BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA
Complaint case no. : 442 of 2017
Date of Institution : 15.12.2017
Date of decision : 25.02.2019
Brij Lal Gupta, Age 73 years son of Shri Panna Lal Gupta Resident of House No. 8, Preet Nagar, Ambala Cantt, Haryana.
……. Complainant.
United India Insurance Company Limited, Tirloki Chambers, Municipal Committee Road, Punjabi Mohalla, Ambala Cantt through its Branch Manager.
….…. Opposite Party.
Before: Sh. D.N.Arora, President.
Sh. Pushpender Kumar, Member,
Dr. Sushma Garg, Member.
Present: Sh. R.K.Jindal, counsel for complainant.
Sh.R.K.Vig, counsel for Op.
As per:- D.N.ARORA PRESIDENT
In nutshell, brief facts of the present complaint are that the complainant has taken Super Top Medical Policy No.1101002814P109480292 in the month of February 2015 from the Op which was got renewed by the complainant on 04.02.2016 to 03.02.2017 vide policy No.1101002815P113098841 and 04.02.2017 to 03.02.2018 vide policy No. 1101002816P114591168. The sum assured amount of the policy during the period from 04.02.2016 to 03.02.2017 was Rs. 3,00,000/-. At the time of issuance of policy in question, the Op indemnify to pay the medical treatment expenses incurred by the complainant on his treatment during the currency period of policy up to Rs. 3.00 Lac. Before taking of the policy the complainant was hale and hearty and had never been suffering HTN, CAD. Suddenly the complainant suffered chest pain on 14.08.2016, immediately the complainant was taken to Mittal Nursing Home, Ultrasound Scan Centre, Nicholson Road, Ambala Cantt where the Dr. C.K.Mittal of the hospital after examination the complainant referred him to Max Super Specialty Hospital, Mohali and in the said Hospital the complainant was admitted where his coronary angiography and angioplasty was one and diagnosed Triple Vessels Deceased for which PTCA with stunt to LCx-OM was done on 15.08.2016 and was discharged on 17.08.2016. The complainant immediately informed the above said facts of his treatment to the Op and Op assured the complainant to make the payment of the expenses incurred by the complainant and he incurred Rs. 3,73,238.63 on his treatment (As medical Expenses) of C.K.Mittal Hospital as well as Max Hospital, Mohali as per detail mentioned in the bill attached with the complaint and in the claim form submitted by the complainant with the Op. The treatment taken by the complainant and the expenses incurred by the complainant on his treatment are fully covered under the policy in question as per the terms and conditions of the policy. The complainant has never been treated for HTN and DM in Mittal Nursing Home and in Max Hospital, Mohali nor the complainant has been suffering from HTN, CAD before taking the policy in question however the complainant was suffering from DM at the time of taking the policy which is disclosed by the complainant in the proposal form for taking the policy in question. The complainant approached the Op and TPA and intimated about the above said treatment taken by him from Mittal Nursing Home and Max Hospital Mohali as per the direction OP the complainant submitted the claim form, bill of medical expenses and all the relevant documents with the Op for the settlement of his claim on 07.09.2016, but the Op did not make the payment of the said medical expenses of which the complainant is legally entitle as per terms and conditions of the policy. Thereafter, the complaint made several representations to the Op to make the payment of the abovesaid medical expenses incurred by the complainant on his treatment as per the terms and condition of the policy, but the OP did not settle the said claim and vide its letter dated 06 March 2017 rejected the claim of the complaint under the policy in question on the ground mentioned in the repudiation letter dated 06 March 2017 mentioning in the said letter that (Exclusion-Pre-existing disease coverage will not be available for an insure person during the first four years since inception of his/her Super Top Up Medicare Policy with the Company N B A pre-existing disease is defined as “any condition, ailment of injury of related condition for which insured person had signs or symptoms and /or was diagnosed and/or received medical advised/treatment within 48 months prior to super Top Up Medicare Polcy with the Company”.) illegally unlawfully without application of mind. Hence, the present complaint.
2. Upon notice, OP appeared through counsel and filed written statement submitting that as per medical history, stunt is one of the last three stages, which are applied upon the heart patient i.e stunt, pacer and bye-pass surgery. On 15.08.2016 stunt was applied in the Max Super Specialty Hospital, Mohali. No heart patient is treated by a specialist, when there is no earlier complaint regarding heart trouble. The complainant was issued policy by the respondent/OP and condition No.4 which excludes the claim reads as under:-
“Waiting period of 48 months for Pre-existing disease.”
It is submitted that on 15.08.2016 stunt was applied, the Doctor did not mention the fact that it was a sudden trouble. Subsequent certificate exposed the connivance of the complainant with the Doctor and as such the same carries no value. Doctor C.K.Mittal of Ambala Cantt only referred the case on 14.08.2016 on account of chest pain. Chest pain is not a disease, which is sudden. It had its pre-existing history which was kept concealed by the complainant in connivance with Dr.C.K.Mittal, Ambala Distt Super Specialty Hospital, Mohali diagnosed and stunt was applied on 15.08.2016. The treatment categorically shows that the trouble was not sudden. If he spent some amount and the entire fault lies upon him for having no exposed the truth at the time of taking policy, he alone is to be blamed. The insurance company is duty bond to take into note the policy alongwith terms and conditions before admitting/declining the claim filed by him. The claim if any is to be considered while taking into consideration the terms and conditions of the policy and the respondent/OP acted within the framework of Policy and as such the expenses incurred by him are not liable to be reimbursed to him. Afterthought and certainly some connivance either with the Doctor or with legal brain cannot be ruled out. Taking into consideration the medical history, stunt is one of the stages which are only applied to the man, who is having heart trouble prior to the treatment. It is denied that the medical expenses incurred is not legally entitled to be reimbursed because the same falls beyond the terms and conditions of the policy and as such the Op rightly repudiated the claim of the complainant. The efforts of complainant to get it set-aside, failed even from the Insurance Ombudsman, Batra Building, Chandigarh after full contest. Since, pre-existing disease was the cause of repudiation, so the complainant is not entitled to have any compensation. It is submitted that the complainant connived with Dr.C.K.Mittal and also with the doctor of Max Super Specialty Hospital, Mohali in getting a subsequent certificate. The subsequent certificate, the doctor had categorically mentioned that his claim not fit for hypertension. So, there is no deficiency in service on the part of OPs and prayed for dismissal of the present complaint.
3. To prove his version complainant tendered his affidavit as Annexure C1/A along with documents as annexure C-1 and C-17 and close his evidence. On the other hand, Counsel for the OPs tendered affidavit as Annexure R/A alongwith documents as Annexure R-1 to R-19 and close their evidence.
4. We have heard both the counsels of the parties and carefully gone through the case file.
5. It has come on the record that the complainant had obtained the Super Top Up Medicare Policy for the period w.e.f. 04.02.2016 to 03.2.2017 (again was renewed for the period w.e.f. 04.02.2017 to 03.02.2018). The above said policy for the period 04.02.2016 to 03.02.2017 was insured for amounting Rs. 3 lacs and having threshold of Rs. 2 lacs. During the above said policy the complainant has suffered chest pain on 14.08.2016 and remained admitted as indoor Hospital in Max Hospital Mohali for the period 14.08.2017 to 17.08.2017 as per discharged summary Annexure C-VI as well as medical certificate issued by Max Health Care vide Annexure CVIII. The complainant had incurred a sum of Rs. 3,73,238.63/- as per medical bill Annexure C-9 to C-15 on the said treatment. It is not disputed that an amount RS. 186000/- has been paid by New India Assurance Co. Ltd. Rest of amount Rs. 1,87,238.63/- is to be paid by the OP out of which the OP had paid Rs. 1,59,700/- on 05.11.2018 during the pendency of the complaint. But Op has failed to pay the rest of the amount Rs. 27,538/- to the complainant. This Forum is of the view that claim of Rs. 1,87,238.63/- of the complainant is to be settled by the OP within a reasonable period of 2 months from the date of the submission of the claim papers as per Annexure R-2 dated 07.09.2016. The complainant has also submitted the documents but OP has failed to pay the above said amount to the complainant. OP has paid the amount Rs. 1,59,000/- to the complainant 05.11.2018. So the complainant is entitled the interest on the above said amount w.e.f. from 07.11.2016 to 05.11.2018 @ 9% P.A. for the above said period. It is to pertinent to mention here that OP has not able to justify before this Forum how and why sum of Rs. 27,538.63/- have been deducted. Therefore, we are of the view that the complainant is entitled for Rs. 27,538.63/- alongwith interest @9% w.e.f. 07.11.2016 to till its actual realization and OP is also directed to pay lump sum Rs. 5,000/- on account of mental agony and deficient in service. Op is further directed to pay Rs.5,000/-indulging the complainant into unwarranted litigation. The OP is also directed to comply with the directions within thirty days from receipt of copy of the order. Copy of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room.
Announced on : 25.02.2019
(PUSHPENDER KUMAR) (DR. SUSHMA GARG) (D.N. ARORA)
Member Member President
