Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 21/25.01.2017
R.R.Jagga son of Late G.C. Jagga
R/o B-5/9, Rajouri Garden, New Delhi-110027 ... Complainant
Versus
OP1. United India Insurance Co. Ltd.,
Regd & Head Office: 24, Whites Road, Chennai-600014
Also At Jeevan VIKAS Building, Door No.30-31A,
Asaf Ali Road, New Delhi-110002
OP2. Goodhealth TPA Services Ltd., Plot No. 49,
Nagarjuna Hills, Punjagutta, Hyderbad-82
OP3. Andhra Bank, Asaf Ali Road,
New Delhi-110001 …Opposite Party
Senior Citizen Case
Date of filing: 25.01.2017
Date of Order: 15.05.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Inder Jeet Singh
ORDER
1.1. (Introduction to consumer dispute of parties) – The complainant/ insured is policy holder issued by OP1/insurer, enrolled under Andhra Bank/OP3 qua Group Health Insurance Policy/ Super Top-up Health Insurance Policy, with sum insured of Rs.5,00,00/- and super top-up sum insured of Rs. 5,00,000/-. The complainant had chest pain from 10.07.2016 to 12.07.2016 and breathlessness 5-7 days prior to his hospitalization from 01.08.2016-11.08.2016, however, his medical bill of his hospitalization and treatment in Sir Ganga Ram Hospital were partly allowed and partly denied. That is why, the complaint was filed for balance bill amount of Rs. 1,50,726/-, apart from interest of Rs.32,409/- on such balance amount as well as compensation of Rs. 1,00,000/- on account of mental agony, pain and harassment caused to him due to long and humiliating mistreatment by OPs.
1.2. Whereas OP1 opposes the complaint, that it is without cause of action and it does not disclose as to how he is entitled for entire reimbursement of amount vis a vis terms of policy are binding on the parties. The complainant was suffering from pre-existing disease as well as the claim was not covered under enhanced sum assured. The OP1 cannot be held liable for claim, which is outside the scope of policy.
1.3. There is no reply by OP3, its right to file reply was closed on 25.05.2017. OP2 had also not filed its written statement.
1.4 It is relevant to mention that the complainant and OP1 have put their respective plea and counter plea, in order to keep clarity and symmetry, case of each of them will be introduced at one place as a whole.
2.1. (Case of complainant) - The Complainant/Insured is a Senior Citizen being policy holder of OP1/Insurer/United India Insurance Co. Ltd through OP2/Good Health TPA Services Ltd., duly enrolled with Banker/Andhra Bank/OP3 Group Health Insurance Policy/Super Top up Health Insurance Policy vide Arogyadaan Policy No. 0504002816P103666002;
Super Top Up Policy No. 0504002816P103621545'
GHID No. GHUIAB00022193 of sum insured of Rs.5 Lakhs and Super Top Up sum insured Rs. 5 Lakhs. During subsistence of the Policy, the complainant felt chest pain between 10.07.2016/12.07.2016 and also breathlessness about 5-7 days prior to his hospitalisation. Initially he was admitted in Delhi Heart and Lungs Institute, Pusa Road, New Delhi, where his angiography was conducted and when it was diagnosed for the first time that he has blockage of arteries. Thus, request for cashless facility was made by complainant for his hospitalisation from 27.07.2016 to 29.07.2016, which was allowed and bills were paid by the OP1 & OP2.
2.2 Then complainant was admitted in Sir Ganga Ram Hospital (being covered in the list of cashless facilities offered by OP2) for better expertise and for bye- pass surgery and request was sent to OP1 and OP2 by Sir Ganga Ram Hospital, New Delhi on 01.08.2016, being within 24 hours of admission for cashless facility. OP2 had assigned reference/claim no. 155202 for this episode. The OP2 has sought information of treating doctors, breakup of the procedure, tariff rates, which were also provided to OP2. Thence, OP2 authorised and guaranteed payment of initial approval of Rs. 1,60,000/- as per policy of complainant. At that time there was no issue, stand, plea or objection of OPs on point of previous/old ailment or pre-existing heart disease, but it was raised subsequently by the OP2.
2.3. The complainant had deposited cash of Rs.5000/- at the time of his admission as advance in Hospital and complainant remained admitted as indoor patient in the hospital from 01.08.2016 to 11.08.2016, he was discharged on 11.08.2016. He was given medical treatment and bye-pass heart surgery was done for curing the blockages of the heart, as diagnosed by the doctors.
The complainant made request for cashless authorisation of the final bill to OP2 at the time of his discharge, however, OP2 had given authorisation and enhancement of just Re. 1/- that too after persistent follow up for cashless till late afternoon, which was adding woes of complainant to wait in anxiety after such a sensitive operation of heart. Yet, there was no issue or objection of pre-existing ailment from the OPs and instead Re.1/- was sanctioned, and had the OP1 and OP2 objection of pre-existing ailment, they would not had sanctioned any such amount of Rs. 1,60,000/- at the time of admission nor Re. 1/- after the surgery. The complainant had no alternate but to pay in cash an amount of Rs. 1,45,726/- at the time of discharge on 11.08,2016, and an amount of Rs.5,000/- was already paid by him (out of the total bill amount of Rs.3,10,727/-). The complainant had paid total Rs.1,50726/- from his own pocket to hospital, since only Rs.1,60,000/- was paid by OP2. It was shocking that further enhancement of the cashless request was not conceded despite the complainant was covered by the Super Top Up facility also for which he paid extra premium, the complainant had been getting renewed this policy for more than 10 years with OP1 and OP2. The acts of the OP1 and of the OP2 is of deficient services and of mala-fide conduct.
2.4. Since the complainant had undergone the bye-pass surgery of heart, it does not fall in the excluded category of diseases as mentioned in clause 6.3 of the policy. Thus for want of approval of the cashless authorisation, the acts of OP1 and OP2 are illegal, arbitrary, unjust and uncalled for and it is also humiliating to authorise only Re.1/- at the time of his discharge. Otherwise, if OPs can approve Re.1/-, then why the balance amount of Rs.1,50,726/- cannot be approved?, this approval of Re. 1/- is incomprehensible and no reasons have been assigned. Hence, it proves that the quantum of approval by OP1 and OP2 is whimsical, arbitrary and not based on any principle, rule or policy and instead in defiance to rules of the policy. The complainant had also sent a registered post letter dated 14.09.2016 to OP2 to address his grievances but no reply by them nor reimbursement of amount nor any plea of pre-existing disease was suggested. However, OPs took stand in the reply that they wrote letter dated 20.09.2016 to complainant about transfer of Rs.1,28,610/- in the account of complainant as settlement of claim, however, neither such letter was received by the complainant nor filed on record nor any amount was transferred to his account.
2.5. The complainant has been annexed with documentary records of his first treatment given at Delhi Heart and Lungs Institute, and of his subsequent treatment in Sir Ganga Ram Hospital, he has also filed the record of letter dated 01.08.2016, 02.08.2016, certificate dated 03.08.2016 issued by Sir Ganga Ram Hospital, authorization/ initial approval by OP2 of Rs. 1,60,000/- vide letter dated 03.08.2016, final approval of Re. 1/- vide letter dated 11.08.2016, receipt dated 01.08.2016 of initial deposit of Rs. 5,000/-, receipt dated 11.08.2016 of balance amount of Rs. 1,45,726/- along with final bill detail, letters and correspondence, legal notice dated 25.11.2016 and a compact disk of complainant’s enquiry to the opposite party prior to taking the insurance.
3.1 (Case of OP1)- The OP1 files its written statement, its verification and supporting affidavit is under the signature of Shri Rakesh Kumar, Assistant Manager, however, the contents of written statement are not signed by Shri Rakesh Kumar, of OP1. Moreover, Vakalatnama in favour of Ms Meenakshi, Advocate & associate is also under seal and signature of OP1. But written statement title is that it is by OP1 and OP2 as if filed jointly, but there is no authority given to OP1 by OP2 to do so, thus written statement is exclusively OP1. There is no declaration that OP1 had also signed written statement for OP2, therefore, at the outset, it is held that there is no written statement of OP2. As per proceedings dated 11.04.2017, it was recorded that written statement is filed by OP1.
It is being mentioned here since relevant, as this has been done intentionally as later-on affidavit of evidence of OP1 and written arguments on behalf of OP1 were also projected as it the same are for OP2, whereas OP1 has not proved any authority to do so nor the counsel for OP1 was authorized/vakalatnama to appear for OP2 too.
In addition, as per rule pleading shall be signed by the parties and by counsel, if any. However, contents of written statement have not been signed by OP1 but verification, which also leaves blank paragraphs to be verified. With this observation, the stand in written statement of OP1 will be referred.
3.2 OP1 in its written statement opposed the complainant, being without cause of action and it does not disclose as to how, he is entitled for entire reimbursement of amount vis a vis terms of policy are binding on the parties, thus OP1 cannot be held liable for claim, which is outside the scope of policy.
3.3 The OP1 take support by referring case of New India Assurance Co. Vs Husmat Begum, AIR 1994 J&K 1, that the liability of the insurer is only to the extent as contained in the insurance policy and United India Insurance Co. Ltd. Vs Lakshmi AIR1990 Madras 108, that in order to fix liability on the insurance company, the liability must be established first against the insured and only thereafter the liability of the insurance company would arise. Since, OP3 cannot be held liable for any reimbursement as alleged in the complaint hence the present claim petition is liable to be dismissed.
3.4 That OP2 had received a cashless request from Sir Ganga
Ram Hospital towards hospitalization expenses
of the complainant for treatment of angina pectoris
the period of admission in the hospital being from 27.7.2016
to 29.7.2016 [it is necessary to mention the complainant had protested this plea of OP1 that he was treated from 27.7.2016 to 29.7.2016 in Delhi Hearts and Lungs Institute, and that Institute had sent request for cashless and it was not Sir Ganga Ram Hospital] and for treatment of chest pain on
breathing- TVD/ unstable angina/HTN, the period of hospitalization was from 01.8.2016 to 11.8.2016. The claims were registered under claim nos. 154925 and 155202. Some query was raised with the
hospital for informing duration of present complaints along with consultation papers, letter from the treating
doctor regarding duration of present ailment and break up of estimate for the procedure planned in the hospital. The documents received were scrutinized and it was observed that only the consultation papers, prior to current hospitalization, was provided by the hospital despite the patient had a history of hypertension since 4 years. Since previous and first consultation papers were not submitted, and the possibility of pre-existing heart disease could not be ruled out, the cashless approval was restricted to the sum insured of Rs.2,00,000/- under policy no- 0504002816P103075013 for the policy period 9.6.2015 to 8.6.2016 (which is prior to enhancement of the sum insured) during which period the current hospitalization is done as per clause no- 5.25. 6.1, 7.15 (4d) and 7.16 of the terms and conditions of Arogyadan Policy. The cashless was approved for Rs. 1,60,000/- as the maximum eligible amount payable for hospitalization expenses related to major illness is 80% of the sum insured which amounts to 80% of Rs.2,00,000= Rs.1,60,000/- with remarks as no further enhancement possible as the ailment for which the claimant was admitted falls under major illness vide clause 7.15(4d).
The total cashless request by the hospital for both the above claims together being Rs 3,38,244/- the cashless claim was settled by M/s GHPL for Rs 1,60,000/- (Rs.17,100/- and Rs 1,42,900/- respectively) as per the terms and condition of Arogyadan Policy mentioned above. That M/s GHPL/OP2 have settled the cashless claim of the hospital considering the sum insured as Rs 2,00,000/- as per the clause of the terms and conditions of the policy.
3.5 As per clause 5.25, pre-existing disease is any condition, ailment or injury or related conditions for which insured had signs or symptoms and/or were diagnosed, and/or received medical advice/treatment, within 36 months prior to the first policy issued by the insurer. The selected sum insured is final till the expiry of policy period. The enhanced sum insured will not be applicable for
pre-existing conditions/disease, when the insured has been hospitalizes for any ailment during the expiring policy
period, even if he/she chooses to enhance the sum insured
under the policy at the time of renewal, the sum insured
would be restricted to the sum insured under the expiring
policy for such pre-existing condition/ ailment.
3.6. On 20.9.2016 OP2 has sent a letter to
the complainant stating that a sum of Rs 1.28,610/- towards settlement of claim has been
transferred on 20.9.2016 to the complainant bank account number furnished to OP2 and the transaction reference number for this transfer is 169K735002U20U16
from BOA (it has been denied by the complainant).
3.7. It is relevant to mention that the OP1 has mentioned in the reply that some documents are filed and there is also reference of letter dated 20.09.2016, however, no documents or letter of 20.9.2016 was filed nor detail was given in pleading or evidence as to how amount was Rs.1,28,610/- calculated or what are the components?
4.1. (Evidence)- Complainant filed his detailed affidavit, along with reference of the record filed with the complaint. The complainant also filed affidavit u/s 65B of Indian Evidence Act in respect of compact disk which he filed with the rejoinder and this CD had also been part of affidavit of evidence. He is exclusive witness of his case.
4.2. OP1 filed affidavit of Sh. Rakesh Kumar, Assistant Manager and this affidavit is replica of reply of OP1.
5.1 (Final hearing)- The complainant as well as OP1 have filed their written arguments in detail, it is compilation of their pleadings as well as documents, by referring appropriate clauses of insurance policy.
The parties were given opportunity to make oral submission, Sh. Amit Jagga, Advocate for complainant made the oral submissions but no oral submissions on behalf of OP1. Their respective contentions will be referred appropriately.
5.2. The complainant made oral submissions on the lines of complaint and documents along with the case law narrated in the written arguments. The complainant reiterates his case within the parameter of policy as well as complainant opposed the stands taken by OP1.
The complainant contends that OP1 has raised two main defences (A) of pre-existing disease and (B) about clause 7.15(4d) of policy, however, both the defences are hollow plea.
The first defence does not sustains for the reasons (i) there was cashless request was approved for treatment w.e.f. 27.07.2016 to 29.07.2016 during his admission in DHL Institute Pusa Road, New Delhi for his angiography; (ii) The cashless request was approved for Rs. 1,60,000/- by OP2 vide letters dated 03.08.2016, after admission in Sir Ganga Ram Hospital, New Delhi and (iii); the approval of Re. 1/- at the time of discharge of the complainant from Sir Ganga Ram Hospital New Delhi on 11.08.2016.
OPs never raised objection at any of the occasions aforementioned and instead approved the requests and thereafter never raised objection of pre-existing disease neither when letter dated 14.09.2016 was sent to OP no.2 nor in reply to legal notice dated 25.11.2016 sent to the OP1 and OP2. It is only for the first time this objection of pre-existing disease has been raised in reply to the complaint under consideration, which also does not sustain. The complainant fortifies his contentions, while referring -
(a) New India Assurance Co. Ltd. vs Murari Lal Bhusri decided on 5.7.2011 by hon'ble National Commission, it was held "there is nothing on the record to show us that the disease for which the treatment was taken on 14-02-1998 the complainant was suffering from the same disease prior to the taking of the policy. Though in common parlance one may say that angina is not a disease but even if it is to be taken a disease of heart, it cannot certainly be said to be triple vessel disease for which treatment was undertaken by the complainant. In these circumstances, leaning towards the consumer, we will hold that the Insurance Co. was not legally right in repudiating the claim of the complainant. We agree with the approach of the District Forum when it allowed the complaint as aforesaid."
It further observed that:- "As apparent from the above discharge summary, there is no history of myocardial infarction in the past and respondent was advised further investigation. Thus, there is no evidence on record to show that respondent was aware of any pre-existing disease at the time when the insurance policy was taken and accordingly there is no suppression of material facts."
(b) New India Assurance Company vs Vimal Vahan Jain decided on 12.03. 2009 by hon'ble State Commission, Delhi, it was held
'we have taken a view that unless and until the insured is hospitalized or undergoes operation for any disease in the near proximity of the policy, say a year or two, he cannot be accused of concealing the factum of pre-existing disease."
(c) Lakhwinder Singh vs United India Insurance Company decided on 7.4. 2010 by hon'ble State Commission, Chandigarh, it was held
"taking these facts into consideration, we are of the opinion that there is no suppression of material fact as complainant was not aware of any pre-existing disease. Our view is supported by the order passed by Honble National Commission in the case titled as Life Insurance Company of India & Ors. Vs. Paria Pally Sujatha & Ors. 120101 CPJ 106(NC)."
(d) United India Insurance Co. Ltd. vs Harchand Singh Brar, Hon'ble State Consumer Disputes Redressal Commission, Dehradoon, on 17 July, 2009 on the clause of pre-existing disease, held "what is significant in these clauses is that the insured person should have the knowledge of the disease, with which he is suffering had sufiered from. The material placed before us only reveals that the family doctor of the insured had referred him to Batra Hospital & Medical Research Centre, New Delhi for the first time in August, 1988. The insured had simply complained of chest pain. Though the treatment papers of Batra Hospital & Medical Research Centre, New Delhi are not available on record, but we can infer out that the problem was not a serious one. The insured had claimed an amount of Rs. 3,468/-, which shows that the problem was not a serious one and the expenses were for investigating steps taken there at above hospital."
(e) The Oriental Insurance Co. Ltd. vs Mr. Kuldip Singh Swani decided on 10.01. 2012, State Consumer Disputes Redressal Commission, Mumbai , held as "in the said case papers of Cumballa Hill Hospital & Heart Institute, supra, it is mentioned that known case of DM & HT since 5-6 years well controlled, History of angina on/of since 1 years on exertion, history of heavious of chest since 1 years on exertion.. Since, the medi-claim policy was taken in 1997 and the event occurred in the year 2002 i.e. after 5 years, lapse of 5-6 years about known case of DM & HT would not make out a case of pre-existing case prior to taking a mediclaim policy in the year 1997. Furthermore, diabetic mellitus and hypertension, no doubt, may lead to the heart problem in the later period, but that is not the sole purpose."
(B). The second defence taken by OPs is of Clause 7.15 (4d). The OPs wrongly perceive that case of the complainant falls under major illnesses vide clause 7.15 (4d) or further enhancement cannot be granted. Whereas, the policy clause 7.15 (4d) provides 80% of sum insured subject to maximum of Rs.4 Lakhs and not Rs.2 lakhs and further it is provided Rs.12 Lakhs in Super Top Up Policy-Cardiac/ Cancer/ Brain Tumor/ Pacemaker, etc. hence, the cardiac problem is specifically covered up-to Rs. 12 Lakhs in Super Top Up policy and the complainant is the holder of the Super Top Up Policy. The case of the complainant covers risks up-to Rs. 12 lakhs.
Furthermore complainant has been policy holder since 2004, which is more than 04 years, hence, the exclusion clause is also not applicable to him. The complainant has filed the compact disc of recording of the said policy of OP2 as informed by the customer care no. 18604253232. In any case the OPs are taking contradictory stand that on the one hand it is mentioning at a major illness which is limited to 80% and on the other hand raising unreasonable and impossible defence of pre-existing disease which are itself contradictory and smacks of illegal stand of the opposite.
5.3. The OP1 has filed the written argument but no oral submissions. However, by looking at the case of OP1, the written arguments are replica of evidence and pleading, its detail has already been given in para no. 3.2 to 3.6 above. The same are not repeated here to overload this final order.
6.1 (Findings)- The contentions of both the sides are considered, keeping in view the material on record, the insurance contract between the parties and its clauses empahsised by the respective party. Since both the parties are referring the insurance policy contract, some of the relevant policy clauses no.- 5.25. 6.1, 7.15 (4d) and 7.16 are reproduced hereunder:-
5.25 Pre-existing disease:
Pre Existing Disease is any condition, ailment or injury or related condition (s) for which you had signs or symptoms, and/or were diagnosed and/or received medical advice/treatment, within 36 months prior to the first policy issued.
6 Exclusions - The company shall not be liable to make any payment under the policy in respect of any exemption whatsoever any incurred to any insured person in connection with or in respect of-
6.1 Any Pre-existing conditions as defined in the policy, until 36 months of continuous coverage of such insured person have elapsed since inception of his/her first policy with the Company.
7.15 Room rent & Nursing expenses:
xxx
(4). Hospitalization expenses limited to -
(d) For specified major surgeries: 80% of SI subject to maximum of Rs.4,00,000/ under Arogyadaan Policy and Rs. 12 Lac under Super Top Up Policy Cardiac/Cancer/Brain Tumour/Pace Maker implantation/Hip replacement/Knee joint replacement/ Sick / Sinus syndrome.
7.16 Enhancement of sum insured
Sum Insured and Premium will vary at the option of each Account Holder.
However, while renewing the policy the Insured Account Holder can enhance Sum Insured.
The selected Sum Insured is final till the expiry of policy period. The Enhanced Sum Insured will not be applicable for Pre-existing conditions/disease i.e. in case the Insured has been hospitalized for any ailment during the expiring policy period, even if he/ she chooses to enhance the sum Insured under the Policy at the time of renewal, the Sum Insured would be restricted to the Sum Insured under the expiring Policy for such Pre-existing condition/ailment. The selected Sum Insured will float amongst all family members. Either one family member or all the family members put together can avail Sum Insured so selected and premium paid subject to policy terms and conditions.
6.2. The circumstances of this case are based on documentary record and it is apparent that there is no dispute that the complainant is Insured and OP1 is Insurer, OP2 is TPA. There is also no dispute that complainant was initially treated in Delhi Heart and Lungs Institute from `10.7.2016 to 12.7.2016, its bill was cashless approved. Later, on 1.8.2011. he was alsohospitalized and there was heart surgery of complainant at Sir Ganga Ram Hospital, where he remained as indoor patient from 01.08.2016 to 11.08.2016 the total medical bill raised was Rs. 3,38,244/-, out of which Rs. 1,60,000/- was initially authorized/ approved vide letter dated 03.08.2016 and at the final stage, the additional approval was of Re. 1/-. The complainant had to pay balance amount of bill of Rs. 1,45,726/-, apart from additional deposit of Rs. 5,000/-. To say, the complainant was paid Rs. 1,60,000/- for his treatment in Sir Ganga Ram Hospital, the remaining medical expenses were borne by the complainant at the time of his discharge, except Re. 1/- which was finally approved by the OP1.
6.3. In the written statement of OP1, states that complainant had undergone treatment earlier in July 2016 for which an amount of Rs. 17,100/- was approved and for subsequent episode for treatment at Sir Ganga Ram Hospital for which an amount of Rs. 1,42,900/- was allowed and total amount allowed was Rs. 17,100/- + Rs. 1,42,900/- = Rs. 1,60,000/-. Since the sum insured was treated as Rs. 2,00,000/- as per initial policy and admissible amount was 80% of sum insured, thus, the amount allowable was Rs. 1,60,000/-, which stand allowed.
Whereas, the documentary record depicts some other circumstances, the complainant has filed documentary record of his treatment from 27.07.2016 to 29.07.2016 at Delhi Heart and Lungs Institute, the total bill was Rs. 27,516.80p out of which Rs.17,100/- was allowed and remaining amount of Rs. 10,417/- was borne by the complainant.
In Sir Ganga Ram Hospital the total medical bill was of Rs. 3,10,727/-, out of which OP2 had recommended Rs. 1,60,000/- as initial payment and at the time of discharge, in the total bill the share of patient was Rs. 1,50,726/- and of OP1/OP2 share was Rs. 1,60,001/-. The final approval letter dated 11.8.2016 does not depict any reference or clue or noting of previous approval of Rs.17,100/- but of Rs.1,60,000/- Since at the initial stage the first approval was Rs. 1,60,000/-, which was paid to the hospital, through TPA/ OP2 and at the time of final bill, out of OP1/OP2 share of Rs. 1,60,001/-, the balance amount of Re. 1/- was approved by the TPA/OP2. This is being culls out from the undisputed documentary record. That is why the reply of OP1 as well as evidence led is not properly projecting the facts in the record of document, the record does not reflects that a sum of Rs. 17,100/- was initially allowed and remaining amount of Rs. 1,42,900/- was allowed as stated on behalf of OP1 in its written statement.
6.4. Now the other issues between the parties are taken and after assessing the evidence the following conclusions are drawn:-
(i) So far the content of compact disk are concerned, it pertains to the period prior to taking the policy by the complainant and the conversation between the complainant and the addressee were confining to certain general inquiries, which were responded by the other sides. As such it was not confining to interpretation of any specific terms or conditions of policy contract.
(ii) The OP1 is taking inconsistent and contradictory stand in its reply as well as in the evidence led.
(iii) The OP1 took objection that the sum insured of Rs. 2,00,000/- of previous policy will be considered instead of super top-up sum insured amount as the complainant was having pre-existence of disease, however, there is no documentary or medical record established and proveed by OP1 of the pre-existence of disease of complainant to treat the previous sum insured. On the other side, the complainant has established that he has been regularly taking insurance policy from the year 2004 and the latest policy was of super top-up sum insured of Rs. 5,00,000/- in addition to Aarogyadan sum insured of Rs. 5,00,000/-.
The circumstances are suggesting that when there was no proof of pre-existing disease and the complainant has been taking the policy from the year 2004, the clause of 4 years exclusion would not be applicable to invoke the sum insured of Rs. 2,00,000/-. On the other-side, the complainant has proved certificate dated 03.08.2016 issued by Sir Ganga Ram Hospital that complainant had history of chest pain for last 20-22 days and breathlessness for last 5-7 days, prior to his admission in the hospital.
(iv) The OP1 is also projecting twin situation that there is pre-existence of disease and as per clause 6.1, there is period of 36 months continuous coverage to be elapsed since the inception of policy and simultaneously the complainant is also awarding amount of Rs. 1,60,000/-. Moreover, the written statement (para no. 13) and affidavit of evidence of OP1 (para no. 10) refers letter dated 20.09.2016 that the same was sent by OP2 to the complainant for settlement of claim of Rs. 1,28,610/- as well as transfer of that amount in the account of complainant being maintained with OP3, however, neither that letter has been filed nor proved nor any fact is mentioned about calculation of Rs. 1,28,610/-. Otherwise, this narration establishes that complainant is entitled for the reimbursement of medical claim.
(v) The complainant was treated in Delhi Heart and Lungs Institute from 10-12.07.2016, for angiography and thereafter it was 01.08.2016 when complainant was admitted in Sir Ganga Ram Hospital. The complainant has proved certificate dated 03.08.2016 issued by Sir Ganga Ram Hospital that complainant had history of chest pain for last 20-22 days and breathlessness for last 5-7 days prior to his admission in the hospital. There is no other fact or record proved by the OP1, which are contrary to that the facts narrated by the complainant and also establishes through certificate dated 03.08.2016 issued by Sir Ganga Ram Hospital.
(vi) The complainant has proved the bills of his treatment, which are within the parameters of sum insured of Rs. 5,00,000/- of Aarogyadan and of Rs. 5,00,000/- sum insured under super top-up.
(vii) OP1 failed to establish its stand and plea to exclude the claim of claimant in reference to certain clauses of insurance policy contract vis a vis the complainant has succeeded to prove his case against OP1 of deficiency of services and reimbursement of balance medical bills.
6.5. By taking into stock the analysis carried and the conclusion drawn above, the complainant is held entitled for reimbursement of balance medical bill amount of Rs. 1,50,726/- from OP1, as this amount was paid by him out of his own pocket despite the cashless facility and risk was covered by the insurance policy in his favour.
The complainant has claimed interest at the rate of 24% pa in his complaint that too from the date of his discharge on 11.08.2016, however, it is not a civil suit but a complaint under the Consumer Protection Act, 1986 and the interest component dealt within the Scheme of Act, 1986. Since complainant had parted with his money, which he could have it saved if there was extension of cashless facility for Rs.1,50,726/- which is yet to be reimbursed. Therefore, the complainant should receive interest on such amount, he had arranged and paid for his treatment, he is held entitled for interest, which is quantified as simple interest at the rate of 6% pa, which will be payable on Rs.1,50,726/- from the date of complaint till realization from OP1.
6.6. The complainant has claimed compensation of Rs.1,00,000/- for immense mental agony, pain, harassment caused to him due to long and humiliating mis-treatment for not settling legitimate medical claim amount, therefore, considering his age of senior citizen, nature of treatment he had under-gone as well as role & conduct of OPs, compensation of Rs.24,000/- will meet both ends, apart from costs of Rs. 5,000/- in favour of complainant and against OP1.
6.7. OP2 is just TPA, a facilitator but the contract of insurance is between the complainant and the OP1, thus complaint against OP2 is dismissed. OP3 is a Banker, no relief is claimed or made out against OP3 nor there is contract of insurance between complainant and OP3; the complainant is also dismissed against OP3 too.
6.8. Accordingly, the complaint is allowed in favour of complainant and against the OP1 to pay amount of Rs.1,50,726/- simple interest at the rate of 6% pa, from the date of complaint till realisation apart from damages of Rs.24,000/- & costs of Rs.5,000/- to be payable within 30 days from the date of receipt of this order.
In case, OP1 does not pay the amount within 30 days from date of receipt of this Order, then simple interest will @ 7% per annum (in place of 6% per annum) on the amount and period mentioned above.
The complaint against OP2 is dismissed and no order against OP3 in any form.
7. Announced on this 15th May, 2023 [वैशाख 25 , साका 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
