Delhi

East Delhi

CC/440/2014

shambhu dayal - Complainant(s)

Versus

UNITED INDIA INS. - Opp.Party(s)

20 Apr 2018

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. 440/14

 

Shri Shambhu Dayal Sharma

S/o Late Shri Ramji Lal

R/o 43, United India Apartments

Mayur Vihar Phase- I Ext.

Delhi – 110 091                                                           ….Complainant

 

Vs.    

 

The Deputy General Manager

United India Insurance Company Limited

Regional Office 2

Scope Minar Complex, Core-I

2^nd Floor, Laxmi Nagar District Center

Delhi – 110 092                                                               …Opponent

 

Date of Institution: 09.05.2014

Judgement Reserved on: 20.04.2018

Judgement Passed on: 01.05.2018

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 Shambhu Dayal Sharma against the Dy. General Manager, United India Insurance Co. Ltd. (OP) under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.         The facts in brief are that complainant Shambhu Dayal Sharma, a retired employee of United India Insurance Company Ltd. was covered under the Group Medical Policy w.e.f. 01.04.1988 which was covering the surviving employees as well as retired employees.  Under this policy, the sum insured was Rs. 3,00,000/- each per family members which was subscribed by the complainant. 

            In the month of March, 2008, the respondent company further modified this group mediclaim policy and allowed maximum sum insured up to Rs. 5,00,000/- per family member which was opted by the complainant. 

            It has been stated that wife of the complainant Smt. Vidhya Devi was suffering from some pain in her both knees which was treated by orthopedic doctors.  In the year 2011, she developed pain in her knees for which complainant sought permission from respondent company to get her treated from Kottakkal Arya Vidhya Sala Ayurvedic Hospital and Research Centre, Karkardooma, Delhi, for treatment with approximate hospitalization/treatment charges of Rs. 66,000/- as intimated by them vide their letter of dated 10.10.2011.  However, the respondent company refused on the ground that the same did not cover under the policy. 

            Thereafter, on 08.05.2012, when the complainant’s wife got acute problem in her knees, he consulted Dr. Rakesh Mahajan, Chief of Joint Replacement and Arthroscopy Surgery of B.L. Kapoor Memorial Hospital, Pusa Road, New Delhi, who advised for knee surgery and also prescribed medicines vide medical prescription of dated 08.05.2012.

            He has further stated that the complainant further consulted           Dr. Naveen Talwar of Fortis Group of Hospitals, New Delhi and on 16.08.2012, he further consulted Dr. Shekhar Aggarwal of Sant Parmanand Hospital who suggested for both knees replacement.  Finally, the complainant decided to get his wife treated at Sant Parmanand Hospital which gave treatment estimate of Rs. 4,25,000/-.

            The complainant requested the insurance company to release the amount of Rs. 4,25,000/- direct to the hospital.  The respondent company only paid an amount of Rs. 2,10,000/- directly to the hospital on 25.08.2012 and the balance of Rs. 2,15,000/- was paid by the complainant himself.  The total estimate of treatment crossed the estimated amount of              Rs. 4,25,000/- to Rs. 4,29,785/-.

            The complainant sent a letter of dated 01.09.2012 to the insurance company for releasing the balance payment of Rs. 2,19,785/-, however, the respondent company reimbursed the expanses of the medical treatment of his wife by paying Rs. 90,000/- against the medical expanses of              Rs. 2,19,785/-.  The respondent company have made a payment of         Rs. 3,00,000/- only against the total claim of Rs. 4,29,785/-.   The complainant submitted bills of Rs. 11,130/- for treatment of his wife alongwith his letter of dated 19.04.2013.  Thus, a total claim amount of    Rs. 4,40,898/- was lodged with respondent company out of which            Rs.  3,00,000/- have been paid leaving a balance of Rs. 1,40,898/-. 

            The respondent company did not make the payment of the balance amount on the ground that for the year 2006-2008, the sum insured was Rs. 3,00,000/- and from 2008-2013, it was Rs. 5,00,000/- and secondly the claim was lodged for B/L TKR at Sant Parmanand Hospital on 20.08.2012 with the history of pain in knees from 4-5 years and lastly, the sum insured was Rs. 3,00,000 for the year 2007-2008 and was applied for the policy period before 01.04.2012.   

            The complainant have stated that the plea taken by the respondent was not the correct position, hence, he has filed the present complaint for reimbursement of Rs. 1,40,898/- with interest @ 18% on account of deficiency in service and compensation of Rs. 50,000/- for mental and physical harassment.

3.         In the written statement, filed on behalf of United Indian Insurance Co. Ltd. (OP), they have stated that the complainant for the year 2006-2008 was holding coverage for a sum of Rs. 3,00,000/- which was enhanced to Rs. 5,00,000/- in the year 2008-2009. 

            Wife of the complainant was suffering from pain in the knees and admitted in Sant Parmanand Hospital on 20.08.l2012.  As per the discharge summary, she was having pain in the knees for the last 4-5 years.  The disease has started 5 years back and at the relevant time, the sum insured was Rs. 3,00,000/- which was reimbursed in full and final settlement.  No further sum of Rs. 1,40,898/- was payable to the complainant.  They have denied other facts also. 

4.         Rejoinder to the WS of OP was filed by the complainant where the contents of the WS have been denied and has reaffirmed the averments of his complaint.

5.         The complainant has filed evidence by way of affidavit where he has examined himself.  He has narrated the facts which have been stated in the complaint. 

            In defence, OP have examined Shri Rajesh Bajaj, who have also deposed on affidavit.  He has narrated the facts which have been stated in the written statement.  He has also got exhibited documents such as copy of terms of Group Medical Policy (Ex. P-1), copy of discharge summary   (Ex. P-2), copy of opinion (Ex. P-3) and letter dated 31.01.2014 alongwith copy of mail (Ex. P-4).

5.         We have heard  Ld. Counsel for the parties and have perused the material placed on record.  It has been argued on behalf of United India Insurance Co. Ltd. (OP) that they have reimbursed a sum of Rs. 3,00,000/- which was admissible under the policy.  They have further stated that for the balance amount, the complainant was not entitled as the treatment taken for his wife for the disease which she was having during the policy for which the maximum limit was Rs. 3,00,000/-. 

            On the other hand, Ld. Counsel for complainant have argued that the treatment taken by the complainant was during the enhanced policy up to Rs. 5,00,000/- and the pain which she was suffering earlier was not covered under the enhanced policy.

            To appreciate, the arguments of Ld. Counsel for the parties, a look has to be made to letter of dated 30.03.2010 of United India Insurance Co. Ltd. (OP) in respect of enhancement of sum insured under tailor made group mediclaim policy.  The relevant condition put in the letter is extracted hereunder:-

“In case of enhancement of Sum Insured at renewal as compared to expiring policy, the enhanced Sum Insured will not be available for those disease which are pre-existing.”

This provision will not apply if the increase in Sum Insured is applicable for the entire group or the sub group to which the individual belongs.”

            To appreciate as to whether this condition was applicable in the case of complainant, discharge summary of Sant Parmanand Hospital is to be looked into.  In the discharge summary, it has been stated that patient presented with complaint of pain in both knees since 4-5 years”.  This discharge summary is of 26.08.2012 which states that the patient was admitted on 19.08.2012.  Prior to this discharge summary, there was a prescription of Dr. Shekhar Aggarwal of Sant Parmanand Hospital which is of dated 10.08.2012 where pain in both knees has been stated of two years. 

            Thus, from these two documents i.e. prescription as well as discharge summary, it has been noticed that there has been a variation in the period of pain.  Since the prescription is of 10.08.2012 which is prior in time, the same has to be taken as correct one.  There is nothing on record as to from where period of 4-5 years as stated in the discharge summary has been taken.  Thus, the pain in the knees may be taken as two years.

            If the period of 2 years is taken prior to the treatment which was taken by wife of the complainant in 2012 i.e. 19.08.2012 as the date of admission and 26.08.2012 as the date of discharge, the year from which wife of the complainant was suffering from pain in both knees was as 2010.  The complainant have got the policy enhanced in the year 2008 from       Rs. 3,00,000/- to Rs. 5,00,000/-.  When the complainant have got his wife treated for knee replacement in the year 2012, the enhanced policy for    Rs. 5,00,000/- was in operation.  When the treatment has been taken under the enhanced policy which was for an amount of Rs. 5,00,000/-, certainly, the complainant was entitled for reimbursement of the amount paid by him.            Even otherwise also, the complainant have taken the group mediclaim policy and it has been stated in the letter of dated 30.03.2010 that the provision of pre-existing disease for the enhanced sum insured will not be applicable if the sum insured was for the entire group or the sub-group to which the individual belongs. 

            In the present case, complainant have got group medical policy for himself as well as his wife.  When he was having group mediclaim policy and the treatment taken by his wife was a member of the said group, the provision of pre-existing disease does not apply.  Thus, the insurance company was deficient in not paying the amount to which the complainant was entitled for.  When there has been deficiency on the part of insurance company, the complainant have suffered mental pain and suffering which is to be compensated.

            In view of the above, we order that United India Insurance Co. Ltd. (OP) shall pay an amount of Rs. 1,40,898/- with 9% interest from the date of filing this complaint till its realization.  We further award a sum of          Rs.  20,000/- on account of compensation which includes the cost of litigation.

            This order be complied within a period of 45 days.  If not complied, the amount of compensation of Rs. 20,000/- shall also carry 9% interest 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