Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 241/20.08.2015
Shalini Chatrath w/o Sh. Amarjit Chatrath
R/o D-4, Rose Apartment, Sector-14 Extn.
Rohini, Delhi-110085 …Complainant
Versus
OP1- United India Insurance Co. Limited
Divisional Office-05,10203, IIIrd floor,
Jamuna House, Padam Singh Road,
Karol Bagh, New Delhi-110005
OP2- Canara Bank
Aggarwal Chambers, Pitam Pura,
New Delhi-110088 ...Opposite Party
Date of filing 20.08.2015
Date of Order: 14.08.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
ORDER
Inder Jeet Singh , President
1.1. (Introduction to case of parties) –The complainant has grievances of deficiency of services against OPs that despite her medical bills and other expenses within the sum insured under policy issued, the OPs had declined it partly on the basis of pre-existing disease or entire amount exceeding sum insured and it is not covered within the specified period from the inception of the policy. The complainant’s claim is after four & half years of the initial policy and she was not suffering from any pre-existing disease, when initial policy was taken and balance amount is covered within sum assured.
1.2. Whereas, the OP1 has opposed the claim that the complainant was entitled for permissible amount of Rs. 2,00,000/- under the policy and that was allowed, the remaining amount was not covered or permissible under the policy, that is why, it was declined. There is no deficiency of services.
1.3. Initially the complaint was filed against United India Insurance Company Limited/OP1 and the Syndicate Bank/OP2, however, the Syndicate Bank was merged into Canara Bank, therefore, the name of Canara Bank was substituted by order dated 06.02.2023 on the application of complainant and notice was also directed to Canara Bank/OP2, which failed to appear. [The Syndicate Bank was also proceeded ex-parte for want of appearance].
2.1. (Case of complainant) – Briefly, the complainant took medi-claim health insurance policy from OP1 through OP2 - “Syn Arogya Group Mediclaim Scheme” vide policy w.e.f. 06.03.2009 to 05.03.2010 for sum insured of Rs. 2,00,000/- vide policy no. 040100/48/08/14/00005286 against payment of premium. The paragraphs 1 & 2 of the complaint narrates renewal of the policy from time to time viz. w.e.f. 06.03.2010 to 05.03.2011, 06.03.2011 to 05.03.2012, 06.03.2012 to 05.03.2013 (sum insured Rs. 4,00,000/-), 06.03.2013 to 05.03.2014 (vide policy no. 040500/48/11/14/00004511 sum insured Rs. 5,00,000/-) , 06.03.2014 to 05.03.15 (sum insured Rs.5,00,000/-), and the last policy was renewed vide no. 040500/48/13/14/000/6400 (SI Rs.5,00,000/-) from 06.03.2015 to 05.03.2016. The insurance policies were issued against regular payments of premium and the policies are in continuation from the inception but without confirming the terms & conditions of agreement to the complainant.
2.2. The complainant was hospitalized from 10.09.2013 to 17.09.2013 for surgery of knees at Medanta Medacity Global Health Pvt. Ltd. and the total bills at the time of discharge was Rs. 3,65,810/- but TPA reimbursed Rs. 2,00,000/- only, the complainant was to pay balance of bill of Rs. 1,65,810/- to hospital. It was during the tenure of policy no.040500/48/11/14/00004511 for sum insured Rs. 5,00,000/- wef 06.03.2013 to 05.03.2014. Moreover, the complainant also incurred other expenses [pre-hospitalized and post hospitalized[, which makes total claim of Rs. 1,77,929/-. The OP1 has partly allowed entitlement of Rs. 2,00,000/-only, whereas, the surgery was after four years & six months, which is in fact during 5th year of policy for sum insured of Rs. 5,00,000/- or previously the sum insured was Rs. 4,00,000/- for policy period of 2012-2013. The complainant never taken any claim from the year 2009-2010 at any point of time. The claim was lodged with the OP1.
2.3. There was a notification “Synd Arogya Group Health Scheme” and the OP1 vide their notification UIN No. IRDA/NL-HLT/UII/P-H/V-1/381/13-14, mentions special condition, which includes clause no. 2.30 (pre-existing disease) that period of 36 months is to be read in place of 48 months in Synd. Arogya health insurance scheme and similarly in clause 5.12 of this scheme (enhancement of sum insured) the renewal/ may be increased to the immediate next to two slabs. Thus, as per this clauses of agreement, the waiting period of pre-existing disease/surgery ends on 2011-2012. There was sum insured of Rs. 4,00,000/- for the policy 2011-2012 and the sum insured was Rs. 5,00,000/- for the year 2013-2014, when the hospitalization had happened, this entitles the complainant for the medi-claim reimbursement of bills. The enhancement of sum insured was within the parameter of those clauses and complainant is covered by them.
However, the OPs have declined the claim. Then complainant sent legal notice dated 12.08.2015 to OPs but no result. There is deficiency of services, breach of contract by the OPs apart from negligence on the part of OPs, which created great mental pressure on the complainant, she suffered loss and mental agony and that is why the complaint.
2.4. The complainant seeks reimbursement of amount of Rs. 1,77,929/- along with interest of 24% pa, compensation of Rs. 1,00,000/- for causing her harassment, inconvenience, frustration and mental agony besides cost of proceedings of Rs. 10,000/-. The complaint is accompanied with copies of insurance policy issued from time to time (single page policy of each year, except last policy with terms and conditions), copies of bills paid, copy of claim form, identity form, discharge summary, letters including repudiation letter dated 17.01.14 issued by OP1
3.1 (Case of OP1)- The OP1 filed its reply and opposed the complaint, on various grounds, that complaint is without cause of action, the admissible claim was allowed as per clause 5.12 of the policy as parties are bound by terms & conditions of the policy contract. The amount allowed was Rs. 2,00,000/- since there is a clause in respect of pre-existing disease, when the insurance cover starts from first time, it was in the knowledge of complainant. The policies issued from time to time are not disputed, however, the claim was reimbursed as per terms of policy.
3.2. The complainant has concealed material information since as per discharge summary, she was diagnosed of 'advanced degenerative joint disease of both knees and hypertension'. The disease was contacted more than two years ago when the original sum insured was Rs. 2,00,000/-. Consequently, the claim, if any, will be considered only upto original amount permissible at the time of enhancement and renewal upto 36 months from the date of enhancement and after 36 months the insured is entitled for enhanced amount. To say, for claiming benefit of enhancement, the policy have to run claim free for three years. Moreover, the complainant had approached Insurance Ombudsman, but it has been concealed by him. Therefore, complaint is liable to be dismissed. The reply is accompanied with letter/circular dated 30.03.2010, copy of policy w.e.f. 06.03.2015 to 06.03.2016.
3.3. (Case of OP2)- The OP2 failed to appear despite service, it was proceeded ex-parte on 05.09.2016, when it was Syndicate Bank. Moreover, when Canara Bank was substituted as OP2, notice was also served, however, it also abstained from the proceedings.
4. (Replication of complainant) – The complainant denies the allegations of reply about the complaint to be without cause of action or there is concealment of any fact or the complainant was suffering from pre-existing disease vis-à-vis the complainant admits that she had approached insurance Ombudsman but it does not demerit her complaint. It was the first time when complainant was having complained in her joints of knees and she was diagnosed and then treatment was given, it was diagnosed by the hospital and then surgery was performed; it was not case of pre-existing disease being suffered by the complainant. The complaint is correct and her case is covered under enhanced sum insured in terms of the clauses already mentioned in the complaint.
5.1. (Evidence)- Complainant led evidence by filing her detailed affidavit with support of all the documents of insurance policies, claim form with medical record and bills.
5.2. The OP led evidence by filing of affidavit of Sh. D. K. Sharma, Senior Divisional Manager, which is brief affidavit being extracts from the reply to establish its case that amount permissible was Rs. 2,00,000/- and none else.
6.1 (Final hearing)- Both the parties have filed their written arguments followed by oral submissions by Sh. Lokesh Kumar Roy, Advocate for complainant and Sh. Vivek Kumar, Advocate for OP1. OP2 failed to make any submissions.
6.2. The submissions of both the sides are on the lines of pleadings and evidence. Both the parties are also referring terms & conditions of the policy. In addition, the complainant relies upon the following case law :-
(i) National Insurance Co. Ltd. Vs. Radhey Shyam Balwada & Anr. II(2014)CPJ 201 (NC) –held that the insured was not explained condition of the policy at the time of submission of the proposal form but valid claim was declined on technical and frivolous ground under the garb of exclusion clause, consequently, the claim was allowed in favour of claimant.
(ii) Oriental Insurance Co. Ltd. Vs. R.C. Goel, (deceased through LRs) First Appeal No. FA 494/09 dod 17.09.2017 –while dealing with the condition of policy as well as claim for heart problem on the point of pre-existing disease, the rules promulgated by IRDA were discussed which were ‘What is pre-existing condition in health insurance policy’. “It is a medical condition/disease that existed before you obtained health insurance policy, and it is significant, because the insurance companies do not cover such pre-existing conditions, within 48 months of prior to the 1st policy. It means, pre-existing conditions can be considered for payment after completion of 48 months of continuous insurance cover”.
(iii) ICICI Prudential Life Insurance Co Ltd. Vs. Veena Sharma & Anr. IV(2014) CPJ 580 (NC)-held, the onus proved that the deceased has obtained policy by suppressing material fact is on the corporation to prove it by leading tangible evidence, which may also includes the proposal form.
[The complaint has also referred a few more cases, however, they have different ratio and are not direct to the issue involved in this case, thus they are not referred].
7.1 (Findings)-The contentions of both the sides are considered, keeping in view the material on record in the form of narration given by the parties and documentary record. The short/narrow dispute is of calculation of period along with the terms & conditions of the policy and of pre-existing disease, by reading them with the facts and features of this case, it would determine the consumer dispute. Therefore, the following conclusions are culled out from the record:-
(i) In the repudiation letter OP1 opines that the complainant was contacted the disease/knee problem more than two years ago when the policy was initially taken, however, the OP1 has not proved any record that the complainant was having this medical issue two years prior to taking the first policy on 06.03.2009. Further, as per discharge summary proved, there was mentioning of advanced degenerative joint disease of knees and hypertension, however, no period is mentioned that it was prior to two years from the said date 06.03.2009. The onus was the OP1 to prove that complainant was suffering from such disease prior to inception of the policy but OP1 failed to discharge this onus to prove it vis-à-vis OP1 is twisting the fact mentioned in the discharge summary to self-serve the purpose. Thus, it is held OP1 could not prove its plea or defense that complainant was suffering from pre-existing disease.
(ii) It is not disputed that the complainant has been subscribing insurance policy regularly from 06.03.2009 - 05.03.2010 to 06.03.2015 to 06.03.2016 regularly against payment of premium, however, initially the sum insured was Rs. 2,00,000/- then it was enhanced to Rs. 4,00,000/- from the policy of 06.03.2012-05.03.2013 and then enhanced to Rs. 5,00,000/- from policy w.e.f. 06.3.2013-05.03.2014
(iii) By reading sub-paragraphs (i) & (ii) above it is apparent that date of surgery was 11.09.2013 and first policy was taken on 06.03.2009 by complainant and there is gap of more than four years and six months, therefore, the clause 2.30 would not be attracted with regard to period of 36 months for want of pre-existing disease nor clause 5.12 in respect of initial sum insured of Rs. 2,00,000/- to be restricted for enhanced sum insured.
(iv) The case law file by the complainant applies to the situation in hand.
(v) Since, the clause of pre-existing disease or other clause of initial sum insured of Rs. 2,00,000/- do not apply, but for want of payment bills amount by OP1, the complainant had paid balance amount of her treatment to the hospital which was Rs. 1,65,810/-.
There is also provision of reimbursement of pre-hospitalization and post-hospitalization expenses, the complainant has also incurred expenses on this account, which has also been proved, thus the total amount paid by her is Rs. 1,77,929/-.
(vi) The OP1 in its letter dated 17.01.2014 repudiated the claim because it was so advised by TPA and from of the contents of the letters it is appearing that OP1 is feeling bound by the opinion rendered by TPA as conclusive opinion, whereas it is legal duty and obligation of OP1 to form its own opinion independently as per the circumstances of each case. It also appears as if OP1 is taking shelter under the opinion of TPA, otherwise what exactly was opinion of TPA has not been filed or proved by OP1.
(vii) As, the complainant has valid claim for reimbursement of remaining bills, which are within the sum insured under the policy but it has been declined by OP1, it amounts to deficiency of service.
7.2. Thus, in view of facts proved by the complainant of her lodging valid medical claim of amount of Rs.1,77,929/- and conclusion drawn above, the complainant is held entitled for reimbursement of Rs.1,77,929/-.
7.3. The complainant has sought interest @ 24% pa, however, considering facts & features of case, complainant was deprived of his claim, the complainant was constraint to pay the amount and she was deprived of her money, thus interest @ 8% pa would be justified for both ends, interest will be computed from the date of complaint till realization of amount against the OP1.
7.4. The complainant has also sought damages of Rs.1.00,000/- towards harassment, mental tension and agony and also by repudiating the claim & costs of Rs.10,000/-; by considering totality of circumstances of case of both sides, that part payment was made during treatment, thus damages Rs 15,000/- and cost of litigation of Rs.10,000/-are determined in favour of complainant and against the OP1.
7.5. Since OP2 is Banker, who facilitates the process of insurance policy from OP1, therefore, no order against OP2, the complaint is dismissed against OP2.
7.6. Accordingly, the complaint is allowed in favour of complainant and against the OP1 to reimburse medical bills amount of Rs.1,77,929/- along-with simple interest @ 8%pa from the date of complaint till realization of amount; apart from to pay damages of Rs.15,000/- & costs of Rs.10,000/- to complainant.
OP1 is also directed to pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, the interest will be 10% per annum on amount of Rs.1,77,929/-.
8. Announced on this 14th August 2023 [श्र!वण 23, साका 1945].
9. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [InderJeet Singh]
Member Member (Female) President
