Delhi

New Delhi

CC/416/2016

S.K.S.Yadav - Complainant(s)

Versus

The Oriental Insurance Company Ltd & Anr - Opp.Party(s)

18 Nov 2019

ORDER

 

 

 CONSUMER DISPUTES REDRESSAL FORUM-VI (DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN,

         I.P.ESTATE, NEW DELHI-110002.

 

Case No.C.C.416/2016                                          Dated:

             In the matter of:

S.R.S. Yadav,

S/o late Sh. Ajay Pal Yadav,

R/o Staff Quarters 32,

National Sports Club of India,

Purana Quila Road, New Delhi.

 

            ……..COMPLAINANT

VERSUS

1.     The Oriental  Insurance Co. Ltd.

               A-25/27, Asaf Ali Road,

                New Delhi-02.

 

           Also at:

          The Oriental Insurance Co. Ltd.,

          88, Janpath, Ground Floor,

           New Delhi-110002.

 

2. Medi Assist India TPA Pvt. Ltd.,

B-20, Sec.2,

New Sector-15, Metro Station,

Opp. HCL Comnet,

Noida-201301, Uttar Pradesh.

Opposite Parties.

                

                                                                                

NIPUR CHANDNA- MEMBER

ORDER

The complainant has filed the present complaint against the OP. The gist of the complaint is that the  complainant purchased a mediclaim insurance policy PNB-ORIENTAL ROYAL MEDICLAIM POLICY from OP-1 on 10/06/2013 for himself, and for his wife, Ms. Geeta Yadav and for his son, Vaibhav Yadav  vide policy no. 272900/48/2014/4217 and the policy was valid from  10/06/2013 to Midnight of 09/06/2014. Premium of the policy was Rs. 6,830/-. It is further alleged  that at the time of signing the said Medi-Claim policy, the complainant had also submitted a proposal form wherein the complainant filled all the necessary information as mentioned in the said proposal form.

2.         It is alleged that on 02/06/2014, the complainant renewed the aforesaid Medi Claim Policy vide policy no. 242900/48/2015/4008 from  on 10/06/2014 to Mid night of 09/06/2015.

3.         On 03/06/2015, the complainant again renewed the said Medi Claim policy vide policy no. 272900/48/2016/4952 from  10/06/2015 to Mid night of 09/06/2016. It is further alleged that complainant had been paying the amount of premium for the policy regularly on time without any default and delay and without any break in period.

4.         On 03/09/2015, Mrs. Geeta Yadav, wife of the complainant, complained of abdomen pain and loose motions and was admitted in the emergency ward of Max Super Specialty Hospital, East Block-2, Press Enclave, Saket, New Delhi-110017. As per the reports Mrs. Geeta Yadav was diagnosed of ‘Acute- Gastroenteritis’ with severe dehydration, shock and sepsis.

5.         It is further alleged that after examination of test reports the treating doctor confirmed that existing ailment of the wife of complainant has no connection whatsoever with any pre-existing ailments/disease and the complainants can easily avail the cashless facility from the OPs in respect of Medi Claim policy in question.

6.         OP-2 despite receiving of all the relevant documents  denied the cashless facility to  the complainant and to harass the complainant, OP-2 raised queries from the Hospital vide its email dated 11/09/2015  and hospital again on the same day had answered all the queries raised by the OP-2. It is further alleged that OP-2 in its email dated 11/09/2015 had specifically assured that once the treatment of Mrs. Geeta Yadav is over and upon furnishing the bills and other necessary documents of the hospital, the complainant can claim reimbursement in accordance with the Medi Claim Policy. Accordingly, the complainant lodged the claim with OP-1 but the same was denied on the false and concocted grounds of pre-existing ailments, hence this complaint.

7.         Complaint has been contested by OP-1.  In its written statement,   OP-1 has not disputed that complainant had taken policy referred above. OP-1 has stated that there is no deficiency in service on its part as alleged by the complainant.  It has been further stated that the claim of the complainant was rightly repudiated on the ground of pre-existing ailments. On the basis of treatment record of the insured Ms. Geeta Yadav, it has been found that the treatment by the insured falls under ambit of clause 4.1 of the terms and conditions of the medical policy and same is not payable.  He further prayed for  dismissal of present complaint.       

8.         Both the parties have filed their evidence by way of affidavits.

9.         We have heard argument advance at the Bar and have perused the record.

10.       It is argued by the complainant that he  filled the necessary forms along with the relevant documents and submitted to OP-1 as advised by OP-2 for reimbursement.  OP-1 repudiated the claim of the complainant vide its letter dt. 13.3.2016 on the grounds of pre-existing disease as per clause  4.1 of policy terms and conditions. It is further argued that despite issuance of the certificate by treating doctor regarding the non-existence of any pre-existing ailment in  favour of the complainant  OP-1 rejected the claim on false and frivolous ground which amount to deficiency in services and unfair trade practices. 

 

11.       OP-1 has pleaded that the present complaint is frivolous and vexatious and is liable to be dismissed  It is stated that the complainant was suffering from pre-existing disease.  According to the Exclusion clause 4.1 of policy ,  the expenses incurred for an existing ailment are not payable by the insurance , hence, the claim was repudiated and prayed for the dismissal of the complaint being not maintainable and frivolous.

 

12.       Perusal of the file shows that the cashless facility was denied by the OP vide its email dated 11/09/2015.  However, the complainant filled the necessary forms along with the relevant documents and submitted the same to OP-1 as advised by OP-2 for reimbursement of his claim. OP-1  repudiated the claim on the ground of pre-existing disease.

 

13.       The controversy involves in the present case is as to whether the repudiation by O.Ps on the ground of pre-existing disease was justified or not.. According to OP-1 the treatment taken by the complainant is of a pre-existing disease prior to inception of the policy. The complainant has not disclosed past medical history while taking the insurance with the O.P which amounts to concealment of fact, therefore, the insurance company while relying upon condition No.4.1 rightly rejected the claim.

 

14.       In the present complaint, OP-1 had failed to place on record the proposal form filled by the  insured at the time of inception of the policy showing his state of health. Obviously the proposal form could have thrown some light as to whether the insured concealed material fact or not. Even otherwise, every disease cannot be termed as pre-existing disease. Pre-existing disease normally would mean the one which was in the knowledge of the insured at the time of taking the policy. Secondly, it is the duty of the insurance company to prove by adducing medical evidence that insured had suffered the disease immediately preceding the inception of policy. Unfortunately in this case, the insurer has neither placed on record the proposal form nor led any evidence to prove the existence of pre-existing disease.

15.       In view of the above discussion, we are of the considered opinion that the OP Insurance Co. has not placed on record any substantial evidence to prove that the complainant was suffering from pre-existing ailment which falls within exclusion clause of the policy.  The repudiation of the claim by OP-1 is not justified and is purely based on conjecture and surmises.  Non-reimbursement of the claim of the complainant on false and frivolous grounds amounts to deficiency in services on the part of OP-1. We, therefore, direct the OP-1 as under:

 

1. Pay to  the complainant for a sum of Rs. 2,89,231/- along with interest @ 9% from the date of filing of complaint i.e. 05/07/2016 till its realization.

 

2. Pay to the complainant a sum of Rs.10,000/- on account of pain and mental agony suffered by him. 

 

3. Pay to the complainant a sum of Rs.10,000/- on account of   litigation cost .

 

 

A copy of this order each be sent to both parties free of cost by post. This final order be sent to server (www.confonet.nic.in ). File be consigned to Record Room.

 

Announced in open Forum on 18/11/2019.

 

 

 

(ARUN KUMAR ARYA)

          PRESIDENT

(NIPUR CHANDNA)                                                  (H M VYAS)

       MEMBER                                                                MEMBER