Delhi

East Delhi

CC/929/2015

ONKAR SINGH - Complainant(s)

Versus

UNITED INDIA INS - Opp.Party(s)

18 Jan 2019

ORDER

            DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.        929/2015

                                                                                                   Date of Institution                21/12/2015

                                                                                                   Order reserved on                18/01/2019       

                                                                                                   Date of Order                        21/01/2019                                                                                    

 

In matter of

Mr Onkar Singh, adult  

R/o- A6/6, Krishna Nagar, Delhi 110051...……………...…………….Complainant

                             

                                      Vs

 

M/s Manager, United India Insurance Co. Ltd. 

D-8, CS, Azad Marg, Laxmi Nagar

Vikas Marg, Delhi 110092 ……………………..……………..….…………..Opponent

 

Complainant  advocate                          Mr. Brijesh Kumar Sharma  &  Md. Vaishali

Opponent  advocate                               Mr. N K Pare              

 

Quorum                     Sh Sukhdev  Singh        President

                                    Dr P N Tiwari                 Member

                                    Mrs Harpreet Kaur       Member                                                                                             

 

Order by Dr P N Tiwari  Member  

Brief Facts of the case                                                                                                

Complainant stated that he had individual mediclaim policy for his family from OP since 1992 and policy continued without break. The policies from 2010 to 2014 were annexed as Anne. C2 to C5. He stated that due to severe chest pain on 27/04/2015 was admitted in Metro Hospital and after treatment he was discharged on 29/04/2015 vide discharge summary Annex. C6. Cashless was given for sum of Rs 1,92,500/-to the hospital against sum insured of Rs 4 lacs Anne. C7. As hospital bill was for Rs 4,94,712/-so complainant paid balance amount Rs 3,02,212/-. It was stated that complainant submitted required documents for balance claim amount, but OP did not pay the amount despite of repeated visit to OP office even after 6 months. This undue delay in paying claim amount was against IRDA guidelines and proved deficiency in OP services. It was stated that in serious illness suffered by complainant, OP did not pass claim. Hence, sent legal notice on 03/09/2015 (Anne.C8) to pay balance policy amount with 24%. When no reply was received, felt mentally harassed due to unfair trade practice adopted by OP, filed this complaint and claimed a sum of Rs 2,07,500/- with 24% from the date of sickness till realization. He also claimed Rs one lac compensation for harassment and mental agony and litigation charges Rs 50,000/-.

In written statement OP denied all allegations of deficiency and unfair trade practice adopted.  It was admitted that complainant remained admitted from 27/04/2015 to 29/04/2015 and as per hospital request cashless was given for a sum of Rs 1,92,500/-after TDS deduction under claim policy vide no. 2215002814P105531482 which was effective from 28/01/2014 to 27/10/2015 (Anne.OPW/1) and as per policy terms and conditions, cashless was paid to hospital under provision 1.2.1 (b) vide claim no. 11117979 under 5^th year policy no 221500/24/14/P105531482 Anne. C. Full and final balance claim was given to hospital under cashless.

The provision 1.2.1 (b) says as –In major surgeries, actual expenses incurred or 70% of the sum assured whichever is less.

It was stated that complainant had cardiac illness and PTCA was done in 2007 and now he suffered from Coronary Artery Double Vessel Disease. PTCA with drug eluting Stunting was done in left and right coronary arteries. Under this diagnosis and procedure comes under major surgeries, so OP paid 70% of sum assured. OP also submitted opinion from their panel doctor who gave his opinion on the basis of discharge summary of Metro Hospital (Ex OPW1/2) and justified 70% payment to sum assured to Rs 2,75,000/-in policy year 2010 to 2011 (Ex OPW1/3).

OP also stated that policy conditions 3.29, 4, 4.1 and 5.12 were applicable under this policy.     Under provision 3.29 (Pre Existing diseases)-says any condition, ailment or injury or related condition/s for which you had signs or symptoms and / or where diagnosis and /or received medical advice / treatment within 48 months prior to the first policy issued by insurer.

Exclusion clause 4.1- Any pre existing condition/s as defined in the policy until 48 months of continuous coverage of such insured person have elapsed since inception of his/her first policy with the company.

Clause 5.12 – Enhancement of sum insured—Enhancement may be allowed when insured seeks in writing before renewal of existing policy and on the discretion of the company, enhancement may be given.  

So in this case, the sum insured was Rs 2,75,000/- in policy 2010 to 2011 and 70% of it was given in the form of cashless (Rs 1,92,500/-). OP acted as per the policy terms and conditions, hence there was neither deficiency in services or unfair trade practice ever adopted by OP as alleged of complainant. OP prayed to dismiss the complaint.  

Complainant submitted rejoinder to written statement of OP and denied all replies of OP. He stated that his facts of complaints were correct and true. He stated that he was having mediclaim policy since 1992 and OP intentionally withheld his balanced amount. He paid in cash and despite of complying claim procedure of OP, no amount was paid and due to which he suffered harassment and mental agony. He also submitted evidences through his own affidavit where he affirmed on oath that all the facts were correct and true. He relied on policy copies (Ex CW1/1 to 5), discharge summary (Ex CW1/6) and legal notice to OP (Ex CW1/8). Despite of submitting all the required documents, OP did not consider his claim and not paid balance claim amount, so OP be directed to process the claim as per policy terms and conditions. 

OP also submitted their evidence on affidavit through Mr Y R Kanojia, Sr. Divisional Manager at OP office and affirmed on oath that all the procedures adopted by them were as per the IRDA guidelines and policy terms conditions. OP relied on claim year policy and sum assured amount in 2010-2011 policy where it was 2,75,000/-(Ex OPW1/1). As per policy conditions, 1.2.1(b), 75% of sum assured was given to the hospital after deducting TDS. There was no question of withholding claim amount rather admissible amount was given to hospital in the form of cashless. So, there was no deficiency in services of OP or any instance of unfair trade practice ever adopted. Rather OP was always bound by the policy terms and conditions under privity of contract between insured and insurer. Hence, all allegations were false and complaint may be dismissed.  

Both the parties submitted written arguments and taken on record.  

Arguments were heard from both the parties. After perusal of materials on record, order was reserved.

Before coming to the conclusion of this case, we framed three clarifications as under –

Q1- Whether proceeding on provision of 1.2.1 of policy by OP was correct?

Q2-Whether complainant is entitled for balance claim amount under the policy conditions?

Q3-Whether OP was deficient at any time of issue?

1- Whether proceeding on provision of 1.2.1 of policy by OP was correct?—After going through the facts of the complaint, it was noted that complainant has mentioned that he had mediclaim policy since 1992, but neither complainant had submitted any evidence of existence of policies from 1992 nor OP had objected for the same. OP have considered 2010 – 2011 policy as 1^st year policy, but discharge summary (Ex CW1/1) showed that complainant had cardiac ailment and had under gone PTCA and this time in 2015, complainant was admitted for advanced complications pertaining to cardiac ailment and on CAG, it was found that he had two vessel occlusion and two drug eluting stents were placed and paid cashless amount to hospital on the basis of 2010 - 2011 policy sum assured on 70% basis when sum assured amount was Rs 2,75,000/-but claim was lodged in 2015 ie in 5^th years policy and sum assured amount was Rs 4 Lacs. Even after 2012 guidelines of IRDA, pre-existing disease are covered after 48 months of continued policy tenure from same insurer.

2- Whether complainant is entitled for balance claim amount under the policy conditions? Seeing evidences on record submitted by complainant, there is NO Final Hospital bill from where it could be seen that exact hospital treatment bill amount. Also there is NO rejection letter from OP to see the reason for non passing claim except Anne. C of OP as full and final claim amount disbursed to hospital in cashless taking 2007 policy consideration. As there were no detail policy copies from 1992 to 2007 and then 2007 to 2010 for seeing continuity of policy tenure, we cannot put liability on OP for non consideration of balance claim amount under 2014-2015 policy year. OP had enhanced sum assured from Rs 2,75,000 to Rs 4 lacs from 2012 onward without any evidence of enhancement. Thus there is no clarity of facts in the consumer complaint and evidences of filing of claim documents on record as pleading has been completed on cashless record.      

3-Whether OP was deficient at any time of issue?

By going through evidences of policy copies on record, we could not see the continuity of policy from 1992 to 2009 and concrete evidence of PTCA was done in 2007 with claim status as OP has applied provision 1.2.1 of policy in 2014-2015 year and mentioned existence of 2007 policy. OP never asked about details of policies from complainant whereas reference of 2007 policy was taken. Also complainant has not filed sufficient and required evidences as hospital bill & claim filing document on record for making final conclusion. So, this complaint deserves to be dismissed on want of proper and required documents from complainant. Though there is no order to cost or any direction to OP, but if complainant comply the claim process as per policy conditions, OP shall work according to claim process. This process shall be completed in 60 days from receiving of this order copy.   

First free copy of this order be sent to the parties under Regulation 18(6) of the Consumer Protection Regulations, 2005 (in short CPR) and file be consigned to Record Room under Regulation 20(1) of the CPR.   

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                  Shri  Sukhdev Singh  President