DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC. No. 198 of 18-08-2009<br /> Decided on : 12-01-2010 <br /> <br /> Harvinder Singh S/o Sh. Ujjagar Singh aged about 49 years R/o A-38, Thermal Colony, Bathinda.<br /> .... Complainant<br /> Versus<br /> <br /> 1.United India Insurance Co. Ltd.,Divisional Office, the Mall, Bathinda, through its Divisional Manager.<br /> 2.M/s. Raksha TPA Pvt. Ltd., 15/5 Mathura Road, Faridabad 121 003 through Manager-Medical & Claims.<br /> ... Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM <br /> <br /> Ms. Vikramjit Kaur Soni, President<br /> Dr. Phulinder Preet, Member<br /> Sh. Amarjeet Paul, Member<br /> <br /> For the Complainant : Sh. M S Bhatty, Advocate, counsel the complainant <br /> For the Opposite parties : Sh. S M Goyal counsel for opposite party No. 1.<br /> Opposite party No. 2 exparte. <br /> <br /> O R D E R<br /> <br /> VIKRAMJIT KAUR SONI, PRESIDENT<br /> <br /> 1. Briefly stated the case of the complainant is that he was purchasing medi-claim policy from opposite party No. 1 since 2003 onwards and lastly he purchased medi claim policy vide policy No. 200400/48/08/97/00000591 effective from 14-08-2008 to 13-08-2009. In the month of September, 2008, he was not feeling well, so he visited Dr. R S Chahal of Kidney Hospital & Lifeline Medical Institute, Jallandhar for check-up and further management. The attending doctor of said hospital admitted him on the same day and he remained admitted there upto 30-09-2009. During his stay, various tests were conducted and he was diagnosed Bilateral Kidney Stores (R) side. He was put under their observations as indoor patient and treated the complainant as indoor patient and ESWL was done. The said hospital issued bills/receipts for Rs. 21,800/-which includes room rent, admission fee, doctor visiting charges, nursing charges, blood sugar charges and besides this he also spent amount for purchasing medicines and in total he spent Rs. 26,109/-. The complainant submitted bills and receipts with opposite party No. 1 for reimbursement who forwarded the same to opposite party No. 2 an agency of opposite party No. 1 for settlement of medi-claims. The opposite party No. 2 demanded original record pertaining to treatment regarding which complainant and opposite party No. 1 conveyed that original record was lying with said hospital and attested copies thereof have already been submitted and that the same can be verified by opposite party No. 2. Opposite party No. 2 vide letter dated 13-02-2009 has conveyed that since no proper reply has been received by them as such, the claim file of the complainant has been closed by them. <br /> Ultimately, opposite party No. 1 vide its letter dated 25-05-2009 conveyed the complainant that since the complainant also took treatment regarding left Kidney stone in the years 1986 and 1996 and the disease was pre-existing, so his claim is not payable and repudiated the lawful claim of the complainant. He alleged that there was no pre-existing disease. He started purchasing the policies from the year 2003 and he took treatment for right side Kidney stone in the year 2008 i.e. after a gap of more than 10 years. Hence, his complaint for issuing directions to the opposite parties to make the payment of Rs. 26,109/- alongwith interest @ 18% P.A. from the date of due till its realisation and also pay him Rs. 1,00,000/- as damages on account of mental tension,agony and physical harassment besides litigation expenses to the tune of Rs. 5,000/-. <br /> 2. Opposite party No. 1 filed reply taking legal objections that complaint is not maintainable; complainant has no locus standi or cause of action; he has concealed true and material facts; complaint is bad for mis-joinder of parties as opposite party No. 1 has been impleaded unnecessarily; complaint is not within limitation; complainant is not consumer and there is no deficiency in service on the part of Insurance Company. On merits, it has been specifically denied that the factum of complainant having Bilateral Kidney Stones ® side was diagnosed only in September, 2008. He was already suffering from this disease and had been treated firstly in 1986 and then in 1996 and as such, he was a known case of this disease. Hence the claim in question is non-payable as per Clause 4.1 of the Policy which states that if the disease is pre-existing to the inception of the policy and has not been disclosed/has been concealed knowingly from the company at the time of getting Insurance Policy, then the company shall not be liable for such claim.<br /> The opposite party No. 2 is not agency of opposite party no. 1 for settlement of Medi-claim, rather is Third Party Administrator who was appointed and nominated by both the parties at the time of purchasing the policy in question and both the parties have admitted that in case of any claim, the same shall be made/referred to TPA i.e. opposite party No. 2. During processing and investigation of claim in question, it was found that complainant was known case of Renal Calculi and he had already underwent treatment for the same in year 1986 and 1996 and as such, he was not diagnosed B/L Renal Calculi for the first time on 29-09-2009 nor first time underwent DSWL (Extracorporeal Shock Wave Lithotripsy) and as such, the claim of the complainant was legally and properly repudiated.<br /> 3. None appeared on behalf of opposite party No. 2 despite due service of Notice and as such, exparte proceedings were taken against it.<br /> 4. In support of his averments contained in the complaint, the complainant has produced in evidence his afidavit Ex. C-1 and the documents Ex. C-2 to Ex. C-45.<br /> 5. In rebuttal, the opposite party No. 1 tendered in evidence affidavit of Sh. Balwinder Singh Ex. R-1 and the documents Ex. R-2 to Ex. R-7.<br /> 6. We have heard learned counsel for the parties and have gone through the entire record of the case.<br /> 7. Complainant had been purchasing medi-claim Insurance policies from opposite party No. 1 since 2003 onwards meaning thereby that he has been purchasing medi-claim Insurance policy from opposite party No. 1 for the last more than five years and lastly he purchased medi-claim policy vide No. 200400/48/08/97/00000591 effective from 14-08-2008 to 13-08-2009. The complainant paid requisite premium to the opposite parties. In the month of September, 2008, he fell ill and went to Dr. R S Chahal of Kidney Hospital & Lifeline Medical Institute, Jallandhar, where he was admitted on the same day as per Ex. C-5. He remained there upto 30-09-2008 and during his stay, they conducted various tests. He was diagnosed Bilateral Kidney Stones ® side. They put the complainant under observation as indoor patient. The complainant was treated there as indoor patient and ESWL was done. The said hospital issued bills/receipts for Rs. 21,800/- and apart from it, he spent amount for purchase of medicines, and tests conducted upon him. In total, the complainant spent Rs. 26,109/- on his treatment. The detailed lists of payments made by the complainant are Ex. C-4 and Ex. C-5. <br /> 8. The opposite parties repudiated the claim of the complainant on account of concealment of true and material facts of his previous disease and his taking treatment for the same, at the time of taking medi-claim Insurance policy from opposite party No. 1. The complainant was suffering from Renal Calculi since 1986 and was treated with Left Pyelo Lithotripsy and ESWL in 1986 and 1996 respectively. The complainant concealed fact of this disease at the time of purchasing the policy in question. The Insurance Company has alleged that the claim of the complainant was processed by TPA which after scrutinizing the claim, has rightly repudiated the same. Therefore, there is no question of deficiency of service on the part of opposite party No. 1.<br /> 9. We have gone through the file as well as documents produced by both the parties. The complainant had been purchasing the mediclaim Insurance policy from opposite party No. 1 since 2003 till the year 2008. During these years, he has not taken any benefit out of this mediclaim policy till the year 2008. He has undergone surgery of Right Renal Calculi and has borne expenses of Rs. 26,109/- as per Ex. C-4. After going through surgery, he applied to opposite party No. 1 vide Ex. C-2 for reimbursement of his claim. On receiving the claim, opposite party No. 1 referred the case to Raksha TPA Pvt. Ltd.,, opposite party No. 2 vide Ex. C-32. The opposite party No. 2 vide letters Ex. C-33 to Ex. C-35 had asked for original investigation reports from the complainant and vide Ex. C-38, opposite party No. 2 demanded some more documents from opposite party No. 1. The complainant vide Ex. C-40 has furnished copies of documents to opposite party No. 1. The opposite party No. 2 vide Ex. C-39 has closed the claim file of the complainant due to non-receipt of proper reply. The opposite party No. 1 as per Ex. C-41 & Ex. C-42 has requested opposite party No. 2 to reopen the file for the settlement of claim but nothing has been placed on file either by opposite party No. 1 or by opposite party No. 2 as to whether the claim was settled at the level of opposite party No. 2 or not. However, vide Ex. C-43, opposite party No. 1 has informed the complainant that he took treatment for the same disease and as such claim stood repudiated as per Clause 4.1 which states that if the disease is pre-existing to the inception of the policy, liability of the claim is to be repudiated. On receiving the intimation, the complainant has requested to return his original documents for filing the claim in his Department but the same has been rejected by opposite party No. 1 vide Ex. C-41.<br /> 10. We have gone through Clause 4.1 at para 16 of page 6 which is reproduced below : <br /> “Exclusions :<br /> The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of :<br /> 4.1 - All diseases/injuries, which are pre-existing when the cover incepts for the first time. For the purpose of applying the condition, the date of inception of the initial Medi-claim policy taken from any of the Indian Insurance Companies shall be taken, provided the renewals have been continuous and without any break.” <br /> 11. As per this clause pre-existing disease when the cover incepts for first time can be excluded. The complainant was diagnosed Renal Calculi in the year 1986 and 1996 and took treatment for left side Kidney stone but no abnormality in the right kidney was found for which he has undergone surgery in the year 2008 nor any such document has been produced by opposite party No. 1 that there was any abnormality in the right kidney of the complainant at the time of inception of policy. Opposite party No. 2 has also not rejected the claim of the complainant due to this reason. Therefore, this Forum is of the view that there is deficiency in service on the part of opposite party No. 1 and the opposite party No. 1 is directed to pay to complainant the actual amount of surgery borne by him i.e. Rs. 26,109/- alongwith interest @9% P.A. from the date of filing of this complaint i.e. 18-08-2009 till its realisation. In addition to this, opposite party No. 1 is directed to pay Rs. 5,000/- as compensation for his mental harassment. <br /> 12. As Third Party Administrator, opposite party No. 2 has failed to appear before this Forum despite service. It is deemed to have accepted the version of the complainant. Opposite party No. 2 has not settled the claim of the complainant despite requests made by opposite party No. 1, therefore there is deficiency in service on the part of opposite party No. 2 also. So, it is directed that opposite party No. 2 will pay to the complainant Rs. 5,000/- as costs.<br /> 13. The Insurance Company shall realise the amount of compensation from its Divisional Manager, Bathinda under intimation to this Forum.<br /> Compliance of this order be made within 45 days from the date of receipt of copy of this order.<br /> Copy of this order be sent to the parties concerned free of costs and the file be consigned.<br /> Pronounced :<br /> 12-01-2010 <br /> (Vikramjit Kaur Soni)<br /> President<br /> <br /> <br /> (Dr. Phulinder Preet)<br /> Member <br /> <br /> <br /> (Amarjeet Paul)<br /> Member <br /> *ik