DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.323/2011
SHRI SURESH KUMAR
R\O 55-MASJID MOTH, NEW DELHI-110049.
….Complainant
Versus
THE ORIENTAL INSURANCE COMPANY LIMITED
DIVISIONAL OFFICE NO. 15, G-8,
NDSE-1, NEW DELHI-49.
….Opposite Party
Date of Institution : 06.09.2011 Date of Order : 25.10.2017
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
Briefly stated, the case of the complainant is that he had taken mediclaim policy bearing No.212700/48/2012/116 with cashless facility from the OP and the complainant had been under medical cover since 2007 under the Reliance General Insurance Co. Ltd. and he had switched to OP since 2009. The policy was valid from 15.04.2011 to 14.04.2012 and the cover value was of Rs. 4,00,000/- and complainant had paid premium of Rs. 14,940/- to the OP against the said policy. On 21.11.2010, the complainant felt some pain in his chest and for check up he went to Max Hospital. After preliminary investigation, the doctor advised him to get himself admitted on the same day for further tests and investigation. He got himself admitted in the hospital. After the complete diagnosis, the complainant was operated for heart. The complainant approached the OP for cashless facility but the same had been denied due to the reason best known to it. Complainant had to deposit the bill amount as demanded by the hospital after taking loan from friends. He remained admitted in the hospital from 21.11.2010 to 08.12.2010. It is submitted that the complainant had lost the bills issued by the hospital and he got the duplicates duly issued by the said hospital and had also submitted an affidavit in support of the same to the TPA of the OP, namely, Raksha TPA Pvt. Ltd. for imbursement. Even after getting all the documents relating to the treatment from the complainant the TPA kept on asking for more information regarding the treatment record and he supplied the documents as and when required. The OP never bothered to inform the complainant but he was enquiring about the status of the claim. It is submitted that after taking almost 6 months, OP vide its letter dated 30.06.2011 rejected the reimbursement claim of complainant on the ground that the complainant had submitted the duplicate bills issued by the hospital and the further ground for the rejection was that the disease was pre-existing.
After rejection of the claim, complainant met with the officials of the OP and requested for the settlement of his claim but the OP bluntly refused for the same. Hence, due to negligent, unethical, unfair and unprofessional attitude of the OP, complainant suffered the mental agony and harassment. Therefore OP is not only guilty of deficiency in service but has also caused substantial financial loss to the complainant besides causing mental harassment and agony and discomfort in the life of the complainant and his family. Complainant has prayed as follows:-
- Direct the OP to reimburse the claim amount of Rs. 3,75,203/- with interest @ 18%.
- Direct the OP to pay the compensation of Rs. 75,000/- to the complainant towards mental agony, mental torture, harassment, financial loss etc.
- Direct the OP to pay Rs. 25,000/- to the complainant towards the litigation and miscellaneous expenses.
OP in its written statement has inter-alia stated that vide letter dated 30.06.2011 OP has rightly repudiated the claim of the complainant which was lodged through the Raksha TPA Pvt. Ltd. who had been appointed as third party administrative by the OP for settlement of claims under the Mediclaim policies after scrutiny of the documents produced by the complainant. It is submitted that the complainant had not submitted the original medical bills for verification but the duplicate receipts worth Rs. 2,81,127/- and Rs. 25,000/- had been submitted and accordingly the claim of the complainant could not be considered and even otherwise the claim of the complainant was not payable under clause 4.1 of the terms and conditions of the policy. It is submitted that the discharge summary of the complainant reveals the history of diabetes, K/C/O of RHD and Asthma and as such as per the Mediclaim policy issued to the complainant, vide condition No. 4.1 all diseases/ injuries which are pre-existing when the cover incepts for the first time are excluded up to 4 years of the policy in force continuously purchased from the same company and as such the claim of the complainant is not payable. It is denied that there is any deficiency in service on the part of the OP as alleged. It is submitted that by paying the premium the complainant cannot enjoy the facilities for which he is not entitled under the terms and conditions of the policy and because of his own fault. Hence, complainant is not entitled to any relief and complaint is liable to be dismissed.
Complainant has filed rejoinder to the written statement of OP. In the rejoinder, complainant has submitted that the duplicate bills of Rs.3,75,203/- were submitted to the OP as the original bills issued by the hospital had been lost and he had got the duplicate bills issued from the hospital and had also submitted the affidavit in support of that as per the direction of the TPA of OP. Hence, the rejection on ground of duplicate (bills) is not correct. OP was bound to investigate about the genuineness of the bills in question from the concerned hospital before rejecting the same. It is submitted that the complainant had earlier policy from Reliance General Insurance and had switched to the OP only after the assurance from the OP i.e. its agent that switching will not affect the continuance of the policy and its inception will be taken from the beginning. Hence, the rejection of the claim by the OP on the basis of the terms and conditions is against the settled law.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. Rajiv Gupta, Senior Divisional Manager has been filed in evidence on behalf of the OP.
Written arguments have been filed on behalf of the parties.
It is not in dispute that the complainant had taken the medi-claim insurance policy bearing No. 212700/48/2012/116 from the OP with cashless facility for the period 15.04.2011 to 14.04.2012 and the cover value was Rs. 4,00,000/- and he paid premium of Rs.14,940/- [(Annx. CW1/1 (Colly)]. Prior to this he had taken similar policies from the OP for the period 15.04.2009 to 14.04.2010 and 15.04.2010 to 14.04.2011 (copies Ex. OPW/1 to Ex. OPW/3). Complainant was admitted to Max Hospital, New Delhi on 21.11.2010 and discharged on 30.11.2010. Copy of the discharge summary is Ex. CW/2 (Colly). He was admitted in the hospital with the following past history:-
“Past History:
- K/C/O Rheumatic Heart Disease (MS with MR) – received penicillin, prophylaxis earlier
- Bronchial Asthma since April 2009 (on inhaler)
- DM X 2 yrs”
He was diagnosed with “(1) Acute Left Ventricular Failure and (2) Bronchial Asthma – Acute Exacerbation (Recovered). The OP repudiated the claim vide letter dated 30.06.2011 on the ground that “the complainant had not supported the original bills for verification and the discharge summary of the complainant reveals the history of diabetes, K/C/O of RHD and Asthma and as such as per the Mediclaim policy issued to the complainant vide condition No. 4.1 all diseases/ injuries which are pre-existing when the cover incepts for the first time are excluded up to 4 years of the policy in force continuously purchased from the same company as such the claim of the complainant is not payable.” Complainant has filed copy of the insurance policy issued by the OP as annexure-A (Ex. OPW/1 to OPW/3. Discharge summary issued by the Max Health Care Super Specialty Hospital is annexure CW/2 and duplicate bills issued by the hospital are annexure CW/3 (colly). The OP filed the copy of terms and conditions of the policy as Ex. OPW/5. Clause 4.1 of the terms of the policy is relevant. The same is reproduced as hereunder:-
Pre-existing health condition or disease or ailment / injuries : Any ailment / disease / injuries / health condition which are pre-existing (treated / untreated, declared/ not declared in the proposal from), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 4 years of this policy being in force continuously.
For the purpose of applying this condition, the date of inception of the policy taken from the Company, for each insured person of the family, shall be considered, provided the renewals have been continuous and without any break in period.
The exclusion will also apply to any complications arising from the pre-existing ailments/ diseases/ injuries. Such complications shall be considered as a part of the pre-existing health condition or disease….”
As per the discharge summary, the Complainant was treated for the following diseases:
(1) RHD with Mild MS
(2) Moderate MR
(3) Diabetes Mellitus
(4) Bronchial Asthma.”
As pointed out hereinabove he had also past history of bronchial asthma since April, 2009 on inhaler. Thus, the bronchial asthma was a pre-existing disease. The onus to prove the fact that while issuing the mediclaim policy for the first time in the year 2009 either the OP or the OP’s agent had given any assurance to the Complainant that the policy shall be in continuation with the earlier policy being taken by the complainant from the Reliance General Insurance Co. Ltd. was on the Complainant. However, the Complainant has not led any iota of evidence to even prove this fact moderately. Exclusion clause 4.1 of the terms and conditions of the policy reproduced hereinabove goes a long way to prove that the exclusion clause will also apply to the complications which shall be a part of the pre-existing health condition or disease. Thus, we are of the considered opinion that the OP was legally justified in repudiating the claim of the Complainant on this ground.
The next questions which falls for consideration is whether non-filing of the original bills by the Complainant with the OP alongwith the claim papers was a ground for rejection of the claim in the facts and circumstances of the present case. Our answer is a big “Yes”. The Complainant has not shown any sufficient reason/s as to why the original bills had been misplaced or lost by him. Even otherwise, the Complainant has filed some policy documents as Annexure CW/1 (Colly) which shows that these annexures include the copies of the policies taken by him from Reliance General Insurance Co. Ltd. since 2007 and w.e.f. the year 2009 from the OP. These papers also have a copy of the policy taken by the Complainant from Reliance General Insurance Co. Ltd., 570, Naigaum Cross Road, Next to Royal Industrial Estate, Wadala (W), Mumbai-400031. The policy agent name is Ashok Kumar and the policy No. is 282510418643 and the previous policy number has been mentioned as 282550098976. The said policy is valid for the period 14.04.09 to the midnight of 13.04.10. We mark the copy of the said policy as Mark C for the purpose of proper identification. What does it mean? It means that the Complainant had simultaneously also taken a mediclaim policy from Reliance General Insurance Co. Ltd. for the period 14.04.09 to the midnight of 13.04.10 alongwith the policy taken by him from the OP for the period 15.04.09 to 14.04.10. Therefore, possibility cannot also be ruled out that the Complainant had also taken similar policy from the Reliance General Insurance Co. Ltd. for the period 14.04.10 to 13.04.11 and he had filed the original bills which are the subject matter of the present complaint with the Reliance General Insurance Co. Ltd. and had claimed the said amount from the said the insurance company. Therefore, in view of the special facts and circumstances of the present case discussed hereinabove the non- filing of the original bills alongwith the claim papers with the OP was a gross deficiency on the part of the Complainant for which he has not explained any sufficient reasons. Therefore, we hold that the claim of the Complainant is not free from doubts and suspicions. Therefore, we hold that repudiation of the claim of the Complainant by the OP on this ground was justified.
In view of the above discussion, we do not find any merit in the complaint and accordingly we dismiss the complaint with no order as to costs.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 25.10.2017.
