Punjab

Ludhiana

CC/14/721

Yash Pal - Complainant(s)

Versus

United India Ins.Co.Ltd - Opp.Party(s)

Rishi Bansal

22 Apr 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                    Complaint No: 721 of 17.10.2014

                                                                   Date of Decision: 22.04.2015

                    

Yash Pal Goyal, aged about 55 years, s/o Late Sh.Ram Lal Goyal, Resident of B-37, Rajguru Nagar, Ferozepur Road, Ludhiana.

.…Complainant

Versus 

1. United India Insurance Co. Ltd. through its Authorized Person/Signatory having Regd. & Head Office at 24, Whites Road, Chennai-600014.

2. United India Insurance Co. Ltd. Division office-5, 108, 3^rd Floor, Surya Tower, The Mall, Ludhiana-141001.

…..Opposite parties 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:    Sh.R.L.Ahuja, President

                    Sh.Sat Paul Garg, Member

                    Smt.Babita, Member

 

Present:      Sh.Rishi Bansal, Advocate for complainant.

                   Sh.D.R.Rampal, Advocate for OPs.

 

 

ORDER

 (SAT PAUL GARG, MEMBER)

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Yash Pal Goyal s/o Late Sh.Ram Lal Goyal, Resident of B-37, Rajguru Nagar, Ferozepur Road, Ludhiana (herein-after in short to be referred as ‘complainant’) against United India Insurance Co. Ltd. through its Authorized Person/Signatory having Regd. & Head Office at 24, Whites Road, Chennai and others (herein-after in short to be referred as ‘OPs’)- directing them to pay the genuine claim of the complainant for Rs.24,675/- as per the terms of the insurance policy, to pay Rs.1.00 lac as compensation and to pay litigation expenses, which the Forum deems just and proper to the complainant alongwith any other relief, which the Forum deems just and proper in the circumstances of the case.

2.                Brief facts of the complaint are that complainant obtained the following Individual Health Insurance Policies from the Ops:-

Insurance Policy No.
201100/48/09/97/00001422	12.3.2010 to 11.3.2011
201100/48/10/97/00001533	12.3.2011 to 11.3.2012
201100/48/11/97/00001290	12.3.2012 to 11.3.2013
201100/48/12/97/00001039	12.3.2013 to 11.3.2014
201100/48/13/97/00002801	12.3.2014 to 11.3.2015

 

                   Under these policies the complainant, his wife namely Smt.Anita Goyal and his son Mr.Rohan Goyal were covered. The complainant continued the abovesaid Health Insurance Plan without any break and timely paid the respective premium for the abovestated policies. During the subsistence of the above-stated Individual Health Insurance Policy bearing no.201100/48/12/97/00001039 which was valid from 12.3.13 to 11.3.14, the complainant suffered from health problem i.e. heaviness in his chest in the month of September 2013. The complainant got himself checked for the said problem at Hero DMC Institute, Ludhiana under the supervision of Dr.Bishav Mohan, where the complainant was found to be suffering from Acute coronary Syndrome. The complainant was admitted in the said hospital on 13.9.13 and Coronary Angiography of the complainant was done on 14.9.13. The complainant was discharge in stable condition from the hospital on 16.09.13. The complainant had spent Rs.24,675/- for the abovesaid treatment in Hero DMC Hospital, Ludhiana. Thereafter the complainant lodged the claim with the Ops for the above state amount and submitted all the relevant documents i.e. medical record, bills etc. alongwith the claim form. Instead of processing and sanctioning the genuine claim of the complainant, the Ops kept the matter pending for considerable long period and ultimately vide letter dated 27.1.14 the Ops repudiated the genuine claim of the complainant on false and flimsy ground i.e. “Patient has history of similar complaints 10 years back and policy is in 4^th year only. Hence Disease is Pre-existing and claim is not admissible under exclusion clause 4.1 and repudiated”. The ground taken by the OPs is far from reality and is concocted one and is not tenable as the complainant was not having any history of similar complaints 10 years back and the complainant suffered from the alleged disease/health problem first time in the month of September, 2013. The complainant also replied to the said repudiation letter vide reply dated 10.2.14 and clarified to the Ops that the abovesaid policy health insurance policy was taken by the complainant for the first time in the year 2010 after all pre medical examinations and there was no medical problem at that time and he for the first time got hospitalized in September, 2013, but the Ops again rejected the genuine claim of the complainant, vide letter dated 19.2.14, the complainant again sent a clarification letter dated 1.3.14 to the OPs, but all in vain. Claiming the above act as deficiency in service on the part of the OPs, the complainant has filed this complaint.

3.                On notice of the complaint, OPs appeared through their counsel and filed written statement taking preliminary objections that complaint is not maintainable in the present form; the complaint is false and frivolous one; the complaint is bad for non joinder and mis joinder of necessary parties; the complainant has not come to this Forum with clean hands and has suppressed the material facts. The case of the complainant was scrutinized by Vipul MedCorp TPV Ltd. and it found that complainant has past history of present ailment for the last 10 years and it recommended that claim of the complainant be treated as ‘No claim’ as complainant was having pre-existing disease and claim of the complainant is falling under exclusion clause 4.1 of the Individual Health Insurance Policy and advised the OPs to repudiate the claim of the complainant and on receipt of opinion of Vipul MedCorp TPA Ltd. and also going through the medical record of complainant, the Ops also found that claim of the complainant is not payable one and is falling under exclusion clause 4.1 of the Individual Health Insurance Policy and same was repudiated by competent authority of OPs and repudiation letter dated 27.1.14 was posted to the complainant repudiating his claim. The complainant submitted reply dated 10.2.14 to said repudiation letter and after considering the reply/representation of the complainant the Ops again observed the facts of the case and found that complainant was suffering from pre-existing disease and policy was in the fourth year and accordingly, ‘No claim’ letter dated 19.2.14 was posted to the complainant. The complainant again replied the said No claim letter of OPs. The Ops again considered the claim of the complainant and found that complainant is not entitled to alleged compensation as he was suffering from pre-existing disease and claim is not admissible and accordingly No claim/repudiation letter dated 19.3.14 rejecting the claim of the complainant was sent to the complainant. Due services have been rendered by the Ops and there is no deficiency on their part. On merits, denying the contents of all other paras of the complaint, Ops prayed for the dismissal of the complaint.

4.                Ld. Counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Yash Pal Goyal Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C19. On the other hand, Ld. Counsel for Ops has adduced the evidence by way of duly sworn affidavit of Sh.Hoshiara Singh, Assistant Manager, United India Insurance Co. Ltd. DO-5, 108, 3^rd Floor, Surya Tower, The Mall Ludhiana Ex.RA, wherein the same facts have been reiterated as narrated in the written statement and also attached documents Ex.R1 to Ex.R16.

5.                Case was fixed for arguments. Ld. Counsel for complainant argued that complainant availed Individual Health Insurance Policy bearing no.201100/48/12/97/00001039 valid for the period 12.3.13 to 11.3.14. During the subsistence of the abovesaid, the complainant suffered from health problem i.e. heaviness in his chest. The complainant got himself checked for the said problem at Hero DMC Institute, Ludhiana and was found to be suffering from Acute Coronary Syndrome. The complainant was admitted in said hospital on 13.9.13 and Coronary Angiography of the complainant was done on 14.9.13. The complainant was discharged in stable condition from the hospital on 16.09.13 and the complainant had spent Rs.24,675/- for his treatment. Complainant lodged the claim with the Ops and submitted all the relevant documents with the OPs, but the Ops vide letter dated 27.1.14 the Ops repudiated the genuine claim of the complainant on false and flimsy ground i.e. “Patient has history of similar complaints 10 years back and policy is in 4^th year only. Hence Disease is Pre-existing and claim is not admissible under exclusion clause 4.1 and repudiated”. Further argues that complainant was not having any history of similar complaints 10 year back and the complainant suffered from the alleged disease/health problem first time in the month of September, 2013. . Ld. Counsel for complainant in support of his version relied upon the judgements passed in cases titled as Bajaj Allianz Life Insurance Co. Ltd. and others Vs Raj Kumar (Mrs.)- 2014 (3) CPC 24 passed by Hon’ble National Commission, New India Assurance Company Limited. Vs Rakesh Kumar- 2014 (3) CPC 114 passed by Hon’ble National Commission.

6.                On the other Ld. Counsel for Ops argued that the case of the complainant was scrutinized by Vipul MedCorp TPV Ltd. and it was found from the medical treatment of complainant given in Hero DMC Heart Institute that complainant was having history similar complaint 10 years back. The policy was in fourth year and disease of the complainant was pre-existing, which falls under exclusion clause 4.1 of the Individual Health Insurance Policy. The OPs also found that claim of the complainant is not payable one and is falling under exclusion clause 4.1 of Individual Health Insurance policy and same was repudiated by competent authority of OPs and repudiation letter was posted to the complainant.

7.                We have gone through the pleadings of the complainant as well as defence taken by the OPs and also perused the entire record placed on file. Considering preliminary objections of the OPs, there is nothing to render the complaint to be non-maintainable.

8.                It is evident that complainant availed the Individual Health Insurance Policy bearing no.201100/48/12/97/00001039 which was valid from 12.3.13 to 11.3.14. During the subsistence of the above said period, the complainant underwent treatment for Acute Coronary Syndrome and was done procedure ‘Coronary Angiography (Non-Critical CAD) and further the past history as per the discharge summary shows there is no mention about the previous history, but describes of the illness mentioned “54 years mail presented with chief complaints of chest heaviness 2 days prior to admission.” Moreover as per the judgement relied upon the by the complainant passed in case titled as Bajaj Allianz Life Insurance Co. Ltd. and others Vs Raj Kumar (Mrs.)- 2014 (3) CPC 24 passed by Hon’ble National Commission, wherein, it was held that Insurance policy was issued after authorized doctor of insurance company was satisfied with the fitness of insured- Death of insured during subsistence of policy – Claim was wrongly repudiated with the plea that insured/deceased had concealed the pre-existing disease of blood cancer- State Commission rightly granted relief as repudiation of claim was not justified. Impugned order upheld. Revision dismissed.

9.                Further there is no tenable evidence or affidavit or cogent reasons put forward by the Ops, whereby it is proved that the complainant was having pre-existing disease and how the exclusion clause 4.1 is applicable in the present case.

10.              Sequel to the above discussion, the present complaint is allowed and Ops are directed to settle and pay the claim of the complainant as per the terms and conditions of the previous policy. Further Ops are directed to pay Rs.5000/-(Five thousand only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days of receipt of the copy of the order, which be made available to the parties, free of costs. File be consigned to record room.

 

                   (Babita)                          (Sat Paul Garg)                        (R.L.Ahuja)

                   Member                             Member                                 President

Announced in Open Forum.

Dated:22.04.2015 

Hardeep Singh