Chandigarh

DF-II

CC/637/2020

Vishal Pahariya - Complainant(s)

Versus

Universal Sompo General Insurance Co. Ltd. - Opp.Party(s)

Surjeet Bhadu Adv

28 Feb 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	637 of 2020
Date  of  Institution	:	01.12.2020
Date   of   Decision	:	28.02.2022

 

 

 

 

 

Vishal Pahariya s/o Ramesh Jain, R/o H.No.3014, Sector 27-D, Chandigarh.  

 

             …..Complainant

 

Versus

 

1]  Universal Sompo General Insurance Company Ltd., Plot No.EL-94, KLS Tower, TTC Industrial Area, MIDC, Mahape, Navi Mumbai 400710, through its MD and CEO Sh.Rajiv Kumar.

 

2]  Universal Sompo General Insurance Company Limited, 1^st Floor, SCO-9, Sector 10, Panchkula 134109, Haryana through its Zonal Manager Amrish Kumar Singh

 

3]  M/s Edelweiss Gallagher Insurance Brokers Ltd. (Formerly M/s Edelweiss Insurance Broker Ltd.) (CIN:U72200MH2000PLC124096) having its office at 2^nd Floor, tower 3 Wing B, Kohinoor City Mall, Kohinoor City, Kirol Road, Kurla (W), Mumbai 400070, through its Director Sh.Anurag Madan (DIN: 00010324)

 

4]  Ericson Insurance TPA Pvt. Ltd., 308, Swastik Chamber, Swastik Park, Chembur, Mumbai 400071, Maharastra, through its MD and CEO Dr.Krishna Jaiswal

 

5]  M/s Jain International Organisation, through its Chairman/Presiding Officer and having its Office at Panchsheel Plaza, A Wing Basement, Near Dharam Palace, Hughes Road, Mumbai, Maharashtra 400007

 

    ….. Opposite Parties

 

 

BEFORE:  SMT.PRITI MALHOTRA        PRESIDING MEMBER 

                    SH.B.M.SHARMA                 MEMBER

                               

For Complainant : Sh.Surjeet Bhadu, Advocates

For OPs         : Sh.Sahil Abhi, Adv. for OPs No.1 & 2

                   Sh.Sanjeev Gupta, Adv. for OP No.3.

                   OP No.4 exparte

                   Sh.Amandeep Singh, Adv. for OP No.5.

 

 

PER PRITI MALHOTRA, PRESIDING MEMBER

         Concisely put, the complainant took Mediclaim Insurance Company from OP No.1 & 2 Company, through OP No.5-Master Policyholder, vide Master Policy No.2839/60615412/00/000, for sum insured of Rs.Ten Lakh, by paying premium of Rs.26000/- valid from 31.10.2018 to 30.10.2019 and renewed further from 31.10.2019 to 30.10.2020.  Unfortunately, the complainant fell sick during insured period on 12.12.2019 and was as such admitted in N.M.Virani Wockhardt Hospital, Gujarat, where he was diagnosed as suffering from Inflammatory Bowel Disease (IBD), Acute Enteritis, Severe Anemiaand Osteomalacia.  Accordingly, a pre-authorization request was moved on 12.12.2019 for cashless hospitalization for medical insurance policy, which was approved by OP No.4 vide letter dated 13.12.2019 for initial amount of Rs.One Lakh (Ann.C-5).  It is averred that the required document which were asked for by OP No.4 were duly sent to it on 13.12.2019 along with filled up claim form ‘C’ for cashless facility.  It is pleaded that the complainant was discharged on 13.12.2019 and the hospital raised final medical bill of Rs.2,97,000/- after giving discount of Rs.70,710/- (Ann.C-8 & C-9).  However, the OP No.4 denied the cashless access and did not pay anything to the hospital, as such the complainant had paid the full bill amount of Rs.2,97,000/- to the Hospital vide receipt Ann.C-13.

         It is submitted that the OP Company has wrongly repudiated the genuine claim of the complainant saying that the patient is having ailment which has genetic etiology vide Ann.C-10, whereas there is no exclusion in the policy for ailment which has genetic etiology.  Hence, this complaint has been filed alleging the said repudiation as illegal and a deficient act on the part of OP Insurance Company.

 

2]       The OPs No.1 & 2 have filed reply and while admitting the factual matrix of the case, stated that as per past history, the complainant was known case of IBD (Inflammatory Bowel Disease) under regular treatment and with previous history of total protocolectomy with ILEO anal pouch Anastomosis (IPAA) in 2004 and the present admission of patient was for sub acute intestinal obstruction and was managed conservatively. It is stated that a cashless authorization was received from treating hospital of complainant by OP No.4 which was duly processed and after due application of mind by doctors of OP No.4, it was denied vide letter dated 14.12.2019.  It is denied that as per terms of policy, the complainant was entitled to 75% of amount if found eligible.  It is submitted that complainant is not entitled to any amount under policy for the disease for which claim is lodged as he is having ailment which is genetic etiology which is not covered as per terms & conditions of policy.  It is submitted that the claim has been rejected in accordance with terms & conditions of the policy which are legal valid and enforceable under the eyes of law. Denying other allegations, the OP No.1 & 2 have prayed for dismissal of the complaint.

         OP No.3 also filed reply stating that answering OP has acted only as a facilitator for liasioning of claims of customers of OP No.1, 2 & OP No.5 and that too without any consideration.  It is submitted that the insurance company/companies severally and directly decides the claims of the customers in pursuance of the terms & conditions of the concerned insurance policy and it is the discretion only of the concerned insurance company to either admit or deny any claim based on merits of the claim.  It is submitted that OP No.3 has fulfilled its duty as insurance broker and that too without any consideration from the complainant.  It is pleaded that OP No.3 has no role in rejecting or approving the claim.  Denying other allegations, OP No.3 has prayed for dismissal of the complaint qua it. 

         OP No.4 did not turn up despite service of notice, hence it was proceeded exparte vide order dated 28.2.2022.

         OP No.5-Jain International organization also filed reply stating that answering OP has no role to play and the medi-claim of complainant is to be decided by the OP Insurance Company.  It is submitted that the services of answering OP has been availed without any consideration (free of charge).  Further pleaded that OP is merely a group organizer and as such there is no relation of the ‘consumer’ and service provider as falsely claimed by the complainant and that the answering OP is merely a formal party.  Denying other allegations being not related to, the OP No.5 has prayed for dismissal of the complaint qua it.  

 

3]       Rejoinder has also been filed by the complainants controverting the assertions made by OP.

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have perused the entire record. 

 

6]       Admittedly, the complainant availed medi-claim policy from OP Insurance Company valid from 31.10.2018 to 30.10.2019 and renewed from 31.10.2019 to 30.10.2020 vide policy Ann.C-1 & C-2.  It is also admitted that the complainant took treatment during the policy period from 12.12.2019 to 13.12.2019, discharged on 13.12.2019 and paid an amount of Rs.2,97,000/- to the hospital towards medical bill.

 

7]       The cashless claim of the complainant for reimbursement got rejected by the OP Insurance Company vide letter dated 14.12.2019 on the ground that ‘After scrutiny of all documents it is found that patient is having ailment which has genetic etiology. Hence cashless denied as per policy terms and conditions.’  

 

8]       The OP Insurance Company has not supported its version/stand with any authentic document in the shape of medical literature to establish that the disease suffered by the complainant has a genetic etiology.  Moreover, the OP Insurance Company failed to highlight the specific exclusion clause in the policy document covering the case of the complainant. Further it has been observed that complainant very fairly prayed for 75% of the claim amount as per terms & conditions of the policy payable to him.  In this view of the matter, we are of the opinion that the OP Insurance Company has illegally and unjustifiably rejected the genuine claim of the complainant, which amounts to deficiency in service on their part.

 

9]       Taking into consideration the above discussion and findings, the deficiency in service on the part of OPs No.1 & 2 (Insurance Company) stands proved. Therefore, the complaint stands allowed against OPs No.1 & 2 (Insurance Company) with direction to pay a sum of Rs.2,22,750/- (75% of Rs.2,97,000) to the complainant with interest @9% p.a. from the date of repudiation i.e. 14.12.2019 till realization.  The OPs No.1 & 2 are also directed to pay a compository amount of Rs.25,000/- towards compensation and  litigation expenses to the complainant.

 

         This order shall be complied with by the Opposite Party within a period of 30 days from the date of receipt of its certified copy, failing which it shall be liable to pay additional compensation cost of Rs.15000/- apart from above relief.

 

10]      However, the complaint stands dismissed qua OPs NO.3 to 5.

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.   

Announced

28^TH February, 2022                                                                         sd/-

 (PRITI MALHOTRA)

PRESIDING MEMBER

 

Sd/-

(B.M.SHARMA)

MEMBER