DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.70/2018
Sh. Harvinder Pal Singh
H.No.12/164, 3rd Floor, (Senior Citizen)
Malviya Nagar, New Delhi ….Complainant
Versus
1. United India Insurance Company Ltd.
Divisional Office No.XII, Flat No.42C,
Floor No.3, Moolchand Commercial Complex,
New Delhi-110024
2. Ram Methawani
Asst. Manager of OP No.1
3. Sh. Sital Methwani
S/o Sh. Ram Methwani
Agent of OP No.1 ….Opposite Parties
Date of Institution : 07.03.18 Date of Order : 04.06.19
Coram:
Sh. A.S. Yadav, President
Ms. Kiran Kaushal, Member
Ms. Kiran Kaushal, Member
ORDER
- Brief facts as pleaded in the complaint are:-
The complainant, Harvinder Pal Singh and his wife Ms. Gurucharan Kaur took a ‘Happy Family Floater policy’ from Oriental Insurance Company Ltd. After three years i.e. in 2015 OP-2/ OP-3 the Assistant Manager and the Agent of United India Insurance Company Ltd. (OP-1) approached the complainant and informed him that he can port his policy from Oriental Insurance Company Ltd. to United India Insurance Company Ltd. The claim/ benefits of last three years will not be disturbed, the same will be included in the said policy. Complainant accepted the said offer and on 23.03.2015 the policy was issued by OP-1 for a premium of Rs. 25,888/-.
1.2 It is averred that the said policy was regularly renewed till date with the premium being paid and duly realized by OP-1 every year.
- It is next stated that on 01.10.2017 the complainant was admitted in Shri Moolchand Kharati Ram Hosptial due to chest pain and breathlessness and was under observation for around six days and was discharged on 06.10.2017. Copies of the medical documents are annexed as Annexure-C (Colly). At the time of discharge, the hospital raised bills of Rs.97,059/-. The complainant raised the claim with OP-1 and vide letter dated 06.10.2017, OP-1 repudiated the claim stating that the disease is pre-existing disease.
- The complainant, being a senior citizen and aggrieved due to the denial of rightful claim, approached this Forum with the prayer to direct OP to pay the claim of Rs. 97,059/- to the complainant. Additionally, directions for compensation towards mental agony, business loss and inconvenience caused and litigation expenses of Rs.11,000/- is prayed for.
- OP resisted the complaint inter-alia stating that as per the concerned insurance policy the claim is repudiated as per clause 4.3 of the terms and conditions of the policy. Clause 4.3 of the insurance policy reads as follows-
Policy exclusion clause 4.3(b) (waiting period) states that-
Waiting period of 48 months for pre- existing diseases.
- OP submits that the policy in question was not ported but was a new policy and the inception date of the current policy is 23.03.2015. The complainant was admitted in the hospital on 01.10.2017 therefore as per exclusion clause of 4.3 of the terms and conditions of the policy the waiting period of 48 months for pre-existing disease were not completed. OP reiterates that as per exclusion clause 4.3(b), claim of the complainant is not maintainable, hence it is prayed that complaint be dismissed with cost.
3. Complainant has filed rejoinder to the reply filed by OP reiterating the averments made in the complaint.
4. Complainant has filed evidence by way of affidavit. On the other hand, affidavit of Sh. Satish Kumar Jagga, Divisional Manager of OP-1 has been filed.
5. Written arguments have been filed on behalf of the complainant and OP-1.
- Counsels of the parties and perused the record very carefully.
7. The claim of the complainant is repudiated on the ground of exclusion clause 4.3 of the terms and conditions of the policy which states that there has to be waiting period of 48 months in the cases of pre-existing disease. As per OP, the date of inception of the current policy is 23.03.2015 and the complainant was admitted in the hospital on 01.10.2017 therefore the waiting period of 48 months for pre-existing disease was not over when the complainant was admitted in the hospital. To decide whether the claim was rightly repudiated or not it is very important to decide the date of inception of the current policy.
8. The first point of contention between the parties is that as per the complainant the said policy was ported whereas OP submits that the policy in question was issued as new policy on 23.03.2015, therefore, the date of inception was 23.03.2015.
9. OP has annexed “Family Medicare Policy 2014’ the current policy as Annexure-D1 along with its written statement. The complainant in his evidence has annexed document which is Marked-A for the sake of identification as ‘Health Insurance Portability Form’ issued by OP company. On careful scrutiny of the above documents, it is observed that the previous policy number is given in both the documents. If the said policy was a new policy there would not be any previous policy number. The old adage comes to the rescue of the complainant that ‘Men may lie but documents do not’. Therefore, we are of the opinion that OP has lied on this aspect.
10. Further it is pertinent to mention the declaration in the ‘Health Insurance Portability Form’ signed by the complainant reads as follows:-
“I am aware that the waiting period for the following disease(s)/ treatment(s) is …. days / years more than the previous policy terms. I hereby agree to observe the additional waiting period for the following disease(s)/ treatments(s)”
11. It is noticed that the ‘waiting period’ is left blank in the above said declaration. Further the OP has nowhere in its pleadings stated that the copy of terms and conditions were supplied to the complainant. Hence, it is affirmed that the complainant was not told / informed about the waiting period.
12. Hence, from the discussion above, we hold OP to be grossly deficient and indulging in unfair trade practices as having taken the premium from the complainant regularly and when the claim was raised by the complainant OP gave false and frivolous excuses to deny the claim of the complainant. Therefore, the complaint is allowed and we direct OP to pay the claim of Rs.97,059/- @ 9% from the date of repudiation of the claim i.e. 06.10.2017 till realization. Additionally Rs.25,000/- to be paid by OP by way of compensation towards mental agony, inconvenience caused and litigation expenses within two month of receipt of copy this order, failing which OP shall become liable to pay interest @ 12% p.a. on the amount of Rs.97,059/- from the date of filing of the claim till realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 04.06.19
