Haryana

Ambala

CC/229/2017

Mrs Saroj Jain - Complainant(s)

Versus

United India Insusurance CO. - Opp.Party(s)

Veerinder Pal Singh Duggal

05 Jun 2018

ORDER

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                                      Complaint case no.        :  229 of 2017

                                                          Date of Institution         :  07.07.2017

                                                          Date of decision    :  05.06.2018

 

 

Mrs. Saroj Jain wife of Late Sh. Bhushan Kumar Jain, House No.91-A, Sector-7, HUDA, Ambala City.

……. Complainant.

 

 

1.  United India Insurance Company  Limited, Branch Office Polytechnic Chowk, Bal Bhawan Road, Ambala City- 134003 through its Branch Manager.

2.  Branch Manager, United India Insurance Company Limited, Branch Office Polytechnic Chowk, Bal Bhawan Road, Ambala City -134003.

 

 ….…. Opposite Parties.

 

Before:        Sh. D.N.Arora, President.

                   Sh. Pushpender Kumar, Member.

 

 

Present:        Sh. VPS Duggal, counsel for complainant.

 Sh.Mohinder Bindal, counsel for Ops.

 

 

ORDER:

                   In nutshell, brief facts of the present complaint is that on the persuation of the Ops, the complainant got an Individual Health Insurance Policy No.1101022817P101742844 for a period from 29.04.2017 to 28.04.2018 for a sum assured of Rs.4,00,000/- from the Ops and it is also worth to mention over here that the complainant  is a regular policy holder for the last many years. In the second week May 2017 the complainant suffered a acute pain in both Knee joints due to which the complainant was facing  difficulty in walking in general and climbing stairs in particular and approached  the Fortis Hospital Mohali  who after complete medical check up of the complainant advised immediate  replacement of both Knee joints and on the medical advise of the Doctors of Fortis Hospital the complainant was admitted  for the replacement of both Knee joints on 17.05.2017 and was discharged on 24.05.2017 after replacement of both Knee Joints. The Fortis Hospital Mohali had submitted bill no.FHM/171/Cs/00008314 dated 24.05.2017 of Rs.4,05,775/-, and when this fact was brought to the notice of the Ops, the complainant was told to pay  the amount of the bill to the Fortis Hospital and subsequently the amount  of the bill will be reimbursed to the complainant  and accordingly, the  family members of the complainant had deposited  the amount of Rs.4,05,775/- with the Fortis Hospital and got the complainant discharged. She further stated that inspite of numerous visits and requests made by the complainant, the Ops have failed to reimburse the amount of Rs.4,05,775/- to the complainant. The complainant also served a legal notice dated 05.06.2017 upon the Ops. Due to the above said act of the Ops, the complainant is suffering mental agony harassment. Hence, the present complaint.

2.               Upon notice, OPs appeared through counsel and filed written statement submitting that the entire claims under the Health Insurance Policies  are being entertained and processed by an independent and IRDA approved  agency consisting  of medical experts namely M/s Meditek(TPA) Services Ltd. on behalf of United India Insurance Company Ltd. that has been authorized  to deal with such claims  independently and the payments are made only as per their approval, recommendations and assessment and also bound with their denial of any claim. It is not out of place to mention here that the entire medi claims are independently being processed and approved by such TPA companies on behalf of all the insurance companies being team of specialized doctors to deal with such claims. In the present case also, the request under the instant policy was received by the TPA from Fortis Hospital for confirmation of policy and a claim was also lodged with them later. Since it was the 4^th year of the Health Insurance Policy wherein  as per Section 4 of the condition of policy, the replacement of joints due to degenerative condition and old age related Osteoarthritis & Osteoporosis falls under exclusion  and are not payable so after pursuing the treatment record, the said claim was denied and rejected by the said TPA with necessary information to hospital and the complainant  and even if these problems are found to be pre-existing  than such treatment is not covered throughout all the subsequent policies. It is absolutely wrong that complainant was ever assured about any re-imbursement by Ops since this claim was never entertained or dealt with by the Ops but only by the said TPA. So, there is no deficiency in service on the part of OPs and prayed for dismissal of the present complaint.

3.                To prove his version complainant tendered his affidavit as Annexure C-A along with documents as annexure C-1 and C-14 and close her evidence. On the other hand, Counsel for the OPs tendered affidavit as Annexure R/A alongwith  documents as Annexure R-1 to R-3 and close their evidence.

4.                We have heard both the counsels of the parties and carefully gone through the case file. It is not disputed that complainant has purchased an Individual Health Insurance Policy for the period from 29.04.2017 to 28.04.2017 for a sum assured of Rs.4,00,000/-. It is proved on file that complainant has also obtained the policy for the period 29.04.2014 to 28.4.2015 as per Annexure C-1, another policy for period 29.04.2015 to 28.04.2016 as per Annexure C-2 and one more policy for the period 29.04.2016 to 28.04.2017. Meaning thereby, the complainant has purchased the Health medical policy continuously for three years i.e. 2014 to 2017 and lastly he has also purchased the 4^th policy in question for the period 2017 to 2018. During policy in question Annexure C-5, the complainant was admitted in the Fortis Hospital and he was diagnosed for Osteoarthritis both knees for which bilateral total knee replacement was done on 18.05.2017 and the complainant got discharged on 24.05.2017. The complainant has incurred an amount Rs. 4,05,775/- for replacement of the both knees and he  has also submitted  all the bills to the OPs  as Annexure C-8 to C-12. But OPs have declined the above said claim of the complainant on the ground that as per the Section 4 of terms and conditions of the Policy Annexure R-1 as under:-

“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 (4.4) During the first four years of the operation of the policy, the expenses related to treatment of Joint Replacement due to Degenerative Condition and age-related Osteoarthiritis & 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 the congenital internal disease before inception of policy, the same will be treated a pre-existing”.

 

5.                          It is not disputed that during the policy period, the complainant had suffered the knee problem. In view of above said Section 4 of terms and condition of the policy, the claim is payable only if knee problem occurred after expiry of the four years. It is proved that the joint knees of the complainant ware replaced within four years of the policy and therefore, claim is not payable since both the parties are bound by terms and conditions of the policy and case of the complainant falls under exclusion Clause 4 of the policy.

6.                          In view of the above discussion, we are considered view that the Ops have rightly declined the claim of the complainant and there is no substance in the present complaint and same is liable to be dismissed. Hence, the present compliant is hereby dismissed with no order to costs. Copy of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room.

Announced on :05.06.2018

                                               

 

 

(PUSHPENDER KUMAR)                    (D.N. ARORA)

                 Member                                                         President