District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.298/2021.
Date of Institution: 01.07.2021.
Date of Order: 07.10.2022.
Mrs. Kamlesh Goyal resident of 107,, New Anaj Mandi, Ballabgarh, Faridabad. …….Complainant……..
Versus
1. United India Insurance Company ltd., SCO-106, 2nd floor, Commercial Complex, Sector-16, Faridabad.
2. United India Insurance Company Ltd., 24, Whites Road, Chennai – 600 014 through its Divisional Manager.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana…………Member.
PRESENT: Sh. Mukesh Tomar, counsel for the complainant.
Sh. M.K.Aggarwal, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant had taken
the family medicare health policy bearing No.2221002816P116358600 and the complainant had paid the premium amount pertaining to the above said policy to the opposite party without any delay. During the mediclaim policy the complainant was admitted in Fortis Escorts Hospital, Neelam Bata Road, Faridabad on dated 19.02.2018 and was discharged on 27.02.2018 and the hospital had raised the bill amount of Rs.1,62,528/- and at that time his client intimated to the representative of the opposite party through telephonically call and the representative of the opposite party assured his client that their claim file No. 171100050760 would be definitely approved, but no fruitful result came out and the said amount had paid by his aforesaid client form her own pocket and alter on his client had sent all related documents regarding the treatment of his aforesaid client for getting the imbursement of the mediclaim amount but no fruitful result came out. The opposite party refused to make the mediclaim amount to the complainant due to age difference in the documents but the age mentioned in the policy was jenvioun as per Government school certificate i.e.10.04.1965 and it was also submitted that at the time of obtaining the policy the age of his above said client was mention in the policy was 51 years however it was also submitted that at the time of the premium of the policy was same till the age of 55 years. As well as the premium of the policy was same of 51 years to 55 years. His client several times requested to the opposite party to make the respective mediclaim amount of Rs.1,62,568/- but the opposite party linger on the matter one pretext to another. The complainant sent legal notice dated 19.04.2021 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) the amount of Rs.1,62,568/- may kindly be allowed in favour of the complainant.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the complainant was having “Individual Health Policy” bearing No.2221002816P116358600 which was valid from 12.03.2017 to 11.03.2018. as per the report of investigation team of TPA of the answering opposite party No.1 the claim of the complainant was recommended for repudiation on account of non-receipt of required documents regarding age proof of the complainant. As per the medical records the age of the complainant/patient was shown as 50 years while a ser the policy and ID proofs of age was 50 years and it was discrepancy from the hospital and complainant and complainant did not submit satisfactory answering as well as proofs regarding her age. The complainant deliberately and intentionally hide her correct age at the time of obtaining individual health policy from the answering opposite party No.1 and this fact disclose through medical documents and other IDs of complainant details were as under:
S.No. | Document name | Document NO. | Date of birth/age (years) | Age on 19.02.2018. |
1 | Adhar card | 3174 3879 8607 | 1962 | 56 years |
2. | Pan card | AHBPG3884G | 01.01.1962 | 57 years |
3. | School leaving certificate | S.No. 34 dated 07.03.2019 | 10.04.1965 | 53 years |
4. | Discharge summary of Forties Hospital Limited | IP ID 188038 daated 27.02.2018 | 50 years | 50 years. |
5. | Insurance policy | 2221002816P 116358600 dated 12.03.2017 | 51 years | 51 years |
The complainant did not follow the terms and conditions of individual mediclaim policy & infringed/b reaches the terms of policy condition, so TPA of answering opposite party No.1 declined claim of the complainant. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– United India Insurance Co. ltd. with the prayer to: a) the amount of Rs.1,62,568/- may kindly be allowed in favour of the complainant .b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .c) pay Rs. 22,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.C1 – Individual health Policy, Ex.C2 – Inpatient bill, Ex.C-3 leaving certificate,, Ex.C-4 – Discharge summary, Ex.C-5 – Claim processing sheet, Ex.C-6 – query letter,,
Ex.C-8 – legal notice, Ex.C-8 & C-9 – postal receipts.
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties, Ex.RW1/A – affidavit of Shri Dinesh Kumar, Administrative Officer of M/s. United India Insurance Company Limited, SCO NO. 106, Commercial complex, Sector-16, 3rd floor, Faridabad, Ex.R-1 – insurance policy,
6. In this case, the complainant had taken the family medicare health policy bearing No.2221002816P116358600. The complainant was admitted in Fortis Escorts Hospital, Neelam Bata Road, Faridabad on dated 19.02.2018 and was discharged on 27.02.2018 and the hospital had raised the bill amount of Rs.1,62,528/-.The opposite party refused to make the mediclaim amount to the complainant due to age difference in the documents but the age mentioned in the policy was jenvioun as per Government school certificate i.e.10.04.1965 and it was also submitted that at the time of obtaining the policy the age of his above said client was mentioned in the policy was 51 years however it was also submitted that at the time of the premium of the policy was same till the age of 55 years It is evident from Query letter dated C-6 in which it has been mentioned that “As per medical records, age of the patient is 50 years while as per ID proof age is 55 years.”
7. After going through the evidence led by the parties, the Commission is of the opinion that the difference between the age of the complainant does not affect with the terms and conditions of the insurance policy. Hence, the complaint is allowed. In the interest of justice, the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the T&C of the policy within 30 days of receipt of the copy of order and pay the due amount to the
complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 07.10.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
