Delhi

East Delhi

CC/22/2016

HOSAM SHARMA - Complainant(s)

Versus

UNIVERSAL GEN .INS - Opp.Party(s)

31 May 2019

ORDER

            DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.           22/2016

                                                                                                   Date of Institution                19/01/2016

                                                                                                   Order reserved on                31/05/2019       

                                                                                                   Date of Order                        06/06/2019                                                                                    

 

In matter of

Mr Horam Sharma    

R/o- 131B, FF, Rani Garden

Shastri Nagar, Delhi 110031...……………...…………….Complainant

                             

                                      Vs

 

1-M/s The Manager

Universal General Insurance Co. Ltd. 

Express IT Park, Plot no. EL 94,  

TTC Industrial Area, Navi Mumbai 400710

 

2-M/s The Manager

E–Meditek TPA Services Ltd.

Plot no. 577, Udhyog Vihar

Phase  V, Gurgaon, Haryana 122016

 

3-Indian Overseas Bank

Vanasthali Branch I.P. Extn

Patpargunj, Delhi 110092..…..……………..….…………..Opponents

 

Complainant  advocate                          Md. Namrata Joshi  

Opponent  advocate                               Mr.B S Arora & Asso.               

 

Quorum                     Sh Sukhdev  Singh        President

                                    Dr P N Tiwari                 Member

                                    Mrs Harpreet Kaur       Member                                                                                             

 

Order by Dr P N Tiwari  Member  

Brief Facts of the case                                                                                                 

Complainant purchased Family Floater Mediclaim Policy vide policy no. 2817/529294200/00/000 having tenure from 15/02/2013 to 14/02/2014 (Ex CW/1) having sum insured Rs 50,000/-for himself and nominee his wife who was also covered. Complainant paid after paying premium amount Rs 1566/-to OP1 / M/s Universal Sampo General Insurance Co. Ltd through OP3 / Indian Overseas Bank as complainant had saving account with OP3. The policy was renewed for 2014 to 2015. Complainant enhanced his sum insured amount to Rs One Lacs in 2015 to 2016 policy (Ex CW/2&3).

Complainant’s wife had pain in abdomen on 05/07/2015 so was admitted at Goyal Hospital at Krishna Nagar, Delhi and discharged on 12/07/2015. As cashless was denied by OP2 as cashless claim note showed CAD, Diabetic Nephropathy, with ARF and Azotonia in case of HTN and Hypothyroidism, so paid hospital bill Rs 75489/-and submitted claim for reimbursement to OP2. Claim was not passed even following OP2 office, but later claim was rejected on the ground of PED as DM2, HTN Diabetic Nephropathy, ARF & Hyperthyroidism. Seeing deficient services of OP2, filed this complaint and claimed treatment bill Rs 75489/- with compensation Rs 10 Lacs for mental harassment.

In written statement OP1/Universal Sompo General Insu. Co. denied all allegations of deficiency and unfair trade practice adopted. It was admitted that complainant remained admitted from 07/07/2015 to 12/07/2015 and as per hospital request cashless showed preliminary diagnosis of Diabetic Nephropathy, CAD, DM2, HTN and Hypothyroidism since 2-3 years as per discharge summary of the treating hospital. The cashless was denied, so complainant claim was scrutinized and a hand written note was taken during investigation. Based on own declaration by complainant, claim was repudiated. It was stated that complainant did not disclose correct and true facts in policy proposal form. So repudiation was justified for non disclosure of material facts. Hence, prayed for dismissal of complaint.  

OP2/TPA submitted that complainant had no contract with OP2, whereas they were only claim processer on the behalf of OP1The mentioned ailments in the discharge summary were of long duration and complainant had knowledge of her ailments and intentionally hidden her ailments. All these ailments were payable after 48 months of continuity of policy without any break (Ex OPW2/A&B). Based on the self declaration by the insured/complainant, claim was rejected. It was also stated that the claim year policy was in third year and complainant had enhanced his sum insured from Rs 50,000/- to One Lacs for the year 2015 to 2016. Hence, no claim could be entertained for pre existing ailments and final claim was rightly rejected vide rejection letter dated 14/09/2015. As per policy terms and conditions under exclusion definition, all pre existing diseases were payable after 48 months of policy tenure without break (Anne.OPW2/1).

OP3/Indian Overseas Bank did not file written statement after taking complaint copy. Despite of personal appearance of OP3, was proceeded Ex-pate.

Complainant submitted rejoinder to written statement of OP1&2 and denied all replies of OP. He stated that his facts of complaints were correct and true and had mediclaim policy since Feb. 2013 and the present claim was in third year. All the ailments were diagnosed by the treating doctor at the time of admission and his wife had never suffered with any ailments. OP did not explain about pre existing diseases at the time of taking policy. He also submitted evidences through his own affidavit where he affirmed on oath that all the facts were correct and true. He relied on policy copies (Ex CW1/1 to 3), discharge summary (Ex CW1/4) and claim form (Ex CW1/5). Despite of submitting all the required documents, OP did not consider his claim and finally rejected genuine claim. So OP be directed to process the claim as per policy terms and conditions.

OP also submitted their evidence on affidavit through Mr Piyush Shankar, Assist. General Manager at OP1 office and affirmed on oath that all the procedures adopted by them were as per the IRDA guidelines and policy terms conditions. OP relied on claim year policy where sum insured was enhanced from 50,000/-to One Lacs and claim was reported for all chronic ailments which falls under pre existing ailments (Ex OPW1/1&2). Rejection was timely intimated to the complainant (Ex OPW1/3). It was submitted that evidence of pre existing was complainant’s own hand writing note. Hence there was neither deficiency in services nor unfair trade practice was adopted so false complaint may be dismissed. 

 Both the parties submitted written arguments and taken on record. 

Arguments were heard from both the parties. After perusal of materials on record, order was reserved.

After scrutinizing facts and evidences of both the parties, claim was rejected by OP1 under Pre Existing clause which means any condition, ailment or injury or related condition/s for which signs or symptoms and / or where diagnosis and /or received medical advice / treatment within 48 months prior to the first policy issued by insurer. Here in this case, claim was reported in third year policy tenure 2015-2016 when complainant had enhanced to One lacs which cannot be applicable for claim. Also neither complainant nor OP had filed policy terms and conditions and policy proposal form on record to see intentional hiding material facts by the complainant. Secondly OP1 submitted that rejection was done on the basis of discharge summary noting which cannot be justified until OP discharges its onus of pre existing ailments were present that she was ever admitted in the hospital prior to taking policy. It is true that enhanced sum insured amount to Rs One Lacs cannot be considered for current year policy claim except in accident cases.

All the disease mentioned in discharge summary states that DM2, Hypothyroidism and Hypertension had since 2-3 years and present complications as Diabetic Nephropathy and Hypothyroidism cannot occur in 2-3 years, but ARF and Azotonia were certainly as acute complications of DM2 and HTN. As OP2 did not investigate properly before rejecting the claim in pre existing clause certainly falls in deficiency of services. OP2 did not produce any concrete pre existing evidence prior to inception of policy. OP2 is a TPA of OP1, both had deficiency in their services. As complainant had sum insured Rs 50,000/- in first two years, so we direct OP1 to clear the claim to sum insured within 30 days from the receiving of order copy. We also award compensation of Rs 5000/-and litigation charges Rs 2000/- to be paid in time essence. If OP1 fails to comply the award in time then complainant shall recover entire amount with 7% interest from the date of order till paid. OP3 being a performa party and had only facilitated bank floater mediclaim insurance from OP1, has no role in the complaint so no liability can be fastened on OP3. 

First free copy of this order be sent to the parties under Regulation 18(6) of the Consumer Protection Regulations, 2005 (in short CPR) and file be consigned to Record Room under Regulation 20(1) of the CPR.  

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                      

                                                Shri  Sukhdev Singh  President