PER SHRI. S.B.DHUMAL - HON’BLE PRESIDENT :
1) In brief consumer dispute is as under –
That the Opposite Party No.3 is a Branch Office of Opposite Party No.1 M/s. New India Assurance Co. Ltd. Opposite Party No.2 is a TPA appointed by M/s. New India Assurance Co. Ltd. Somewhere in the year 1997 the Complainant had taken mediclaim policy from the Opposite Party No.3 in which sum assured was Rs.1 Lac. The Complainant renewed the policy without any break. Subsequently, sum assured was increased to Rs.3 Lacs by in the year 1996-97. The Complainant obtained additional mediclaim policy for Rs.2 Lacs from the Opposite Party No.3 and thus, the Complainant had available sum assured in aggregate of Rs.5 Lacs.
2) In the year 1997 the Complainant had undergone angioplasty at P.D. Hinduja Hospital, Mahim. Thereafter the Complainant preferred claim of around Rs.2 Lacs with Opposite Party No.3. Opposite Party No.3 sanctioned the said claim without any deduction. Subsequently, Opposite Party settled and small claim for post angiography without any complication. The Complainant renewed the policy from time to time by paying requisite amount from Opposite Party No.3.
3) On 19/10/07, during regular health check-up it was found that there were some heart blockage and Dr. S. Mathew and Dr. Ajeet Menon suggested the Complainant to undergo angioplasty. The Complainant contacted Opposite Party No.3 and Opposite Party No.2 and they sanctioned an amount of Rs.99,875/- + Rs.30,400/- i.e. aggregate sum of Rs.1,30,275/- as against the total hospital charges of Rs.5,12,395/-.
4) Since the year 2003, the Complainant is holding an additional policy of Rs.2 Lacs with Opposite Party No.3. In the said policy Opposite Party No.3 has included exclusion clause on existing disease.
5) The Complainant submitted Pre-Authorization form as prescribed by Opposite Party No.2 and which was received by Opposite Party No.2 on 30/10/07. Subsequently, query raised by Opposite Party No.2 was replied by Dr. Menon vide his letter dtd.06/11/07. After completing CT Coronary Angio SOS PCCA, Complainant filed claim for as prescribed by Opposite Party No.1 & 2 dtd.26/11/07. Opposite Party No.2 rejected claim of the Complainant on the ground that Complainant had Blood Pressure since the last 17 years. On 21/01/08 the Complainant wrote a letter to Opposite Party No.2 informing that he is not accepting the claim settled for Rs.1,30,275/- instead of Rs.5,12,395/-. Opposite Party No.3 vide their letter dtd.04/01/08 informed Opposite Party No.2 about the claim settled in 1997 of the Complainant for Rs.1,92,917/-. Opposite Party No.2 in reply to the Complainant’s letter informed the Complainant vide their letter dtd.14/0/08 reason for deduction of claim amount as the history of hypertension since last 17 years.
6) It is case of the Complainant that in the year 1990 when he subscribed to the policy of Opposite Party No.3 there was no mention of any exclusion clause in the original policy. This itself proves beyond doubts that all the above said illness and diseases were covered in the original policy. The Opposite Parties are jointly and severally responsible for repudiating the valid claim of the Complainant by following unfair trade practice. Opposite Party No.3 has taken the premium amount from the Complainant for last several years but Opposite Party No.3 has repudiated the valid claim without any sufficient reason. At the request of Development Officer – Mr. Ashok Shah, the Complainant wrote letter dtd.28/08/08 to the Divisional Manager of Opposite Party No.1. Despite receiving the said letter, the Opposite Party did not respond. Then Complainant sent notice to the Opposite Party dtd.06/10/08 and called upon them to settle the claim of the Complainant by giving proper opportunity of hearing. Administrative Officer Grievance Cell of Opposite Party No.1 vide letter dtd.15/12/08 informed the Complainant that they are taking up matter with Opposite Party No.2 and shall revert back. However, thereafter there was no response from the Opposite Party. In response to the legal notice of the Complainant, Opposite Party No.1 wrote letter dtd.14/01/09 to the Advocate of the Complainant interalia stating that case of the Complainant thoroughly observed at MRO-1 and decision taken by Opposite Party No.2 for settlement of the claim for Rs.1,30,275/- is in order.
7) It is case of the Complainant that he was not suffering from Blood Pressure when he obtained mediclaim policy from the Opposite Party in the year 1999 and the same policy was renewed without any break. There was no such exclusion clause mentioned in the First Policy. Opposite Parties have illegally and wrongly amended the terms and conditions of the policy without any notice to the Complainant to declare any such ailment. The Opposite Parties have repudiated claim of the Complainant without application of mind and decision is against terms and conditions of the mediclaim policy and therefore, Complainant had filed this complaint.
8) The Complainant has requested to direct Opposite Party No.3 to pay to the Complainant a sum of Rs.5 Lacs for illegally repudiating valid claim of Rs.5 Lacs alongwith interest @ 15 % p.a. The Complainant has further requested to direct Opposite Parties to pay to the Complainant compensation of Rs.50,000/- for mental torture and agony and Rs.25,000/- as legal cost. Alongwith complaint, the Complainant has produced xerox copies of the document at Exh.‘1 to 10’.
9) Opposite Party Nos.1 to 3 have filed their common written statement and thereby resisted claim of the Complainant contending interalia that claim was repudiated on the basis of pre-existing condition, as per the terms and condition of the policy, as the Complainant had Blood Pressure since last 17 years. It is contended that there is no deficiency in service on the part of Opposite Party and the complaint deserves to be dismissed. There are discrepancies in the facts of the case stated in the complaint and claim preferred by the Complainant is not payable and therefore, it was repudiated by the Opposite Party by applying mind and giving reasons.
10) Opposite Parties have admitted contents of complaint para no.1, 2, 3.1, 3.3, 3.4, 3.6, 3.7, 3.8, 3.10, 3.17, 3.18 and denied contents of complaint para no.3.11, 3.12. The Opposite Parties have not admitted contents of complaint para no.3.5, 3.14, 3.15, 3.16 and para no.6. The Opposite Parties have denied contents complaint para no.3.19. They have also denied rest of the allegations and submitted that complaint is liable to be dismissed with cost.
11) The Complainant has filed affidavit in support of complaint and in the said affidavit the Complainant has denied allegations made in the written statement of Opposite Parties. It appears from the roznama that after filing of written statement from 08/11/09 the Opposite Parties have not appeared before this Forum. The Complainant has filed written argument on 12/07/2011. Ld.Advocate Mr. Anand Gawand for the Complainant has pass pursis submitting that Complainant’s written argument be treated as oral argument and therefore, matter was closed for order.
12) Following points arise of our consideration and our findings thereon are as under -
Point No.1 : Whether Complainant has proved deficiency in service on the part of Opposite Party No.1 to 3 ?
Findings : Yes.
Point No.2 : Whether Complainant is entitled to recover Rs.5,00,000/- as claimed with interest, compensation and cost of this
proceeding from Opposite Parties ?
Findings : As per final order.
Reasons :-
Point No.1 :- Following facts are admitted fact that Opposite Party NO.3 is a Branch Office of Opposite Party No.1 M/s. New India Assurance Co. Ltd. Opposite Party No.2 is a TPA of M/s. New India Assurance Co. Ltd. On 19/03/97 the Complainant had obtained mediclaim policy from the Opposite Party No.3 and the said Policy No. 111700/34/07/70/00000388 was valid upto 1/04/08 for sum assured of Rs.2 Lacs. Alongwith complaint, the Complainant has produced photo copy of mediclaim policy bearing No.111700/34/06/20/00000198 in which sum assured given to the Complainant was Rs.3 Lacs and cumulative bonus is recorded as Rs.1,05,000/- against the name of Complainant. Photo copy of another mediclaim policy bearing No.110601/34/08/11/00000069 is produced by Complainant and in this policy sum assured is Rs.2 Lacs and pre-existing condition – Hypertension and Diabetics are excluded from the mediclaim policy.
It is undisputed fact that Complainant availed mediclaim policy in the year 1990 and sum assured was Rs.1 Lac. In the year 1996-97 sum assured in renewed policy was enhanced to Rs.3 Lacs with unclaimed bonus of Rs.1,05,000/- subsequent additional mediclaim policy of Rs.2 Lacs with cumulative bonus of Rs.10,000/- was obtained by the Complainant. Thus, the Complainant had available sum assured in aggregate is Rs.5,15,000/-
It is admitted by the Opposite Parties that in the year 1997 Complainant had undergone Angioplasty at Hinduja Hospital and thereafter Complainant filed claim of around 2 Lacs with Opposite Party No.3. The said claim was sanctioned by Opposite Party No.3 without any deduction. Then in the next year the Complainant submitted small claim of post-angiography which was also settled Opposite Party No.3 without any complications.
It is the case of the Complainant that in a regular health check-up on 19/10/07 the Complainant found that there were some heart blockages. Dr. S. Mathew and Dr. Ajeet Menon suggested the Complainant to undergo angioplasty. The Complainant contacted Opposite Party No.2 and Opposite Party No.3 and Opposite Party No.2 sanctioned an amount of Rs.99,875/- + Rs.30,400/- i.e. total Rs.1,30,275/- as against the total hospital charges of Rs.5,12,395/-. After completing CT Coronary Angio SOS PCCA, the Complainant submitted claim form on 26/11/07 to the Opposite Parties. Opposite Party No.2 has rejected claim of the Complainant on the ground that the Complainant had Blood Pressure since the last 17 years. Photo copy of repudiation letter is produced by the Complainant at Exh.‘5’ in which it is stated “As per the Policy Exclusion, amount payable restricted to Rs.96,500/- + 35 % (Rs.33,775/-) Cumulative Bonus i.e. Rs.1,30,275/-. Rs.99,875/- already paid in cashless facility and balance of Rs.30,400/- paid now. Hence, Rs.69,600/- deducted”
The Complainant wrote a letter dtd.21/01/08 to Opposite Party No.2 informing that he is not accepting the claim settled for Rs.1,30,275/- instead of Rs.5,12,395/-. Copy of the said letter is produced at Exh.‘6’. Opposite Party No.2 informed the Complainant that the Complainant has history of Hypertension since last 17 years so amount was deducted. Photo copy of aforesaid letter is produced at Exh.‘C’. The Complainant sent letter dtd.15/10/08 to the Grievance Cell of the Opposite Party No.1 but there was no response. Legal notice dtd.14/11/09 was sent to the Opposite Party No.1. In a reply Opposite Party informed to the Complainant that decision taken by Opposite Party No.2 for settlement of claim for Rs.1,30,275/- is in order.
It is submitted on behalf of Complainant that his claim was unreasonably deducted by the Opposite Party on the ground of pre-existing disease of Hypertension. It appears from the discharge card that the Complainant was admitted in the P.D. Hinduja Hospital on 23/04/97 and was discharge on 28/04/97 and further it is recorded that PTCA with strent implant turn of LCx – done. It appears that when Complainant was admitted in the Hinduja Hospital diagnoses were CAD, HTN. It is mentioned H./O. - HTN since last 7-8 years. According to the Complainant, after discharge from the Hinduja Hospital, he had submitted his claim of R.2 Lacs to Opposite Party No.3 which was sanctioned by Opposite Party No.3 without any deduction and this fact is admitted by the Opposite Parties in their written statement – on page no.4. The Complainant has further stated that after angiography in the next year he had preferred small claim for post angiography which was also settled by Opposite Party No.3 without any objection. The Opposite Parties in their written statement have admitted the said fact. According to the Complainant, his earlier claim were sanctioned inspite of he was having Hypertension for last 7-8 years. The Opposite Parties have wrongly and illegally deducted very large amount from the claim submitted by the Complainant in the year 2007. The Complainant had submitted claim of Rs.5,12,395/- and Opposite Party sanctioned only sum of Rs.1,30,375/-. Alongwith settlement voucher, a cheque of Rs.30,400/- was sent to the Complainant but Complainant has refused to accept the said amount. The Complainant in legal notice dtd.06/10/08 has recorded aforesaid facts but Opposite Parties have not settled the claim balance amount.
It appears from the documents produced on record that in the month of October, 2007, in a regular health check-up the Complainant was advised By Dr. Mathew and Dr. Menon to undergo angiography as some heart blockages were detected. Then Complainant contacted Opposite Party No.2 & 3. Opposite Party No.2 sanctioned an amount of Rs.99,875/- as cashless facility. After completing CT Coronary Angio SOS PCCA, the Complainant submitted his claim of Rs.5,12,395/- to the Opposite Party on 26/11/07. Vide letter dtd.28/12/07 Opposite Party No.2 sanctioned total sum of Rs.1,30,275/-. Out of said sanctioned amount Rs.99,875/- was already paid as cashless facility. Cheque of balance amount of Rs.30,400/- was sent to the Complainant but he refused to accept the same contending that his claim was illegally rejected. Admittedly, the Complainants claim form for angioplasty done at Hinduja Hospital was sanctioned by Opposite Party No.3. In discharge card of Hinduja Hospital, it is clear that the Complainant had history of Hypertension since last 7-8 years, even then aforesaid claim was sanctioned by the Opposite Parties. However, subsequently, in the year 2007 claim of the Complainant was unreasonably reduced on the ground of pre-existing condition i.e. Hypertension. As discussed above, inspite of Complainant having Hypertension for about 7-8 years Opposite Party sanctioned earlier claim of angiography of Complainant done at Hinduja Hospital. Hypertension may be one of the causes for heart ailment but it is not only cause of heart ailment. The Complainant was suffering from HTN, but it cannot be said that he suffered heart ailment because of HTN. Therefore, we hold that the Opposite Parties have on untenable ground reduced large sum from the amount claimed by the Complainant. Hence, we hold that Complainant has proved deficiency in service on the part of Opposite Party No.1 to 3. In the result, we answer point no.1 in the affirmative.
Point No.2 :- It appears from the record on 19/10/07 when the Complainant undergone regular health check-up that time Dr. Mathew and Dr. Menon advised him to undergo angiography as some heart blockage were noticed. Then the Complainant contacted Opposite Party No.2 & 3. Opposite Party No.2 sanctioned Rs.99,875/- as a cashless facility and the said amount was paid to the said hospital. After completing CT Coronary Angio SOS PCCA, the Complainant was discharged from the hospital and then Complainant submitted his claim of Rs.5,12,395/- to the Opposite Party. The Complainant has produced copy of Pre-Authorization claim form and claim form. in the claim for the Complainant has claimed total amount of Rs.5,12,395/-. He has not deducted amount of Rs.99,875/- which was already paid by the Opposite Party as cashless facility to the Complainant. It is necessary to deduct the aforesaid amount of Rs.99,875/- from the total amount claimed by the Complainant. After deducting Rs.99,875/- from the total claim of Rs.5,12,395/- balance comes to Rs.4,12,520/-. The Complainant has refused to accept cheque of Rs.30,400/- which was sent by the Opposite Party alongwith settlement voucher. The Complainant has not produced bills of Cumballa Hill Hospital. The Complainant has produced claim form in which he has stated total hospital bills of Rs.5,12,395/- but he has not deducted amount of Rs.99,875/- paid by Opposite Party to the hospital as cashless facility. In the complaint, the Complainant has claimed recovery of medical expenses under the two mediclaim policies from Opposite Party No.3. Therefore, we think it just to direct Opposite Party No.3 to pay to the Complainant an amount of Rs.4,12,520/- towards reimbursement of the medical expenses under mediclaim policies.
The Complainant has claimed interest @ 15 % p.a. on aforesaid amount. The Complainant has claimed interest at excessive rate. We think it just to direct Opposite Party No.3 to pay to the Complainant interest on aforesaid amount of Rs.4,12,520/- @ 9 % p.a. from 28/12/07 till realization of entire amount to the Complainant.
The Complainant has claimed Rs.50,000/- towards compensation for mental agony and Rs.50,000/- towards legal cost. Considering facts and circumstances of the case, we think it just to direct Opposite Party Nos.1 to 3 to pay to the Complainant Rs.10,000/- as compensation for mental agony and Rs.3,000/- as cost of this proceeding. Hence we answer point no.2 accordingly.
For the reasons discussed above, we pass following order –
O R D E R
i. Complaint No.120/2009 is partly allowed.
ii.Opposite Party No.3 shall pay an amount of Rs.4,12,520/- (Rs. Four Lacs Twelve Thousand Five Hundred
Twenty Only) to the Complainant with interest @ 9 % p.a. from 28/12/2007 till realization of the entire
amount.
iii.Opposite Party Nos.1 to 3 shall pay jointly and/or severally an amount of Rs.10,000/-(Rs. Ten Thousand
Only) as compensation for mental agony and Rs.3,000/- (Rs. Three Thousand Only) towards cost of this
proceeding to the Complainant.
iv.Opposite Partyshall comply with this order within 1 month from the date of receipt of this order.
v.Certified copies of this order be furnished to the parties.
