Chandigarh

StateCommission

A/189/2023

VIJAY MANOCHA - Complainant(s)

Versus

UNITED INDIA INSURANCE COMPANY - Opp.Party(s)

ROHIT GOSWAMI

19 Apr 2024

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

Appeal No.	:	189 of 2023
Date of Institution	:	31.07.2023
Date of Decision	:	19.04.2024

 

Vijay Manocha wife of Sh. Rajinder Maoncha, House No.278, Sector 17, Panchkula, Haryana.

.… Appellant/Complainant

V e r s u s

1. United India Insurance Company, Divisional office SCO 123-124, Madhya Marg, Sector 17, Chandigarh. Regd. & Corporate office:24, Whites road, Chennai 600014.
2. Karvat Cover More Assist Pvt. Ltd. Mistry  Bhawan, 4^th floor, next to K.C. College, Dineshaw Vacha road, Churchgate, Mumbai 400020. (complaint qua Op No.2 dismissed vide order dated 14.10.2019 being not pressed).
3. Satish Kumar Arora, agent of United India Insurance Company r/o House No.92, Sector 12-A, Panchkula.

.  … Respondents/Opposite Parties

BEFORE:              JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                             MR.RAJESH K. ARYA, MEMBER.

 

Present:-              Sh.Vishal Aggarwal, Advocate for the appellant.

                             Sh.Sukaam Gupta, Advocate for Respondent No.1 (on VC)

          Name of respondent no.2 deleted vide order dated         07.08.2023.

          Sh.Satish Kumar Arora, respondent no.3 in person.

 

PER JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

 

M.A. No.590 of 2023 (Condonation of delay):-           

                   Alongwith this appeal, this application has been filed by the applicant/appellant/complainant for condonation of delay of 14 days (as per office 15 days) in filing the same. Arguments of the contesting parties, on this application heard.

                   For the reasons stated in this application, we are of the considered view that the applicant/appellant has been able to satisfy that there had been a sufficient cause for not preferring an appeal within the stipulated period. In this view of the matter, this application stands allowed and the delay of 14 days (as per office 15 days) days in filing the appeal is condoned. Accordingly, this application stands dispose off. 

 

Order under appeal:-

2.           The  complainant-Vijay Manocha (now appellant) has filed this appeal, assailing the order dated 10.05.2023 passed by the District Consumer Disputes Redressal Commission-I, U.T., Chandigarh (in short the District Commission), whereby consumer complaint bearing no.996 of 2019 filed by him against the respondents was dismissed with no order as to cost.

 

Factual scenario:-

3.           The complainant had purchased a mediclaim health insurance policy bearing No.UI009452 valid for the period from 14.8.2015 to 13.8.2016, on making payment of premium amount of Rs.18,264/-, for coverage of Rs.3 lacs. On the allurement of opposite party no.1, the complainant ported the said policy on 31.7.2017 and submitted all the documents related to existing policy and accordingly opposite party no.1 issued the policy in question to the complainant.  The complainant got the said policy renewed from time to time  i.e. from 14.8.2018 to 13.8.2019. On 16.05.2019, the complainant  all of a sudden, suffered joint knee pain, as a result of which, on 19.05.2019, the complainant had to undergo surgery for knee replacement in Max Hospital. Due intimation to this effect was given to opposite party no.1 but her cashless claim was rejected by opposite party no.3, on 23.5.2019 on the ground that the disease for which the complainant took treatment fell under the  exclusion  clause 4.3 which says that any treatment taken due to degenerative condition and age-related Osteoarthritis and Osteoporosis, during the first policy period of 4 years/48 months i.e. starting from 14.08.2015 is not covered under the policy in question. Under those circumstances, the complainant spent Rs.4,20,000/- for hospitalization and treatment from her own pocket. Hence the consumer complaint was filed before the District Commission. 

 

Reply by opposite party no.1:-

4.           The complaint was contested by opposite party no.1 solely on the ground that since knee replacement of the complainant has taken place within a period of 48 months from the date of obtaining the policy in question, as such, it fell within the exclusion clauses 4.3 and 4.4 i.e. the period of 48 months of continuous coverage was not over yet, as per exclusion clauses.

 

Service of opposite party no.2 not pressed:-

5.           Complaint against opposite party no.2 was dismissed vide order dated 14.10.2019 as its service was not pressed by the complainant.

 

Reply by opposite party no.3:-

6.           Opposite party No.3 in its reply stated that the policy in question was issued through Security  Insurance Brokers and it has no concern with agent Security Insurance Brokers. The complainant obtained the policy in question starting from 14.8.2015 from the United India Insurance Company, and as such, question of portability on the asking of OP No.3 did not arise.  The premium of the policy was paid to opposite parties no.1 and 2 and only cashless facility has been denied by TPA i.e. Medsave Health Insurance TPA Limited with advice of submission of documents for reimbursement.

 

Rejoinder filed by the complainant:-

7. In the rejoinder filed, the complainant reiterated all the averments made in her complaint and controverted those of opposite parties no.1 & 3.
8. The contesting parties led evidence in support of their case.

 

Decision on consumer complaint:-

9. The District Commission after hearing the contesting parties and on going through the evidence on record, dismissed the consumer complaint, while holding as under:-

“………On perusal of documents, it is observed that on 19.5.2019, surgery was conducted and intimation of admission was given to OP No.1. It is also observed that the cashless was denied under exclusion clause 4.3 (illness not payable in policy for 4 years) and OP No.3 was asked to collect the expenses from the complainant.

 

We have perused the Annexure R-1, which is a policy under which the claim was raised by the complainant. Current period of insurance is seen as from 14.8.2018 to 13.8.2019. There a is clear cut mention in Annexure R-1 the policy document at page 9  that the inception date of the policy is 15.8.2015. There is a continuous coverage of approximately 3 years 9 months from the date of inception as mentioned in the current policy.  The relevant portion of the exclusion clause 4.4. of the policy is reproduced as under:-

 

“4.4. Unless the Insured has 48 months of continuous coverage, expenses related to treatment of Joint Replacement due to Degenerative Condition and age-related Osteoarthritis & Osteoporosis are not payable. If these diseases mentioned in Exclusion no.4.3 and 4.4 (other than congenital internal disease) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal subject to the pre-existing disease exclusion clause. If the insured is aware of the existence of Congenital internal disease before inception of the policy, the same will be treated as pre-existing.”

 

We are of the view that since the insured did not have continuous coverage of 48 months period for the treatment of joint replacement, hence, in view of exclusion clause 4.4., complainant is not entitled for the reimbursement of her claim.  Thus, the complainant has not been able to prove any deficiency on the part of the OPs.

 

In view of the aforesaid discussion, the present consumer complaint, being devoid of any merit, is hereby dismissed leaving the parties to bear their own costs.……….”

 

 

Submission of the contesting parties:-

10.           We have heard the contesting parties and have also gone through the entire record of this case, very carefully.
11.           Counsel for the appellant/complainant submitted that as per class 4.4 of the insurance policy the waiting period of 48 months is applicable only in case, the expenses are related to treatment taken by the insured qua joint replacement due to degenerative condition and age-related Osteoarthritis and Osteoporosis. He further submitted that, in the present case there was a sudden pain and injury in the knee of the complainant which resulted into surgery of knee replacement and there is no evidence on record to establish that it was due to degenerative condition and age-related Osteoarthritis and Osteoporosis  and as such the impugned order is not maintainable and is liable to be set aside.
12.           On the other hand counsel for respondent no.1 submitted that since knee/joint replacement of the complainant has taken place within a period of 48 months from the date of obtaining the policy in question, as such, it fell within the exclusion clauses 4.3 and 4.4 i.e. the period of 48 months of continuous coverage was not yet over as per exclusion clauses.

 

Admitted facts:-

13.           Issuance of Health First Floater Policy, Annexure C-1 in  favour of the complainant valid for the period from 14.08.2015 to 13.08.2016; payment of premium of Rs.18424/- vide receipt dated 12.08.2016, Annexure C-2; porting of the policy in question with respondent no.1 vide form, Annexure C-3; and issuance of policy, Annexure C-4 valid for the period from 14.08.2017 to 13.08.2018, are not in dispute between the contesting parties. It is also evident from the proposal form, that the complainant has declared that she is suffering from allergy and low sodium; she was admitted in hospital in July 2016;  and that she is also suffering from hypertension and cholesterol.

 

Findings/observations of this Commission:-

14.           The respondent no.1 has relied upon the terms and conditions of the insurance policy i.e. clauses 4.3 and 4.4 which are reproduced below:-

“…4.3 Unless the Insured has 24 months of continuous coverage, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases are not payable.

 

4.4 Unless the Insured has 48 months of continuous coverage, the expenses related to treatment of Joint Replacement due to Degenerative Condition and age-related Osteoarthritis & Osteoporosis are not payable. If these diseases mentioned in Exclusion no.4.3 and 4.4 (other than congenital internal disease) are pre-existing at the time of proposal they will not be covered even during Congenital Internal Diseases before inception of the policy, the same will be treated as preexisting…”

 

15.           A bare perusal of the above said clauses make it very clear that replacement of knee/joint due to Degenerative Condition and age-related Osteoarthritis & Osteoporosis are not covered under the insurance policy. Thus, relying on these clauses, the cashless claim of the complainant has been rejected specifically by stating that her case falls under exclusion clauses 4.3 and 4.4 i.e. she was suffering from Degenerative Condition and age-related Osteoarthritis & Osteoporosis.

It may be stated here that knee pain and knee replacement depends on different persons, in each age group. Sometimes, younger persons could go for knee replacement and some persons continued with the natural knee joint till their last breath. There is no record provided by the respondent no.1 if the replacement of knee of the complainant was due to Degenerative Condition and age-related Osteoarthritis & Osteoporosis, yet, its case is based on presumptions only. There cannot be any assumption and presumption, in the absence of any medical record/evidence, to say that knee replacement of the complainant was done, as she suffered from Degenerative Condition and age-related Osteoarthritis & Osteoporosis, due to her age. No medical record of any doctor saying that the complainant was suffering from Degenerative Condition and age-related Osteoarthritis & Osteoporosis has been placed on record by respondent no.1.

16.           Under above circumstances, it can easily be said that the provisions of clause 4.3 and 4.4 of the policy in question are clearly inapplicable to the present case because this is not a case of knee replacement due to Degenerative Condition and age-related Osteoarthritis & Osteoporosis. Thus, rejection of cashless claim of the appellant/ complainant by respondent no.1 was illegal and arbitrary. Our this view finds support from the observations made by the Hon’ble National Commission in the case titled as New India Assurance Co. Ltd. Vs. Dr. N.K. Bohra, 2016 (4) CPR 116  wherein it was held that if joint replacement became necessary on account of injury, it would not be a case of joint replacement due to degenerative condition. However, the District Commission fell into a grave error in dismissing the consumer complaint filed by the complainant, by holding to the contrary.
17.           Keeping in view the above discussion, we are of the considered view that the impugned order passed by the District Commission, dismissing the consumer complaint, being not based on the correct appreciation of evidence and law on the point, suffers from illegality and perversity, warranting the interference of this Commission. 

 

Decision of this Commission:-

18.           Consequently, this appeal stands allowed and the impugned order stands set aside. The consumer complaint filed by the complainant stands partly allowed. The respondent no.1/opposite party no.1 is directed as under:-
    1. To pay/reimburse the amount to the appellant/complainant, spent on her  treatment of knee replacement (to the extent of sum assured under the policy in question), alongwith interest @9% p.a. from the date of rejection of cashless claim.
    2. To pay compensation to the tune of Rs.2 lacs to the appellant/complainant, for causing her mental agony and harassment and also deficiency in providing service, negligence and adoption of unfair trade practice by rejecting her genuine cashless claim.
    3. To pay cost of litigation to the tune of Rs.35,000/- to the appellant/complainant.
    4. This order be complied within a period of 45 days from the date of receipt of a certified copy thereof, failing which the awarded amounts shall entail interest @12% p.a. from the date of default till realization.
19.           Complaint against opposite parties no.2 and 3/respondents no.2 and 3, is dismissed with no order as to cost.
20.           Pending application(s) if any, stand disposed of, accordingly.
21.           Certified copies of this order be sent to the parties, free of charge and one copy thereof be placed in the file of District Commission, forthwith.
22.           The concerned file be consigned to Record Room, after completion.

Pronounced

19.04.2024

 

Sd/-

[JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

 

Sd/-

 (RAJESH K. ARYA)

MEMBER

Rg.