DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.64/2011
Sh. Om Prakash Yadav
S/o late Sh. Fateh Singh
DSOI, Dhaula Kuan,
New Delhi-110010 ….Complainant
Versus
1. United India Insurance Co.
D.O. No.-1, 54, Janpath,
New Delhi-110001
2. Med Save Health Care Limited
F-701 A, Lado Sarai, Behind Golf Course,
New Delhi-110030
3. M/s Artemis Medicare Services Pvt. Ltd.
Sector-51, Gurgaon-122001 ….Opposite Parties
Date of Institution : 10.02.2011 Date of Order : 25.11.2017
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
Case of the Complainant, in nutshell, is that he had obtained medical cashless policy bearing No. 040100/48/09/14/00000630 valid for the period 06.05.09 to 05.05.10 from OP No.1 for himself and his wife. He was admitted in OP No.3 hospital on 13.07.09 who sent duly filled pre-authorization form for hospitalization to OP No.1. However, the OP No.2, the TPA of OP No.1 denied the cashless facility. The Complainant incurred expenses of Rs.75762.84p on his treatment and the original papers were submitted to the OP No.2 but despite lapse of more than 1 year the amount has not been reimbursed to the Complainant so far inspite of making written requests, notice and reminders. Hence pleading deficiency in service on the part of the OPs the Complainant has filed the present complaint for directing the OPs to reimburse the amount of Rs.75762.84p towards the medical expenses alongwith 18% interest from the date of filing of the claim with OP No.2, to pay Rs.3 lacs as compensation for humiliation and harassment caused to him and also to pay Rs.50,000/- towards cost of litigation.
In its reply OP No.1 has inter-alia stated that the OP No.3 had issued discharge summary of the Complainant wherein the final diagnosis was shown to be Hydrocephalus, early cardiomyopathy and in the claim form submitted by the Complainant it was mentioned at Sr. No.4 that the nature of illness of the complainant was diagnosed as Early Cardiomyopathy Hydrocepholos. Vide letter dated 22.12.10 the OP No.2 intimated OP No.1 that the case was investigated by OP No.2 and as per the IPD records “ the presenting complaints since two months which falls in the first 30 days of inception of policy.” As per exclusion clause 4.2 of the policy the Complainant had contracted the diseases during the first 30 days from the commencement date of policy and hence his claim was not admissible under the exclusion clause 4.2. The Complainant was accordingly informed about the rejection of his claim by OP No.1 vide letter dated 15.02.11. It is stated that there was violation of the terms and conditions of the policy and hence the claim was repudiated. It is prayed that the complaint be dismissed.
OP No.2 is exparte.
OP No.3 has filed written statement and has denied the averments made in the complaint.
In the rejoinder to the reply of OP No. 1 the Complainant has stated that the policy in question started from 06.05.09 while the Complainant was diagnosed with his ailment on 25.06.09 and hence exclusion clause 4.2 did not apply to his case.
Rejoinder to the written statement of OP No.3 is also filed.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. Shyam Singh, Sr. Div. Manager has been filed on behalf of the OP No.1.
Thereafter, OP No. 3 has also been proceeded exparte.
Written arguments have been filed on behalf of the parties.
None has appeared on behalf of the parties to advance arguments.
The OP No.1 has not marked Exhibit Nos. on the documents as per the Exhibit Nos. given to them in affidavit of the OP No.1’s witness.
We mark the copy of the insurance policy containing the terms & conditions as Mark A. We shall discus it at a later stage. We mark the copy of claim form (hospitalization & Domiciliary Hospitalization Benefit Policy) as Mark B wherein the disease/illness of the complainant has been mentioned as Early Cardiomyopathy Hydrocepholos and the date of injury sustained as 25.06.09. We mark the copy of the discharge summary issued by the OP No.3 to the complainant as Mark C which shows that the Complainant had visited the OP No.3 hospital on 13.07.09 and operated on 14.07.09 and discharged on 16.07.09. He was admitted in the OP No.3 hospital with the following “presenting complains”:-
“Presenting Complaints : Headache x 20 days
Vertigo and Vomitings x 10 days
History : Pt was admitted with h/o persistent
headache x 20 days and vertigo and
tinnitus for last 10 days. Associated
with nausea or vomiting. Improved with
acetazolamide.”
Thus, even as per the claim made in the claim form (copy Mark B) the illness was deducted on 25.06.09. Admittedly, the policy in question had been issued in favour of the Complainant and his wife by OP No.1 on 06.05.09 meaning thereby the policy in question had come into effect on 06.05.09. Clause 4 of the policy in question deals with exclusion. Claus 4.2 is material. It reads as under:-
“4 Exclusion
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:
4.1 ……………….
4.2 Any disease other than those stated in clause 4.3, contracted by the insured person during the first 30 days from the commencement date of the policy, condition 4.2 shall not however, apply in case of the insured person having been covered under this Scheme or Group Insurance Scheme with any of Indian Insurance Companies for a continuous period preceding 12 months without any break.”
Therefore, in order to bring the case of the Complainant within the said exclusion clause 4.2 the OP No.1 and OP No.2 had the burden to prove that the Complainant had contracted the disease in question within 30 days from the date of commencement of the policy. Copy of the repudiation letter is marked as Mark D. Vide this letter the claim of the Complainant had been dismissed on the following grounds:-
…We got this case investigated (investigation report is enclosed). As per the IPD records, the presenting complaints since 2 months which falls in the first 30 days of inception of policy. As per exclusion clause no. 4.2 of the policy any disease contracted by the insured person during the first 30 days from the commencement date of policy is excluded from the scope of policy. Hence, this claim is not admissible and we intend to repudiate this claim under the exclusion clause no.4.2 of the policy…”
We must say at once that there is no iota of evidence on the record which may even show that the Complainant had been suffering from the said disease for the last two months or he had contracted the said disease within the first 30 days of the inception of the policy. Even if the disease was detected on 25.06.09 it was beyond the period of 30 days as provided under the exclusion clause 4.2. Therefore, OP No.1 was not at all justified in repudiating the claim of the Complainant.
In view of the above discussion, we hold the OP No.1 guilty of deficiency in service while rejecting the claim in question of the complainant. We, therefore, allow the complaint and direct the OP No.1 to pay Rs.75763/- (round figure) along with interest @ 6% p.a. from the date of filing of the complaint till realization towards the claim in question and Rs.30,000/- in lumpsum towards compensation for mental agony and harassment and cost of litigation to the complainant within one month from the date of receipt of copy of this order failing which OP No.1 shall become liable to pay the above stated amount of Rs.75763/- along with interest @ 9% p.a. from the date of filing of the complaint 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 25.11.17
