Delhi

North East

CC/42/2021

Krishan Kashyap - Complainant(s)

Versus

The United India Insurance Co. Ltd. - Opp.Party(s)

28 Apr 2023

ORDER

7DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.42/21

In the matter of:

 

	Sh. Krishan Kashyap S/o Sh. Jagdish Prasad Kashyap, R/o C-1/201, Yamuna Vihar, Delhi-110053	Complainant
	Versus
	The Regional Manager, The United India Insurance Co. Ltd. & Oth., Ro-1, 8th Floor, Kanchanjunga Building, Bara Khamba Road, New Delhi-110001	Opposite Party

 

DATE OF INSTITUTION:        JUDGMENT RESERVED ON:                        DATE OF ORDER  :

12.03.2021 10.10.2022 28.04.2023

 

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

 

                                                               ORDER

Anil Kumar Bamba, Member

The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019.

 

      Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant took the family Member Policy 2014 from the Opposite Party on 17.10.2015 under policy no. is 0417812815P108220748 for a sum insured of Rs. 5,00,000/- by paying a premium of Rs. 13,328/- which was subsequently renewed every year on or before due date of policy. Now the current policy no. 0417812818P109182416. On 10.05.2019, the Complainant suffered with acute pain in stomach and he was rushed to the nearby Dr. Chaudhary Moral Hospital Pvt. Ltd., Block C-1/2A and C-1/1 Yamuna Vihar Delhi-110053 where he was admitted on 10.05.2019. Where certain test were conducted, where it was diagnosed that the Complainant is suffering from tubular cyst in gall bladder fossa. The Hospital showed some laxity in treatment but the pain was continuously increasing, therefore, the family members decided to shift the patient to somewhere else. The Complainant was discharged on 13.05.2019. The hospital charges was Rs. 22,280/- as per the bill. Complainant informed the Opposite Party in respect of his admission vide e-mail dated 13.05.2019. Then the Complainant decided to go St. Joseph Hospital Ghaziabad in OPD on 14.05.2019 where certain test i.e. MRCP were prescribed and it was conducted at Vedanta Imaging and Diagnostics Vasundhara, Ghaziabad and it was diagnosed as K/C/O Type II DM with tubular cyst in gall bladder fossa. The doctors advised for an operation to remove the cyst. On 05.06.2019, the Complainant was admitted in St. Joseph Hospital for operation and discharged on 08.06.2019. On this treatment the Complainant incurred a sum of Rs. 56,443/-. Hence, the total amount incurred by the Complainant on the treatment comes to Rs. 78,723/-. The Complainant again informed the Opposite Party in respect of his admission vide e-mail dated 05.06.2019. The Complainant submitted his mediclaim for reimbursement of all the bills along with prescription, hospital papers and discharge summary along with all original documents including original medical bills to the Opposite Party on 17.06.2019 through speed post to the third party administrator i.e. Vipul Medi Corp., Udyog Vihar, Industrial Complex Dundahera, Gurgaon, Haryana 122016. The Complainant supplied all the required documents to Opposite Party but Opposite Party was not releasing the genuine claim of the Complainant. All the promises by the Opposite Party for the prompt and honest services are demolished by their own acts as the genuine claim is not released as yet, which clearly shows deficiency in services on the part of the Opposite Party. The Complainant has prayed to direct the Opposite Party to pay Rs. 78,723/- for making payment of medical bills along with interst @ 18 % p.a. without any further delay, Rs. 15,000/- on account of litigation expenses and Rs. 50,000/- on account of mental harassment.

      Case of the Opposite Party

2. The Opposite Party contested the case and filed its written statement. It is the case of the Opposite Party is that a Family Medicare Policy 2014 bearing no. 0417812818P109182416 for a period 17.10.2018 to 16.10.2019 was issued by the Opposite Party insurance company in favour of the Complainant. The inception date of first policy taken by the Complainant was 17.10.2015 and thereafter, the said policy was renewed from time to time. The Complainant was duly bound by the terms and conditions of the policy in question. It is submitted here that the Complainant lodged two claims with Opposite Party one for hospitalization in St. Joseph’s Hospital on 05.06.2019. Both the claims were filed by the Complainant under policy no. 041781281PP109182416 and the same were registered by TPA of Opposite Party. The Complainant got admitted for the first time in the Dr. Chaudhry’s Moral Hospital on 10.05.2019 as he suffered acute pain in stomach and where it was diagnosed that Complainant came with nausea, dyspepsia, vomiting for 02 days, pain upper abdomen for 2 days with history of LAP. The Complainant got discharged from the said hospital on 13.05.2019. The complainant did not inform the TPa of Opposite Party in advance regarding his admission for   in the abovementioned hospital which also amounted to violation of terms and conditions of the insurance policy. It is also submitted here that the Complainant has not provided the TPA of Opposite Party with the necessary clarifications, requirements and documents which were requested may times by the TPA of the Opposite Party and for which the TPA of Opposite Party insurance company had sent many letters dated 28.05.2019, 06.06.2019, 10.06.2019, 18.06.2019, 26.06.2019 and 10.07.2019 and for the second claim for which also TPA of Opposite Party had sent many letters dated 25.06.2019, 03.07.2019, 11.07.2019, 20.07.2019, 16.10.2019, 24.10.10.2019, 01.11.2019 and 14.11.2019. The complainant had therefore committed gross breach of conditions no. 5.3 to 5.5 of the insurance policy. The same are reproduced hereunder:

“5.3 Notice of claim- upon the happening of any event which may give rise to a claim under this policy notice with full particulars shall be sent to the TPA named in the schedule immediately and in case of emergency Hospitalization within 24 hours from the time of Hospitalization.

5.4 All supporting documents relating to the claim must be filed with the TPA within 15 days from the date of discharge from the hospital. In case of post hospitalization, treatment, all claim documents should be submitted within 7 days after completion of such treatment.

Note: Waiver of this condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the company that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit.

5.5 The insured person shall obtain and furnish to the TPA with all original bills, receipts and other documents upon which a claim is based and shall also give TPA/Company such additional information and assistance as the TPA/Company may require in dealing with the claim”

3. It is submitted here that the Complainant had failed to provide all thetreatment record of the past for the surgery for LAP CHOLE etc. done 4 years back as the same was mentioned in the discharge summary of both the hospital where the Complainant was admitted that he had history of Laparpscopic Cholecystectomy 4 years back and the treatment record of the same was require d by TPA of Opposite Party in order to process the claim of the Complainant. Since the Complainant failed to provide the said past record as demanded by the TPA of Opposite Party despite various reminders through letters and notices, the same amounted to violation of terms and conditions of the insurance policy and therefore, the Complainant is not entitled to any claim and the complaint is liable to be dismissed. Since, the insured/Complainant did not comply with requirements as mentioned in the letter dated 15.11.2019 sent by Opposite Party to the Complainant, therefore, the Opposite Party sent a repudiation letter dated 30.11.2019. Since the claim of the Complainant could not be settled for non-submissions of required documents and information sought vide various letters, notices and also the last letter dated 15.11.2019 for the first claim and letter dated 24.01.2020 for the second claim and as per the terms and conditions of insurance policy and also on account of non-compliance of required documents for processing the claim, hence the present complaint is not maintainable and liable to be dismissed.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

4. The Complainant in support of his case filed his affidavit wherein he has supported the assertions made in the complaint.

Evidence of the Opposite Party

5. To support its case Opposite Party has filed affidavit of Sh. R.N Singh, Manager United India Insurance Company Ltd. In affidavit, he has supported the case of the Opposite Party as mentioned in the written statement.

Arguments & Conclusion

6. We have heard the Counsel for the Complainant and Opposite Party. We have also perused the file and written arguments filed by the Complainant and Opposite Party. The case of the Complainant is that he is having Family Member Policy  with the Opposite Party on 17.10.2015 and renewed the said policy every year and paid due premium on time. During the validity of medi-claim policy Complainant suffered with acute pain in stomach on 10.05.2019 and admitted to the Hospital wherein certain tests were conducted and it was diagnosed that Complainant is suffering from tubular cyst in gall bladder. Since, the hospital showed some laxity in treatment, family member decided to shift the patient to other hospital. The Complainant was discharged on 13.05.2019 and hospital charges were Rs. 22,280/-. Complainant informed the Opposite Party in respect to admission vide email dated 13.05.2019. Then, the Complainant decided to go to another hospital on 14.05.2019 where certain tests was again conducted and doctor advised him for  operation. On 05.06.2019, the Complainant was admitted in St. Joseph Hospital for operation and discharged on 08.06.2019. On this treatment, the Complainant incurred a sum of Rs. 26,443/-. Hence, the total amount incurred by the Complainant on the treatment coms to Rs. 78,723/-. The Complainant informed the Opposite Party in respect to his admission in St. Joseph Hospital vide email dated 05.06.2019. As per the Complainant he has submitted his medi-claim for reimbursement of all the bills along with all necessary documents to the Opposite Party on 17.06.2019. In spite of submitting all requisite documents to the Opposite Party his claim was repudiated by the Opposite Party. Hence, there is a deficiency of service on the part of Opposite Party. The case of the Opposite Party is that the Complainant was having a medi-claim policy with the Opposite Party which was valid up to 16.10.2019. It is also admitted by the Opposite Party that Complainant lodged two claims with the Opposite Party. Opposite Party repudiated the claim of the Complainant on the ground that he has not informed the Opposite Party about his admission in the hospital and did not submit necessary clarification and documents which was requested many times by the agent of the Opposite Party for which they have reminded the Complainant time and again. Therefore, the Complainant committed gross breach of condition no. 5.3 to 5.5 of the insurance policy. Hence, there is no deficiency on their part.
7. After going to the evidence filed by the Complainant we are of the opinion that the Complainant has given all necessary information and required documents to the Opposite Party. Hon'ble Supreme Court of India, in the case of Manmohan Nanda Vs. United India Insurance Co. Ltd., Civil Appeal No. 8386/2015  held as below:

69. The object of seeking a mediclaim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent and which may occur overseas. If the insured suffers a sudden sickness or ailment which is not expressly excluded under the policy, a duty is cast on the insurer to indemnify the appellant for the expenses incurred thereunder.

70. Hence in the instant case, the repudiation of the policy by the respondent insurance company was illegal and not in accordance with law. Consequently, the appellant is entitled to be indemnified under the policy. In view of the aforesaid discussion, we hold that the Commission was not right in dismissing the complaint filed by the appellant herein.

 

8. In view of the above discussion and law laid down by the Hon'ble Supreme Court of India, the complaint is allowed. Opposite Party is directed to pay an amount of Rs. 78,723/-  to the Complainant along with interest @ 6 % p.a. from the date of filing the complaint till recovery. Opposite Party is also directed to pay an amount of Rs. 15,000/- to the Complainant along on account of mental harassment and litigation expenses along  with interest @ 6 % p.a. from the date of this order till recovery.
9. Order announced on 28.04.23

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)           Member

(Surinder Kumar Sharma) President