Delhi

East Delhi

CC/887/2013

PARVESH KUMAR - Complainant(s)

Versus

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

22 May 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO.  887/13

 

Shri Parvesh Kumar

S/o Shri Rajbir Singh

R/o C-3, Village Gazipur

Delhi – 110 096                                                           …….Complainant

Vs.

1. The Branch Manager

United India Insurance Co. Ltd.

Unit No. 218-222, Kshitij Complex

Sector-4, Vaishali, Ghaziabad

UP – 201 010

 

2. The Grievance Cell

    United India Insurance Co. Ltd.

Regional Office: 2 Core-1, 2^nd Floor

Scope Minar, Laxmi Nagar, Delhi – 110 092

 

3. The Branch Manager

East West Assist Pvt. Ltd.

97, Manekshaw Road, Sainik Farms

New Delhi – 110 068                                                       ….Opponents

 

Date of Institution: 20.12.2013

Judgment Reserved on: 22.05.2017

Judgment Passed on: 25.05.2017

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Sh. Sukhdev Singh (President)

 

 

JUDGEMENT

          This complaint has been filed by Shri Parvesh Kumar against the Branch Manager, United India Insurance Co. Ltd. (OP-1), the Grievance Cell, United India Insurance Co. Ltd. (OP-2) and the Branch Manager, East West Assist Pvt. Ltd. (OP-3) under Section 12 of the Consumer Protection Act, 1986. 

2.       The facts in brief are that the complainant Shri Parvesh Kumar purchased a family medicare policy from Bajaj Allianz Insurance Company Ltd. vide policy no. OG-10-9994-6010-00000696, valid from 11.06.2009 to 10.06.2010.  He renewed the said policy as follows:

Date of renewal	Policy No.	Valid from	Valid to	Issued by
26.06.2010	OG-10-9994-6010-00000928	26.06.2010	24.06.2011	Bajaj Allianz Insurance Company Ltd.
25.06.2011	OG-10-9994-6010-00000173	25.06.2011	24.06.2012	United India Insurance Co. Ltd.

 

          On 21.07.2011, wife of the complainant, who was also a beneficiary of the said policy was admitted in Sumitra Hospital, Noida for the treatment of abdominal pain.  On 22.07.2011, the TPA department of hospital informed OP for the case of the complainant and requested for grant of authorization letter for treatment and guarantee of payment, but OP refused to pay any amount against the health policy on the ground “claim payable after 30 days waiting period”.  After various tests and observations, the hospital advised the surgery of the wife of the complainant, but the complainant discharged his wife from the hospital on 23.07.2011 after paying the amount of bill in cash, as OP had refused to pay the benefits of the health policy.   

          On 25.07.2011, the complainant got admitted his wife in Shyam Hospital, Ghaziabad, where the surgery of his wife was conducted on 26.07.2011.  The wife of the complainant got discharged on 30.07.2011 and all the bills were paid by the complainant in cash.

          After full treatment of his wife, the complainant contacted OP and it was revealed that OP had released an amount of Rs. 12,000/- in favour of Sumitra Hospital, Noida, but the same was returned as the bill was paid in cash.  The complainant also submitted his two claim applications related to two different hospitals for an amount of              Rs. 50,929/- before OP on 11.08.2011. 

          It was further stated that on 14.10.2011, OP rejected the claim applications of the complainant on the ground “There is a break in the policy of 15 days. Hence, a claim cannot be settled.  The claim can be admitted only on the third year of the continuous policy”.  At this stage, the complainant approached his previous insurance company i.e. Bajaj Allianz Insurance Co., who issued a letter that the policy NO. OG-10-9994-6010-00000928 was in continuation of policy No. OG-10-9994-6010-00000696, but OP had rejected the claim on the ground that the first two years health policies, done by Bajaj Allianz Insurance Co. were not a continuous policy as there was a break of 15 days between them.

          A legal notice dated 19.07.2013 was served, which was replied in the month of August 2013 (wrongly mentioned August, 2012) in which OP denied the reimbursement of the claim stating that  “your policy may not be treated as continuation renewal policy because the previous insurer is not the same (As per IRDA rules and policy conditions continuation of the policy may be treated if the previous insurance policy is from the same insurance company but may be of some other Branch or Divisional Office and not the different company)”.  Thus, the complainant prayed for direction to OP to pay an amount of Rs. 50,929/- alongwith interest @ 15% p.a., Rs. 1,50,000/- compensation on account of loss and Rs. 22,000/- as litigation expenses.

3.       In WS, OP have taken various pleas such as the disease was contracted within 30 days from the inception of United India Policy; the claim under clause 4.1 and 4.2 as the (Left Creteric Colic) is only payable in the 3^rd year of the policy period and the policy cannot be treated as continuation renewal policy because the previous insurer is not the same as per Insurance Regulatory and Development Authority (IRDA) rules and policy conditions.  IRDA had issued guidelines on portability of Health Insurance Policies to be introduced from 1^st July, 2011 and decided to implement the portability of Health Insurance Policies w.e.f. 01.10.2011.  It has further been stated that Rs.12,000/- was released to Sumitra Nursing & Maternity Home for a disease “Acute Enterocolitis” which can be paid after 30 days from the inception of the policy, but during the process, it was found that the treatment was for Ectopic Pregnancy and not for Acute Enterocolitis, which was payable only on the 3^rd year of the operation of continuous policies period.  Claim forms were submitted after expiry of stipulated time as per condition no. 5.4 of the policy.  The policy issued by the answering respondent cannot be treated as continuation renewal policy because the previous insurer was not the same.  Other facts have also been denied. 

4.       The complainant has filed rejoinder to the WS of OPs, wherein he has controverted the pleas taken in the WS and reasserted his pleas.

5.       In support of its complaint, the complainant has examined himself on affidavit.  He has narrated the facts which have been stated in the complaint.  He has also got exhibited policy no. OG-10-9994-6010-00000696 valid from 11.06.2009 to 10.06.2010 (Ex.CW-1/1), policy no. OG-11-9994-6010-00000928 valid from 24.06.2010 to 24.06.2011 (Ex.CW-1/2), policy no. 222004/48/11/06/00000173 valid from 25.06.2011 to 24.06.2012 (Ex.CW-1/3 colly.), letter dated 23.07.2011 issued by TPA (Ex.CW-1/4), medical record of Sumitra Hospital (Ex.CW-1/5 colly.), medical record of Shyam Hospital (Ex.CW-1/6 colly.), letter dated 22.07.2011 (Ex.CW-1/7), claim application related to two different hospitals (Ex.CW-1/8 colly.), letter issued by Bajaj Allianz Insurance Co. (Ex.CW-1/9), postal receipts (Ex.CW-1/10) and (Ex.CW-1/12). reply of OP dated 06.08.2013 (Ex.CW-1/13) and complaint (Ex.CW-1/14).  

          In defence, United India Insurance Co. Ltd. has examined        Shri Rajesh Bajaj, Assistant Manager, who has deposed on affidavit.  He has also narrated the facts, which have been stated in the WS.  He has also got exhibited letter of United India Insurance Co. Ltd. dated 06.08.2013 (Ex.RW/1/A), IRDA circular dated 09.09.2011 (Ex.RW/1/B), letter dated 23.07.2011 (Ex.RW/1/C), conditions of the policy (Ex.RW/1/D), discharge summary of Sumitra Hospital (Ex.RW/1/E), letter dated 06.08.2013 (Ex.RW/1/F) and IRDA circular dated 09.09.2011 (Ex.RW/1/G).

6.       We have heard Ld. Counsel for the parties and have perused the material placed on record.  It has been argued on behalf of OP that the policy issued by the United India Insurance Company cannot be treated as continuation of the earlier policy of the complainant which were issued by Bajaj Allianz Insurance Company Ltd. as the earlier insurer was not the same.  He has further argued that as per the IRDA circular, the portability clause was to be implemented from 01.10.2011, whereas policy of the complainant was issued by United India Insurance Co. Ltd.  on 25.06.2011 which was prior to the date of portability and cannot be treated as ported health insurance policy.

          On the other hand, Ld. Counsel for complainant have argued that United India Insurance Co. Ltd. made the proposal on 15.06.2011 and paid the premium on the very day itself and the policy was continued w.e.f 25.06.2011 to 24.06.2012 showing the same as in continuation.  Further, with regard to IRDA circular of dated 10.02.2011, it has been stated that if it was to be implemented from 01.10.2011, then why the policy of complainant was ported w.e.f. 25.06.2011. 

          To appreciate the arguments of Ld. Counsel for the parties, a look has to be made to the testimony of complainant Parvesh Kumar and testimony of Rajesh Bajaj, Manager United India Insurance Co. Ltd. and the documents exhibited by both of them.  If a look is made to the testimony of Parvesh Kumar, it is noticed that he got a medicare policy from Bajaj Allianz Insurance Company Ltd., which was valid from 11.06.09 to 10.06.2010 as per Ex.CW1/1.  This policy was got renewed from 26.06.2010 to 24.06.2011 as per Ex.CW1/2.  Thereafter, this policy was got renewed from United India Insurance Co. Ltd. from 25.06.2011 to 24.06.2012 as per Ex.CW1/3.  The only question that arises for consideration is as to whether the portability of the policy was as per rules of IRDA, which was renewal of policy or it was a fresh policy.  For this, a look has to be made to the IRDA circular of dated 09.09.2011.  In this circular, the meaning of portability has been explained as:-

          “Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break”.

          From the bare reading of this definition, it comes out that it gives right to an insurer to switch over from one insurer to another insurer or from one plan to another plan of the same insurer provided the previous policy has been maintained without any break.  Here, the option has been given to the insurer to switch off from one insurer to another insurer meaning thereby that insurer is at liberty to switch over to one insurance company to another insurance company and secondly he can switch over to one plan to another plan of the same insurer.  The word used in this definition of the same insurer applies only to the change of plan and not to the change of insurance company. 

          In the present case, the complainant has got changed his insurance policy from Bajaj Allianz Insurance Company Ltd. to United India Insurance Co. Ltd. and his policy was in continuation as the United India Insurance Co. Ltd. have renewed the policy from 25.06.2011.  Thus, the policy issued by United India Insurance Co. Ltd.  cannot be said to be a fresh policy, but it was in continuation of its earlier policies issued by Bajaj Allianz Insurance Company.  Therefore, the arguments advanced on behalf of United India Insurance Co. Ltd. that the portability was not as per IRDA regulations do hold not good.  Thus, it goes.

          With regard to the second argument that the portability was to commence from 01.10.2011 and it was not applicable to the policy of complainant which was issued on 25.6.2011, there is no force in the argument of Ld. Counsel for United India Insurance Co. Ltd. as the circular itself states that portability of health insurance policies would be mandated to commence not later than 01.10.2011.  It means that it was

the outer limit for commencement of portability.  It does not say that the portability cannot be done prior to October 2011.  Thus, the policy of the complainant being of 25.06.2011 was said to be ported as per IRDA rules. 

          When the policy of the complainant was not a fresh policy, but it was in continuation of its earlier policy, issued by Bajaj Allianz Insurance Company Ltd. and portability was as per IRDA circular, the plea taken by United India Insurance Co. Ltd. that the treatment taken by the complainant was not covered cannot be accepted.  It was found that the treatment taken by the complainant for “Left Ureteric Colic with UTI with Gastritis with  Ectopic Pregnancy and not for Acute Enterocolitis”, which was a different disease which was payable only on the third year of the operation of the continuous policies period as there was no continuity cannot be accepted.  Thus, the treatment taken by the complainant was in the third year of the operation of the policy which was payable, therefore, the same was not hit by exclusion clause 4.1 and 4.2 of the policy. 

          With regard to submission of medical claim, he has stated in his testimony that he submitted two claim applications relating to two different hospitals before OP on 11.08.2011, which has been got exhibited as Ex.CW1/8.  Submission of claim applications has not been denied by the insurance company.  Thus, the fact remains that he submitted two different applications for claim amounting to Rs. 50,929/-.  Therefore, the claim rejected by the insurance company amounts to deficiency in service.  When the claim was rejected without any reason and have not been paid as per terms of policy, certainly, the complainant has suffered mental pain and agony for which she has to be compensated.

          In view of the above, it is ordered that OP shall refund an amount of Rs. 50,929/- with compensation of Rs. 25,000/- on account of mental pain and agony which includes the cost of litigation.   This order be complied within a period of 45 days.  If not complied, then Rs. 75,929/- shall carry interest @ 9% p.a. from the date of order.

          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