Repudiation letter dated 17.12.2009, Annexure R-5  Copy of E.mail issued by TPA and closed the evidence on behalf of OP. 

4.                     We have heard the learned counsels for both the parties and have gone through the pleadings as well as documents placed on file very minutely & carefully.  

                        The only plea of the OP is that there is a gap of 12 days between the inception of the insurance policy under which the claim has been lodged and previous policy for the period from 23.2.2008 to 22.2.2009. Therefore, there is no continuity of the insurance policy. Hence as per terms and conditions of the insurance policy the disease for which diagnosis was taken by the insured is not covered under the policy in question being fresh in nature. Therefore, the OP vide its letter dated 7.12.2009 has rightly repudiated the claim of the complainant being not payable.  

                        On the other hand, counsel for the complainant argued that complainant is getting insurance policy since 2007 continuously without any claim and disease is fully covered under the present policy and the complainant is entitled to get full reimbursement of Rs. 17000/-. It has been further argued that as per guidelines of the IRDA medical policy can be renewed within a grace period of 15 days, hence the OP cannot take the benefits of a gap of 12 days and cannot repudiate the claim of the complainant on this ground. It has been further argued that it is not the case of the OP that disease of the complainant is pre existing disease. Moreover the complainant had undergone an operation of his throat on 5.9.2009 and discharged on 6.9.2009 i.e. near about after six months of the commencement of the policy in question which was valid from 6.3.2009 to 5.3.2010.

                        In the present complaint, there is no disputes with regard to the policy of insurance which was taken by the complainant known as hospitalization benefits policy and the same was continuing from the year 2007. Last policy was taken by the complainant covering the risk from 6.3.2009 to 5.3.2010. Complainant Rakesh Kumar remains admitted in Garg Hospital at Dehradun on 5.9.2009 and discharged on 6.9.2009 and filed the claim for re-imbursement of the expenses of Rs. 17000/- with the OP. Opposite party repudiated the claim vide letter dated 7.12.2009 on the ground that there was a gap of 12 days in the renewal of the policy from 22.2.2009 to 6.3.2009. Hence the policy is considered as fresh policy. In order to prove its case the opposite party placed the copy of insurance policy which are continuing from 23.2.2008 to 22.2.2009 as Annexure R-2 and copy of insurance policy continuing from 6.3.2008 to 5.3.2010 as Annexure R-3. Discharge summary Annexure-4. The Opposite party filed the term and condition of the Medi-claim policy. Under exclusion Clause 4 & 4.3 which is reproduced as under: -

                        Clause 4

The company shall not liable to make any payment under this policy in respect of pre-existing diseases. All diseases which are pre-existing when the cover incepts for the first time.

Clause 4.3

                        “During the first year of the operation of insurance cover, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hyperthrophy, Hysterectomy for monorrahagia of Fibromyoma, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre- existing at the time of proposal they will not be covered even during subsequent period of renewal too”.

                        After going through the contents of this clause, it is clear that Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty etc. (shown in Annexure R-5) is not mentioned in this clause i.e. 4.3. Hence, the interpretation of the opposite party that under the policy the disease of complainant i.e. Benign ENT is not covered being fresh policy as mentioned in the schedule is not tenable. Opposite party wrongly interpret the terms and conditions of the policy. Complainant was not suffering from any disease at the time of inception of the policy.  From the perusal of Discharge summary Annexure-4 clearly shows that illness occurred to the complainant for the first time on 5.9.2009 and he was admitted in the hospital on the same day and was diagnosed with the disease Cyst Right Vocal Cord and discharged on 6.9.2009. Policy was continuing since the year 2007 and this exclusion is not applicable to the complainant. Moreover, as per the latest guidelines of the IRDA the delay in the renewal of the health insurance policy is condonable up to maximum period of 15 days from the renewal due date. Hence the repudiation of the claim by the opposite party is unjustified and amounts to deficiency in service. The complainant incurred an expenses of Rs. 17000/- as the claim filed by the complainant and the bills of the expenses produced by the complainant. So, the complainant is entitled for a sum of Rs. 17000/-.

                        In view of the above discussion, the present complaint succeeds. We hereby  partly allow the present complaint with a direction to the opposite party to pay a sum of Rs. 17000/- to the complainant within a period of 30 days failing which OP shall be liable to pay interest at the rate of 9% per annum from the date of filing of complaint till realization. The cost of litigation quantifies at Rs. 2000/- is also allowed to be paid by the opposite party to the complainant. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court. 6.7.2015.

                                   

                                                                                          ( ASHOK KUMAR GARG)

                                                                                           PRESIDENT

 

 

 

                                                                                          (S.C.SHARMA)

                                                                                           MEMBER