BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 109 of 2019
Date of Institution : 06.3.2019
Date of Decision : 27.08.2019.
Sham Lal son of Sh. Ganpat Ram, resident of Gali Neki Ram Gujjar Wali, Rania Gate, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. United India Insurance Company Limited through its Divisional Manager, Divisional Office Dabwali Road, Sirsa.
2. Medsave Health Insurance TPA Ltd. through its Managing Director, SCO 46, 2nd Floor, Sector-40C, Chandigarh (File no. 20180529B009RH00549)
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SMT. SUKHDEEP KAUR……………… MEMBER.
Present: Ms. Sonam Goyal, Advocate for the complainant.
Sh. Kapil Sharma, Advocate for opposite party No.1.
Opposite party no.2 exparte.
ORDER
The case of the complainant in brief is that complainant has been purchasing mediclaim health policies from the insurance company since long without any break. That unluckily the complainant had fallen ill and remained admitted at Medatna, The Medicity Gurugam from 9.5.2018 to 18.5.2018 and had underwent CABG Surgery on 11.5.2018 for coronary artery disease known as heart attack bypass surgery. At that time, he was insured with op no.1 vide policy no.1119002817P110943159 valid from 27.10.2017 to 26.10.2018. It is further averred that at the time of issuance of policy, the complainant was assured about cashless treatment in the hospital and during his treatment at the hospital he had applied for cashless facility but surprisingly the op no.2 denied for providing the cashless facility to him vide letter dated 10.5.2018. He was bound to pay the hospital bill in cash for which he was not at all ready under the assurance of the ops. It is further averred that somehow the complainant arranged for the payment of hospital bill and was discharged from the hospital. Thereafter, again the ops had assured the complainant for reimbursement of amount of Rs.3,21,613.57. The op no.2 required a number of documents from the complainant time and again to process the claim which were duly supplied by complainant. Despite this, the op no.2 again kept on demanding the same documents from him time and again and lastly vide letter dated 10.8.2018, the complainant informed the op no.2 about the supply of all the documents. That since then the complainant has not heard a single word from the side of ops about the process of the claim and payment of reimbursement amount to the complainant. The act and conduct on the part of ops amounts to gross negligence in service. The complainant also got issued a legal notice upon ops on 14.12.2018 but to no effect. Hence, this complaint.
2. On notice, opposite parties appeared. Op no.1 filed written statement taking certain preliminary objections. It is submitted that TPA has written letters dated 20.6.2018, 18.7.2018, 30.7.2018 and 17.8.2018 to the insured asking him to provide certificates from Consulting Doctor stating the duration of hyper-tension, previous policies for the years 2013-14, 2014-15 and 2015-16 etc. but the insured/ complainant did not provide the desired documents/ certificates and as such the TPA has rightly closed the file of the insured/ complainant. It is further submitted that patient admitted for coronary artery disease (CAD/ heart disease) and history of hyper-tension and accordingly the company required the last four years policies copies and duration of hyper tension for process of the claim as per the terms and conditions of the insured policy. It is further submitted that otherwise also the complainant has obtained the policy fraudulently by suppressing the material fact and particular at the time of proposal. He is guilty of concealing pre-existing disease. The complainant/ insured has knowingly furnished false declaration for obtaining the policy regarding his previous illness. As per the exclusion clause of the policy, the company shall not be liable to make any payment under this policy in respect of any pre-existing condition as defined in this policy, until 48 months of continuous coverage of such insured person have elapsed since inception of his/her first policy. It is further submitted that insured has violated the terms and conditions of the insurance policy, which rendered himself disentitle to any claim whatsoever. With these averments, dismissal of complaint prayed for.
3. We have heard learned counsel for the parties and have perused the case file carefully.
4. The complainant in order to prove his complaint has furnished affidavit Ex.CW1/A in which he has deposed that he being a regular customer of the op no.1, has been purchasing mediclaim health policies from the insurance company since long without any break. That unluckily the complainant had fallen ill and remained admitted at Medatna, The Medicity Gurugam from 9.5.2018 to 18.5.2018 and had underwent CABG Surgery on 11.5.2018 for coronary artery disease known as heart attack bypass surgery. At that time, he was insured with op no.1 vide policy no.1119002817P110943159 valid from 27.10.2017 to 26.10.2018. He applied for the cashless facility but the same was declined after the admission he spent of Rs. 3,21,613.57 for which he claimed with the opposite party but the same has not been paid. The complainant has also tendered the documents i.e. Ex.C1 and Ex.C2 copy of TPA details, Ex.C3and Ex.C4 copy of medical reports, Ex.C5 discharge summary, Ex.C6 fitness certificate, Ex.C7 claim report, Ex.C8 Neft Format, Ex.C9 details of bill enclosed, Ex.C10 to Ex.C32 medical bills, Ex.C33 legal notice, Ex.C34 and Ex.C35 postal receits, Ex.C36 and Ex.C37 track consignment.
5. On the other hand, the ops have relied upon affidavit of Sh. Balram Bhadu, Senior Divisional Manager, United India Insurance Company Limited, Sirsa, Ex.R1, who has deposed and reiterated the averments made in the written statement of the op. He has specifically deposed that the TPA has written letters on dated 20.06.18, 18.07.2018, 30.07.2018 and 17.8.2018 to the insured asking him to provide certificates from consulting Doctor stating the duration of hyper-tension, previous policies for the years 2013-14, 2014-15 and 2015-16 etc but insured/complainant did not provide the desired documents/certificates and as such TPA closed the claim file of the complainant.
6. During the course of the arguments the Ld. counsel for the complainant has stated at bar that the complainant never refused to supply the documents as alleged by the op and he is still ready and willing to supply the same which are necessary for the settlement of the claim.
7. On the other hand, the Ld. counsel for the op has also insisted that the documents as required by op as Ex.R7 and R8 should be supplied by the complainant.
8. In view of the above discussion, we partly allow this complaint and direct the complainant to supply the documents i.e. (1) A certificate from the consulting doctor stating the duration of hypertension. (2) Provide policy copy of year 2013-14, 2014-15, 2015-16 with si mentioned on it as per Ex.R7 within 15 days from the receipt of the copy of this order and thereafter the op are directed to re-open and consider the claim file. They are further directed to settle and pay the claim of the complainant as per the terms and conditions of the insurance policy. But keeping in view the facts and circumstances of the present case with no order as to costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:27.08.2019. Member District Consumer Disputes
Redressal Forum, Sirsa.
