DISTRICT CONSUMER DISPUTE REDRESSAL FORUM : NORTH-WEST
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 229/2014
D.No._____________________ Dated: ________________
IN THE MATTER OF:
AZAD SINGH S/o LATE SH. TEK CHAND,
R/o H. No. 1688, OPP.-METRO PILLAR No.541,
NEAR POOJA NAMKIN, VILL. & P.O.-MUNDKA,
NEW DELHI-110041. … COMPLAINANT
Versus
UNITED INDIA INSURANCE CO. LTD.,
D.O. No. 29, PLOT No. 36, SATYA BHAWAN,
2ND FLOOR, COMMUNITY CENTRE,
WAZIRPUR INDL. AREA, RING ROAD,
NEW DELHI-110052. … OPPOSITE PARTY
CORAM :SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 14.02.2014
Date of decision: 06.07.2018
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against the OP under Section 12 of the Consumer Protection Act, 1986 therebyalleging that the complainanttook a Mediclaim ‘Individual Health Insurance Policy’ vide policy no. 222700/48/12/09/00002336 forhimself as well as his wife Smt. RajpatiKataria from OP for the period from 24.10.2012 to 23.10.2013 and the said policy is
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renewed from time to time and at present also, the same policy is existing and earlier the complainant and his wife took the Mediclaim policy from The New India Assurance Co. Ltd. since year-2001 upto 2011 and has been paying the premium against the policy from time to time. However, in the year-2011, as the complainant wanted to have the medical policy from OP and the complainant visited the office of OP and contacted one Sh. Wadhwa, D.O. and apprised him about his earlier Mediclaim policy since the year-2001 as well as about his intention of continuing with the same policy on the same terms & conditions arising out of the policy. Thereafter, seeing the record of the earlier policy of the complainant held with The New India Assurance Co. Ltd., Sh. Wadhwa assured the complainant that if the complainant takes the policy from OP and the terms & conditions will remain the same and he will get the benefit of the earlier policy and that they will convert the same into the present policy as it is their internal matter and the complainant took the Mediclaim policy under the cover name ‘Individaul Health Insurance Policy’ for himself and his wife and paid the requisite premium of Rs.10,688/- on 07.10.2011 against receipt which was duly acknowledged by OP. The complainant further alleged that OP was required to start the policy of the complainant from 07.10.2011 itself i.e. on which date the premium was paid by the complainant and OP instead of
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commencing the Mediclaim policy of OP from 07.10.2011 continued the earlier policy of the complainant w.e.f. 24.10.2011 and all this was done by OP of its own on the pretext that by doing so and the policy of the complainant will be deemed to be continued with his earlier policy. The complainant further alleged that in the month of May/June, 2013, the wife of the complainant started some eye problem and she was facing vision problem and the wife of the complainant was taken to Vasan Eye Care Hospital, Janakpuri, New Delhi on 03.06.2013 and upon checking the doctors diagnosed that the wife of the complainant is suffering with Eye Ailment and Cataract Surgery required and the complainant intimated the factum of proposed eye ailment of his wife and surgery to be conducted in this regard on 04.06.2013 to the T.P.A., Medi Assist of OP and they suggested the complainant to undergo the operation and submit all the papers with them to enable to make the payment thereof. Thereafter, on the advice of the doctors of the hospital, the wife of the complainant undergone an Eye Cataract Surgery on 06.06.2013 and all the payment of hospital charges and other bills were paid by the complainant which were to the tune of Rs.20,332/- and after the eye operation of the wife of the complainant on 07.06.2013, the complainant submitted the original bills of Rs.20,332/- with the relevant medical papers with OP/TPA and also filled up the claim form. On 21.06.2013, the officials of the
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TPA Medi Assist of OP asked the complainant to produce some other documents such as Lab Investigation Report dated 03.06.2013 with doctor’s prescription advising for investigation, original numbered bill receipt of payment made to the hospital, previous years policy papers of the year-2010. The complainant further alleged that the complainant also submitted/handed over all such papers with OP/TPA Medi Assist on 22.06.2013 and at that time also, the complainant was also assured by the TPA officials of OP that the claim of the complainant would be shortly settled and the payment will be made in the account of the complainant and the complainant was shocked and surprised the TPA of OP illegally repudiated the claim of the complainant on the false and flimsy ground on the pretext that since the policy of the complainant is less than 2 years, so the ailment of the wife of the complainant does not cover under the policy. The complainant further alleged that the complainant even after receipt of information regarding repudiation of his genuine claim made various personal visits to the office of OP as well as wrote various letters/correspondence including letter dated 29.06.2013 & 05.07.2013 to OP and other offices of OP requesting them to reconsider the claim of the complainant and to make the payment of his claim and till more than 7 months have passed but OP till date not cleared the claim of the complainant nor OP have sent any intimation to the complainant regarding the fate
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of his claim lodged with OP and refusal by the OP to reject the claim of the complainant amounts to deficiency in service.
2. On these allegations the complainant has filed the complaint praying for direction to OP to refund the amount of Rs.20,332/- being the expenditure incurred by the complainant for his wife treatment aswell as compensation of Rs.1 lakh for causing harassment, mental agony and tension and also sought a sum of Rs.25,000/- towards litigation cost.
3. OP has been contesting the complaint and has filed written statement. In the written statement, OP submitted that the complaint is not maintainable and liable to be dismissed. OP further submitted that as per the documents submitted by the complainant and terms & conditions of the insurance policy, the claim of the complainant was found not admissible as per section 4.3 of the terms & conditions of the insurance policy which excludes the payment of claim in respect of mentioned disease in first 2 years of commencement of the insurance policy with OP and past 2 years policy from the same company are required from OP taken by the complainant first time for a period from 24.10.2011 to 23.10.2012 as fresh case and claim was found inadmissible as condition of continuous policy for 2 years with OP not fulfilled. OP further submitted that the impugned claim is for hospitalization from 03.06.2013 to 06.06.2013 whereas the policy commenced w.e.f.
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24.10.2011 i.e. the hospitalization is within 2 years of the commencement of the insurance policy with OP and hence OP has rightly repudiated the claim and there is no deficiency in service on the part of OP.
4. The complainant filed replication and denied the submissions of the OP and submitted that the OP has taken a false plea.
5. In order to prove his case the complainant filed his affidavit in evidence and has also filed written submissions. The complainant also placed on record copies of policiesfor the period from 24.10.2001 to 23.10.2002, 24.10.2002 to 23.10.2003, 24.10.2003 to 23.10.2004, 24.10.2004 to 23.10.2005, 24.10.2005 to 23.10.2006, 24.10.2006 to 23.10.2007, 24.10.2007 to 23.10.2008, 24.10.2008 to 23.10.2009, 24.10.2009 to 23.10.2010 & 24.10.2010 to 23.10.2011 issued by The New India Assurance Co. Ltd., policies for the period from 24.10.2011 to 23.10.2012 &24.10.2012 to 23.10.2013 issued by OP. The complainant also placed copies of medical cards issued by TPA Medi Assist India Pvt. Ltd., copies of e-mail communication between the parties & copy of letter dated 05.07.2013 sent by the complainant to OP.
6. On the other hand, Sh. Veerbhan, Senior Divisional Manager of OP filed his affidavit in evidence and OP has also filed written arguments.
7. This forum has considered the case of the complainant as well as
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OP in the light of evidence and documents placed on record by the complainant. The documents and evidence of the parties shows that the wife of the complainant was diagnosed as suffering from Eye Ailment and Cataract surgery required by the hospital i.e. Vasan Eye Care Hospital at JanakPuri, New Delhi on 03.06.2013 and thereafter on the advise of the doctors of the said hospital she under went Eye Cataract surgery on 06.06.2013 and all the hospital charges & bills to the tune of Rs.20,332/- were paid by the complainant and as already discussed, the OP has not disputed this fact as well as the fact that the complainant has taken a Mediclaim Policy since the year 2001 though with a different company. It is also not disputed by the OP that the wife of the complainant namely RajpatiKatariaunderwent Eye Cataract surgery on 06.06.2013. Thus, the OP is not justified in contending that the complainant’s claim is covered under exclusion clause 4.3. This Forum is of opinion that the OP ought to have considered the fact that the complainant and his wifeare insured since the year 2001 and as such the ailment/disease of the wife of the complainant is not covered under clause 4.3 of the policy and OP has wrongly denied the claim. Thus, OP is held guilty of deficiency in service.
8. Thus, holding guilty for the same, we direct the OP:
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amount of medical expenses for hospitalization, purchase ofmedicines etc. on the treatment of his wife.
ii) To pay to the complainant an amount of Rs.15,000/- for harassment and mental agony suffered.
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9. The above amount shall be paid by the OP to the complainant within 30 days from the date of receiving of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of receiving of this order till the date of payment. If OP fails to comply with the order within 30 days from the date of receiving of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.
10. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 6thday of July, 2018.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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