DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No. 564/2010
Ms. Kalpana Kapoor,
W/o Shri Prakash Vir Kapoor
House No.63, Gandhi Gali,
Fatehpuri, Delhi-110006 ….Complainant
Versus
- United India Insurance Company Limited
Division at Office No.8,
503-504 Kailash Building
5th Floor, Kasturba Gandhi Marg,
New Delhi.
- United India Insurance Company Limited
Division at Office 010500
64 Armenian Street
Chennai-600001
- India Bank
Pragati House, Ground Floor,
47 & 48, Nehru Place,
New Delhi-110019. ….Opposite Parties
Date of Institution : 2010 Date of Order : 02.01.2019
Coram:
Sh. R.S. Bagri, President
Ms. Naina Bakshi, Member
Ms. Kiran Kaushal, Member
ORDER
Member - Kiran Kaushal
Briefly put the case of the complainant is:-
- The complainant Ms. Kalpana Kapoor had purchased Arogya Raksha Medi Claim Policy offered by Indian Bank (OP-3) under arrangement with United India Insurance Company Ltd.(OP-1). The mediclaim policy was for the period from 16.04.2009 to 15.04.2010 for the insured amount of Rs.2,00,000/- on payment of premium amount of Rs.4,340/-. It is averred that the complainant was insured and informed on 11.05.2009 about the policy number under Indian Bank Arogya Raksha Plan ‘B’ for mediclaim policy. It is next stated that policy containing detailed terms and conditions or guide book was not issued and sent to the complainant. Vide letter dated 26.02.2010, the complainant was advised by Indian Bank to renew the mediclaim policy and the policy was renewed upto 15.04.2011.
- It is next stated that the complainant fell ill and was admitted in Indraprastha Apollo Hospital on 11.04.2010 where she was operated on 12.04.2010 and discharged on 16.04.2010. The complainant paid a bill of Rs.1,02,375/- including pre and post expenditure on operation. The complainant informed the OP and their agent TTK Health Care Private Ltd. (OP-2) about the illness.
- It is next stated that on 22.04.2010, the complainant submitted all the requisite documents along with the claim form to OP’s agent through registered letter. After lapse of about one month, the complainant was informed about the claim being repudiated for following reason:
“On scrutiny of the claim documents submitted, the claim is medically repudiated under the clause 4.3 as this illness is not payable in the first year of the policy”.
- It is next averred that the complainant was shocked to know about the claim being repudiated as it was the first time that the complainant was not hearing about clause 4.3 as neither any guide book nor the terms and conditions of the insurance policy were provided to the complainant by the OPs. Aggrieved by the repudiation of valid claim the complainant approached the Forum with the prayer to direct the OP to pay the entire medical claim bills amounting Rs.1,02,375/- and to grant compensation of Rs.2,00,000/- for mental agony and harassment. It is further prayed to grant Rs.25,000/- towards litigation charges and to provide interest on the medical claim bills amount from the date of claim to the date of payment.
2. Notice was duly served to the OPs. Someone on behalf of OP-1 and OP-2 put in appearance but failed to file written statement. Hence, OP-1 and OP-2 were proceeded exparte on 14.11.2011.
3. OP-3 in the written statement has inter-alia stated that the mediclaim insurance cover is provided in the said scheme by OP-1 and in the event of any claim being lodged, the same is processed by the TPA that is OP-2. Therefore, OP-1 and OP-2 are the necessary parties in the present complaint. It is also stated that under the said scheme, account holders of the Indian Bank who are in the age group of 18-65 years are eligible to apply and the health insurance cover, which is available to the said account holders for a very low premium, which is far below the normal premium if the policy is taken individually by the account holder, directly from the Insurance Company.
4. It is further stated by the OP-3 that as per the agreement between Indian Bank (OP_3) and Insurance Company (OP-1), OP-3 in case of claim will not undertake any responsibility or will not accept any correspondence and the same will have to be perused with the insurance company/ specified TPA only. The said agreement had been read and accepted by the complainant. Hence,OP-3 is not liable to pay the complainant as the contract is between the complainant and OP-1.
5. Complainant has filed rejoinder reiterating the averments made in the complaint. Complainant has filed his evidence by way of affidavit. On the other hand, affidavit of Shri V.Gopal Assistant General Manager of OP-3 has been filed in evidence.
6. Written arguments have been filed on behalf of the complainant and OP-3.
7. Arguments on behalf of the complainant and OP-3 are heard and material placed on record is perused.
8. Averments made in the complaint and evidence led by the complainant have remained uncontroverted and unchallenged qua OP-1 and OP-2. Therefore, there is no reason to disbelieve the version of the complainant.
9. Admittedly the complainant purchased Arogya Raksha Medi Claim Policy offered by Indian Bank (OP-3) under arrangement with United India Insurance Company Ltd.(OP-1) wherein the complainant paid the premium amount of Rs.4,340/- for the period of one year from 16.04.2009 to 15.04.2010. The said policy was further renewed for period of 16.04.2010 to 15.04.2011. The insured amount for the said policy was Rs.2,00,000/-.
10. The complainant fell ill and was operated upon in Indraprastha Apollo Hospital on 11.04.2010 and was discharged on 16.04.2010. Discharge summary is enclosed as Annexure-C. The complainant states that the he paid bill of Rs.1,02,375/- for the medical expenses. Hence, complainant filed the insurance claim which was repudiated stating that under clause 4.3 the illness that complainant was suffering from is not payable in the first year of the policy.
11. The main contention of the complainant is that the complainant was neither informed about the terms and conditions governing the policy nor any guide book or terms and conditions were provided to the complainant. Hence, the clause 4.3 under which the claim is repudiated was unknown to her.
12. On perusal of the record, it is observed that on the back side of the certificate provided to the complainant the exclusion clause is clearly mentioned under the summary of terms and conditions governing Arogya Raksha Policies. Further it is mentioned that “for full details please call for the Detailed Terms and Conditions from the Branch”. Therefore, we are of the considered opinion that the complainant cannot deny that she was unaware or did not have knowledge regarding the terms and conditions governing the policy. For ready reference the above said clause is reproduced here asunder:-
4. “Expenses on treatment of certain disease such as Cataract, Benign, Prostatic, Hyperthrophy, Hysterectomy for Menorrhagia, or Fibromyoma, Hernia, Hydrocele, Congenital Internal disease, Fistula in annus, piles, Simusitis and related disorders, Gall Bladder Stone Removal, Gout & Rheumatism, Calculus Disease, Joint Replacement etc. are payable only after the first renewal of Arogya Raksha Policy i.e. from the second policy-year onwards.”
13. It is further noticed that as per the said clause, the complainant was entitled for the claim after the first renewal of Arogya Raksha Policy i.e. from the second policy year onwards.
14. It is pertinent to mention here that the first policy-year ended on 15.04.2010 and the complainant was admitted to the hospital on 11.04.2010 and discharged on 16.04.2010. Complainant thus, suffered illness and incurred expenses on treatment during the validity of first year of policy. Such a claim is barred as per clause 4.3 of the policy. Renewal of policy on the day of discharge would not bring the claim within the scope of renewed policy.
15. Hence, the Forum is of the considered opinion that OP-1 has rightly repudiated the claim and no deficiency of service is established against the OPs. Therefore, the complaint is dismissed with no order as to costs.
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 02.01.2019.
