Delhi

East Delhi

CC/918/2013

KAILASH KAUSHIK - Complainant(s)

Versus

U.I.I. - Opp.Party(s)

15 May 2017

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 918/13

 

Shri Kailash Kaushik

S/o Shri Ram Karan Sharma

R/o C-395, G.F., Yojana Vihar

Delhi – 110 092                                                                ….Complainant

Vs.

Sr. Divisional Manager DO – 1

United India Insurance Company Limited

Divisional Office I, 60 Janpath

New Delhi – 110 001                                                           ….Opponent

 

Date of Institution: 08.11.2013

Judgment Reserved on: 02.05.2017

Judgment Passed on: 16.05.2017

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Ms. Harpreet Kaur Charya (Member)

 

 

JUDGEMENT

 

The present complaint has been filed by Shri Kailash Kaushik, the complainant against Sr. Divisional Manager DO-1, United India Insurance Company Limited (OP) under Section 12 of the Consumer Protection Act 1986.

2.       Facts in brief are that the son of the complainant was covered under various mediclaim policies since June 2008 to July 2013.  Unfortunately, the complainant lost his son on 04.04.2013 due to post operative complications in liver transplant surgery.  The complainant has stated that he had incurred Rs. 50,00,000/- on the treatment of his son by taking loan from family and friends.  The son of the complainant had Super Top UP Medicare Policy bearing no. 040300/48/11/36/000001573 for a period from 16.07.2012 to 15.07.2013.  The claim under Super Top Up Policy was rejected by OP vide letter dated 12.07.2013 stating that as per policy terms and conditions, the treatment expenditure was excluded as it was pre-existing disease.  It is stated in the complaint that the son of the complainant was not suffering from any disease at the time of taking Super Top Up Policy.  The treatment for the said disease started from September 2011.  The complainant has stated that all the earlier claims had been settled by the TPA except the one in question.  Hence, the present complaint seeking directions to OP to settle the claim of Rs. 5,00,000/-, compensation for mental and physical harassment as Rs. 2,00,000/-.

          Copy of policies for the year 2008-2009 to 2012-2013, copy of Super Top UP Medicare Policy for the year 2011-2012 and 2012-2013, repudiation letter dated 12.07.2013, letter written by the complainant to OP dated 11.08.2013, claim form alongwith condonation of delay in intimation to OP, cashless denial dated 05.03.2013 and discharge summary alongwith death certificate have been annexed with the complaint.

3.       Reply was filed by OP upon the service of the summons of the complaint.  It was stated that the son of the complainant was admitted on 02.02.2013 for liver transplant and as per treating doctor, the patient was asymptomatic till September 2011, when he developed pedal distension and was referred to M/s. Indraprastha Apollo Hospital for further evaluation.  After evaluation, he was diagnosed as a case CLD (Chronic Liver Disease Ascites)

          It was also stated that the complainant had got his son insured and claim under Individual Mediclaim Policy no. 040300/48/12/97/ 00000412 had reached threshold level and the claim under the Super Top Up Medical Policy no. 040100/48/12/36/000001573 for the period from 16.07.2012 to 15.07.2013 with sum insured of Rs. 5,00,000/- was rejected under exclusion clause no. 4.1:-

          “The company shall not be able to make any payment under this policy in respect of any expenses whatsoever, incurred by any Insured Person in connection with or in respect of: Any pre-existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person has elapsed since inception of his/her Super Top UP Medical Policy with the Company…”.

           It was further stated that Super Top Up Medical Insurance Policy was a contract thus both parties were bound by the terms and conditions and the complainant being well versed in the Insurance field, thus had knowledge of the same.  It was stated that the individual health insurance policy was different from Super Top Up Medical Insurance Policy and the claim had been settled under individual health policy.  Thus, the claim of the complainant had been validly rejected.  Copy of terms and conditions had been annexed with the WS.    

4.       Rejoinder was filed by the complainant, where it was stated that the son of the complainant was first time admitted on 24.09.2011 which was after taking the policy on 13.07.2011, and the insured and his attendants were unaware of any disease.  Discharge summary dated 01.10.2011 was annexed with the rejoinder.  Contents of the WS were denied and those of the complaint were reiterated.

5.       Evidence by way of affidavit was filed by both the parties where complainant examined himself and relied on copy of election Card (Ex.CW-1/A), copies of individual health insurance policies (Ex.CW-1/B), copy of letter dated 12.07.2013 issued by United India Ins. Co. (Ex.CW-1/C), copy of email dated 11.08.2013 (Ex.CW-1/D), copy of letter dated 17.08.2013 (Ex.CW-1/E), copy of acknowledgement dated 23.04.2013 (Ex.CW-1/F), claim form (Ex.CW-1/G), letter written by the complainant to the Sr. Divisional Manager of OP (Ex.CW-1/H), format for condoning delay in intimation (Ex.CW-1/I), letter dated 04.03.2013 issued by E-Meditek (TPA) Services Limited (Ex.CW-1/J), letter dated 05.03.2013 issued by E-Meditek (TPA) Services Limited (Ex.CW-1/K), email dated 10.05.2013, 16.05.2013 and 21.05.2013  (Ex.CW-1/L, Ex.CW-1/M and Ex.CW-1/N), Death certificate of Nitin Kaushik (Ex.CW-1/O), medical document/reports (Ex.CW-1/P) and discharge summary (Ex.CW-1/Q).

          Shri Shyam Singh Senior Divisional Manager was examined on behalf of OP, who reiterated the contents of the WS and exhibited copy of terms and conditions as Ex. OP/1.

6.       We have heard the Ld. Counsel for the complainant and OP and have perused the material placed on record.  The dispute is with respect to claim under Super Top Up Medical Insurance Policy only, OP has already paid under Individual Health Insurance Policy.  What is to be decided was whether the complainant was entitled to claim under Super Top Up Medical Insurance Policy?  Careful reading of Super Top Up Medical Insurance Policy no. 040100/48/12/36/00001573 reveals that the period of insurance was from 16.07.2012 to 15.07.2013, and the date of proposal and declaration are dated 16.07.2012, even the Super Top Up Medical Insurance Policy for the year 13.07.2011 to 12.07.2012 bearing no. 040300/48/11/36/00000630 has date of proposal and declaration as 13.07.2011.

          The discharge summary of Indraprastha Apollo Hospital, annexed by the complainant with his rejoinder shows the date of admission of  Mr. Nitin Kumar as 24.09.2011 and date of discharge as 01.10.2011.  He was diagnosed as a case of “CLD with PHT”, which shows that he was suffering from Chronic Liver Disease with Portal Hypertension.  Under the column History, it has been stated as:

“Mr. Nitin Kaushik, 35 years old male non-diabetic, non hypertensive presented with history of off and on swelling both feet for one and half year and progressive distension of the abdomen for 2 months.  There was no history of fever, GI bleed, altered sensorium or jaundice at present.  History of Jaundice one year back.”

          Here, it would be relevant to have reference to exclusion clause 4, which reads as under:-

4.       Exclusion

          The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured Person in connection with or in respect of:

4.1     “Any pre-existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed, since inception of his/her SUPER TOP UP MEDICARE Policy with the Company. 

Pre-Existing Condition/Disease definition – Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment, within 48 months prior to his/her SUPER TOP UP MEDICARE Policy with the Company.”

 

          A bare reading of this clause shows that under the Super Top Up Medical Insurance Policy, the insured person have not to be paid for any pre-existing condition untill 48 months after inception of the policy have elapsed.  It means that expenses incurred under the Super Top Up Medical Insurance Policy having any pre-existing condition have to be borne by the insurance company after expiry of 48 months of the policy.

          Further, from the definition of pre-existing condition/disease, it comes out that the definition covers signs or symptoms for which the medical advice or treatment was taken by the insured within 48 months prior to his Super Top Up Medical Insurance Policy. 

          In the present case, Super Top Up Medical Insurance Policy having No. 040300/48/11/36/000001573 was for the period from 16.07.2012 to 15.07.2013.  The Death Summary / Discharge Summary got exhibited by the complainant in his testimony as Ex.CW1/Q show that Mr. Nitin Kumar was admitted in Indraprastha Apollo Hospital on 02.02.2013 and expired on 04.04.2013.  The claim made by the complainant has been during the operation of this policy, which was valid from 16.07.2012 to 15.07.2013.  Under this policy, the date of proposal and declaration are of dated 16.07.2012.  When the proposal and declaration are of dated 16.07.2012 and the policy was valid from 16.07.2012 to 15.07.2013, the treatment of Mr. Nitin Kumar was taken during the operation of this policy and as per the discharge summary, placed by the complainant himself with his rejoinder shows that Mr. Nitin Kumar was suffering from CLD with PHT.  Thus, he was suffering from pre-existing disease, which was excluded under Clause 4.1 until the expiry of 48 months. 

          Not only this, even if his earlier Super Top Up Medical Insurance Policy no. 040300/48/11/36/00000630, which was valid from 13.07.2011 to 12.07.2012 of which the date of proposal and declaration was 13.07.2011 is taken into account, even then the treatment taken by the complainant for his son Nitin Kumar was hit by exclusion clause as cumulative period of both the policies was only of 24 months, though, for any pre-existing disease, the insured was to wait until the expiry of 48 months from the inception of policy.  In the present case, both the policies were for two years i.e. from 13.07.2011 to 15.07.2013, which is less than 48 months.

          In view of the above, we are of the opinion that the treatment taken by the complainant for his son was not covered under the Super Top Up Medical Insurance Policy and the same was hit by clause 4.1 of the terms and conditions of the said policy and there was no deficiency on the part of insurance company.  Therefore, the complaint has no merit, which deserves its dismissal and the same is dismissed.  There is no order as to cost. 

          Before parting with, it would not be out of place to express our sympathy with the family as Mr. Nitin Kumar was their only son.  However, we are bound by the law to act.                 

          Copy of the order be supplied to the parties as per rules.

File be consigned to Record Room.

 

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member 

 

 

            (SUKHDEV SINGH)

                                                      President