Delhi

East Delhi

CC/245/2015

YASH PAL - Complainant(s)

Versus

UNITED INDIA INS - Opp.Party(s)

22 Aug 2017

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM EAST GOVT OF NCT DELHI

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

                                                                                                      Consumer complaint no.        245/2015

                                                                                                      Date of institution               09/04/2015

                                                                                                      Order reserved on               22/08/2017

                                                                                                      Date of order                       24/08/2017

 

In matter of

Mr. Yash Pal Dhawan,

R/o 51 D, Pocket F Mayur Vihar,

Phase-II Delhi 110091………………………………………………………………………Complainant

 

Vs

 

United India Insurance Company Limited

Divisional Office-68/1, Janpath,

New Delhi-110001………………………………………………………………………….Opponent

 

Quorum                      Sh Sukhdev Singh      President

                                    Dr. P N Tiwari             Member

 

Order by Dr P N Tiwari, Member

 

Brief facts of the case

 

Complainant purchased health insurance policy from OP from 18/01/2008 to 17/01/2009 for sum assured Rs 5 lakh and continued to 2015 without break or claim. The complainant paid his last premium amount Rs 7316/- for policy no. 04052814106379207 having policy tenure from 06/12/2014 to 05/12/2015(Ex. CW1/1 to Ex. CW1/8). It was stated that complainant was admitted in Indraprastha Apollo Hospital on 31/10/2014 and was discharged on 01/11/2014 for multiple small renal calculi/kidney stones. Intimation was given to OP from hospital, but cashless was rejected by OP vide Ex CW1/9. On demand from OP, complainant submitted certain additional documents for reimbursement of his claim.

As his cashless was rejected, so he paid   hospital bill of Rs.38,910/-as Ex CW1/10. OP did not pass his claim due to which complainant suffered depression for illegal act and unfair trade practice besides deficiency in service. Complainant sent legal notice (Ex. CW1/11) and demanded reimbursement of hospital bill along with compensation. When he did not get reply of his legal notice, he filed this complaint claiming treatment cost a sum of Rs. 1,60,823/-with 24% interest and compensation of Rs.50,000/- for harassment and Rs.15,000/- as litigation charges.

OP submitted the written statement and denied the allegations which were wrongly made in the complaint by the complainant. It was admitted that complainant had taken family health shield policy from OP in 2007. There was break in the continuity of the insurance policy for about 10-11 months and a new policy was issued as a fresh from 06/12/12 to 05/12/13 and the present claim was reported in 2^nd year of the policy. As claim for cashless was received from Apollo Indraprastha Hospital for Renal Calculi (kidney stones), so cash less was rejected on the basis of terms and conditions of the said policy. It was admitted that after having discharged from the hospital, complainant had paid the hospital bill. It was also mentioned that complainant was suffering from Diabetes Miletus from 8 years and had history of CAD (coronary artery disease) with PTCA in 2009. He also had cholecystectomy in 2012. These diseases were preexisting in nature in reference to his new policy and present claim for renal stones was rejected under pre-existing clause 4.1 of policy, so claim was repudiated. Hence, OP had no deficiency in service and neither any unfair trade practice was adopted against complainant. Thus OP prayed for dismissal of this complaint with heavy cost.

Complainant filed his rejoinder with additional evidence in the form of post hospitalization treatment bills of Rs 30,000/- dated 17/01/2015 and Rs 8,910/-as marked Ex CW1/12 and CW1/13 and he stated by way of affidavit where he affirmed on oath that all the facts and evidence were correct to his knowledge. Secondly, he has also stated that there was no break in continuity in his policy and his premium was also paid through demand draft which was duly credited in the account of OP and the genuine claim repudiation was not justified. It was also stated that the evidence Ex. CW1/1 to Ex.CW1/10 were submitted with his complaint and Ex. CW1/11, 12 and Ex. CW1/13 were on record as additional evidence.

Arguments were heard from both the party counsels. After perusal of facts and evidences on record, order was reserved. During arguments from complainant, it was submitted that OP had neither taken a new policy proposal form nor any related medical tests were got done and issued this claim policy after receiving premium through DD. Hence, claim was wrongly rejected by OP.    

Complainant relied upon one judgment from Hon’ble National Commission in OIC V/s K. Anandam in RP 3/2007 CPJ 450 NC, where rejection of OP was challenged as unjustified as clause 4.1 & 4.2 were challenged. In this judgment the importance was given to the observation of doctor and policy proposal form in reference to terms and conditions of the policy. The order of District Forum was set aside as rejection was justified on the lapse of nine days in the continuity of policy due to dishonoring of cheque and a fresh policy was issued.

In reference to this case, above cited judgment does not hold weight as no cheque was dishonored, but OP issued new policy after much lapsed period and received premium by way of DD. So facts do not apply in this case. We have also gone through all the annexure and  facts of the case and observed that complainant had a policy from 18/01/2008 to 17/01/2009, 18/01/2009 to 17/01/2010, 18/01/2010 to 17/01/2011, 18/01/2011 to 17/01/2012, these four policies were continued without break, but there was a considerable gap of eleven months and fresh policy was issued from 06/12/2012 to 05/12/2013, 06/12/2013 to 05/12/2014 and again a gap of four days ie from 09/12/2014 to 18/12/2015, but OP continued the policy tenure.

As the present rejected claim for removal of kidney calculus falls in the second year of policy which had been calculated from 06/12/2012, was rejected under execution of calculus in first two years of continuation of policy mentioning thereby the claim was not claimed in third year. As OP had mentioned for pre-existing disease as DM, Heart disease, Gall Bladder stones  Operation prior to fresh inspection of policy in 2012, but OP had neither submitted any concrete evidence to prove it as pre-existing in case category 4.1 & 4.2, secondly there was no evidence of policy proposal form was ever taken by OP while issuing fresh policy after gap of eleven months and no evidence of any required medical disease were done. This shows that OP had issued the policy without putting Pre existing diseases in exclusion clause in policy. Though OP had mentioned in his written statement passed on discharged card only for being any claim under preexisting disease proper investigation has to be carried out which was not evident in their evidence filed on record. Since the present claim which was rejected on the basis of limitation clause as non payable but seeing the deficiency of OP itself by not following the proper guidelines of IRDA, the policy was itself higher sum assured, the complainant age was above 55 years.

Hence, we are of the opinion that complaint is having merit and to be allowed. OP is directed to reimburse the hospital bill of Rs. 1,60,823/-(one lakh sixty thousand eight hundred twenty three) with Rs. 20,000/-as compensation for mental harassment and Rs 5,000/-as litigation charges.

The awarded amount shall be paid within 45 days from the date of receiving of this order. If order is not complied within stipulated time, the entire awarded amount shall be payable with 9% interest from the date of filing this complaint.    

Copy of this order be sent to the parties as per Rules and file be consigned to Record Room

 

(Dr) P N Tiwari   Member                                                             Shri Sukhdev Singh   President