DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.687/2008
Hitesh Choudhary
S/o Sh.Subhash Choudhary
R/o B-2/2231, Vasant Kunj,
New Delhi ….Complainant
Versus
1. East West Assist
97, Manekshaw Road
Sainik Farm, Near Anupam Gardens,
New Delhi-110068
2. United India Insurance Co. Ltd.
Divisional Office-8,
503-504, Kailash Building,
K.G. Marg, New Delhi ……Opposite Parties
Date of Institution : 23.09.08 Date of Order : 20.07.16
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
Sh. S. S. Fonia, Member
O R D E R
Briefly stated, the case of the Complainant is that his employer M/s Cadtech Consultants Pvt. Ltd., New Delhi had taken mediclaim policy from OP No.2 to cover their employees and the same was renewed from time to time. He was one of the beneficiaries of the policy upto a sum of Rs.1.5 lacs. OP No.1 was appointed to process cashless claim of the insured persons. He had pain in his right side of his abdomen. He was admitted in emergency in Fortis Hospital on 26.10.07. He was referred to nephrologist and advised various tests such as ultrasound, blood and urine test. At the time of conducting these tests such as ECG and Echo it showed some complication in the heart. The said hospital referred him to National Heart Institute where he was admitted on 19.11.07 and advised for Open Heart Surgery. As he was insured for cashless claim with the OPs, he requested for authorization from OP No.1 for the claim on 19.11.07. OP No.1 gave an authorization for cashless claim for a sum of Rs.1.45 lacs vide its letter dated 20.11.07. When he was in critical condition, the OP No.1 sent another letter on the same day whereby it stated that the disease is congenital (CHD) and the same was excluded as per clause 4.3 of the Mediclaim Policy. He paid a bill of Rs.1.45 lacs to the National Heart Institute. He filed his claim on 27.12.07 with the OP No.1 which was rejected by the OP No.1 vide letter dated 05.02.08. The act of the OPs of repudiation of claim is not only arbitrary but amounts to deficiency in service. He sent a legal notice on 30.07.08 to the OPs but no reply was received from the OPs. The Complainant has prayed as under:-
- Direct the OPs jointly and severally to pay/reimburse a sum of Rs.1,50,000/- to the Complainant being the amount incurred by the Complainant on his treatment,
- Direct the OPs jointly and severally to pay a sum of Rs.50,000/- as compensation for causing mental agony and harassment to the Complainant in the critical stage of his illness as also interest including pendentelite interest on the sum awarded alognwith cost of this complaint.
OP No.1 has been proceeded exparte vide order dated 27.04.09 passed by our Predecessors.
In the written statement OP No.2 has inter-alia stated that the Complainant has failed to comply with the terms and conditions of the policy. Clause 4.3 of the Mediclaim Policy states that “if these diseases (other than congenital internal disease) are pre-existing at the time of proposal day will not be covered even during subsequent period of renewal….” This fact was admitted by the Complainant that “this problem though is congenital but detected only at the age of 23 year”. The mediclaim policy was issued when the Complainant had accepted the terms and conditions of the policy and OPs have rightly repudiated his claim according to the law and as per clause 4.3 the Complainant is not entitled for any relief and, hence, the complaint is liable to be dismissed with exemplary costs.
Complainant has filed rejoinder to the written statement of OP No.2 reiterating the averments made in the complaint. In the rejoinder the Complainant has stated that when the terms and conditions of the policy were not communicated to him, then there is no question of admission of the same in the absence of communication. OPs were under obligation to ensure before issuing the policy whether the person was fit to be insured or not? After issuing the policy and collecting the premium the OPs cannot turn around to say that the disease was pre-existing. It is further stated that when OP No.1 had even given an authorization for cashless claim for an amount of Rs.1.45 lacs, then OP No.2 cannot retract from the same as an afterthought by alleging that the disease is congenital. It is also not the case of the OPs that there was any suppression of the facts by the Complainant at the time of taking medi-claim policy.
Complainant has filed his own affidavit in evidence and has relied upon documents Ex. C-1 to C-12.
On the other hand, affidavit of Sh. Deepak Asstt. Manager has been filed in evidence on behalf of OP No.2.
Written arguments have been filed on behalf of the parties.
We have heard the arguments on behalf of the Complainant and have also examined the record carefully.
Admittedly the Complainant had taken a mediclaim policy through his employer (Copy annexure C-1). He was admitted in the Fortis Hospital on 27.10.07 and he was referred to the National Heart Institute for further treatment where he was admitted on 19.11.07 for conducting open heart surgery. The OP No.1 issued an authorization letter dated 20.11.07 for guaranteed payment of Rs.1,45,000/- (Copy annexure C-7). The OP No.1 again sent a letter dated 20.11.07 (copy annexure C-8) wherein they mentioned that the disease was congenital (CHD) and the same is excluded as per clause 4.3 of the mediclaim policy in question and hence the claim was not admissible. The Complainant paid the bill amount to the National Heart Institute amounting to Rs.1,45,00/- (Copy annexure C-9). The Complainant filed his claim on 27.12.2007 with the OP No.1 (copy annexure C-10). The OP No.1 repudiated the claim of the Complainant vide letter dated 05.02.08 (Copy annexure C-11) on the ground that the claim of the Complainant was not admissible as per clause 4.3 of the policy and they had closed the file as no claim. The Complainant sent a legal notice dated 30.07.08 to the OPs but no reply was received by the Complainant.
It transpires that the OP No.1 vide letter dated 20.11.07 had mentioned that an amount of Rs.1.45 lacs will be paid to the Complainant but on the same day another letter was issued by the OP No.1 to the Complainant that as per clause 4.3 of the Mediclaim Policy the Complainant was not entitled to any claim. The cashless benefit was declined to the Complainant on the basis of clause 4.3 of the terms and conditions of the insurance policy in question. OPs after receiving the claim closed the case only on the ground of exclusion clause 4.3 of the terms and conditions of the policy. To our utter surprise, OPs did not give any specific reason in their letter dated 05.02.08 for repudiating the claim of the complainant. Therefore, the suppression of the disease while taking the policy in question was/is no ground to repudiate the claim of the Complainant. We proceed on the assumption that it was a congenital disease. However, as per the case of OP-2, as made out in the reply, the complainant had told the OPs that though the disease was congenital it was detected only at the age of 23 years (at the time of surgery). Diseases are not made by the human beings. Your bodies might be having hundred of diseases. In other words, you may be suffering from hundreds of diseases. However, you do come to know about the existence of any particular disease in your body unless you get some problem or some symptoms of the disease are reflected in your body. If we accept the contention of the OPs that it was a pre-existing congenital disease, then perhaps 99% of the claim cases in health insurance policy matters would be dismissed. Was the complainant supposed to undergo the medical examination immediately after his birth or at any subsequent stage or at the time of taking the policy in question through his employer to find out whether he was suffering from any congenital disease or any other disease? If the OPs were so meticulous and particular about the disease they should have asked the complainant to undergo a detailed medical examination before issuing the policy to him through his employer but, however, they did not do so. We have observed in number of times that while giving the health insurance policies to the clients, the officers of the Insurance Companies act very liberally and do not make much inquiry and issue the policy with close eyes and close minds. They only come out of their slumber when the claims are filed before them and they start investigating into the matter. Such a practice, in our opinion, adopted by the Insurance Companies is not laudable or praiseworthy. The repudiation of the claim of the complainant in the present case was very ridiculous and funny. As stated hereinabove, in the repudiation letter dated 5.2.2008 it has been simply stated that the claim is not admissible as per the terms and conditions contained in Clause 4.3 of the policy. No mention is made therein that as the complainant was suffering from a congenital disease his claim was being rejected for that reason. Therefore, we hold that by repudiating the claim of the Complainant, the OPs committed serious deficiency in service.
Therefore we allow the complaint and direct the OP No.2 to refund a sum of Rs.1,45,000/- alongwith 6% interest p.a. from the date of filing of the complaint till the date of realization and Rs.40,000/- towards mental agony and harassment undergone by the Complainant including the cost of the litigation.
The order shall be complied within 30 days of receipt of copy of this order failing which OP No. 2 shall become liable to pay interest @ Rs. 9% per annum on the amount of Rs. 1,45,000/- from the date of filing of the complaint till its 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.
(S. S. Fonia) (Naina Bakshi) (N. K. Goel)
Member Member President
Announced on 20.07.16.
Case No. 687/08
20.7.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. OP-2 is directed to refund a sum of Rs.1,45,000/- alongwith 6% interest p.a. from the date of filing of the complaint till the date of realization and Rs.40,000/- towards mental agony and harassment undergone by the Complainant including the cost of the litigation. The order shall be complied within 30 days of receipt of copy of this order failing which OP No. 2 shall become liable to pay interest @ Rs. 9% per annum on the amount of Rs. 1,45,000/- from the date of filing of the complaint till its realization. Let the file be consigned to record room.
(S. S. Fonia) (Naina Bakshi) (N. K. Goel)
Member Member President
