Delhi

East Delhi

CC/6/2015

NITA KAUSHIK - Complainant(s)

Versus

VIPIN GUPTA - Opp.Party(s)

12 Feb 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO.  06/15

 

Smt. Nita Kaushik

W/o Shri Yogesh Kaushik

Flat No. H-202, Sarshwati Apartments

97, I.P. Extensionh, Patparganj, Delhi-92                     ….Complainant

 

Vs.

 

1. Shri Vipin Gupta

R/o 32C, Pocket B-5

Mayur Vihar Phase-3

Delhi – 110 096

 

2. Oriental Insurance Co. Ltd.

Regd Off.: A-25/27, Asaf Ali Road

New Delhi – 110 002

Branch Off.: C-30, Sector-II, Nodia

Gautam Budh Nagar, UP – 201 301

 

3. Good Health Plan Ltd.

4/23, East Patel Nagar, Delhi                                          …Opponents

 

Date of Institution: 07.01.2015

Judgement Reserved on : 12.02.2018

Judgement Passed on: 12.02.2018

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Sh. Sukhdev Singh (President)

 

JUDGEMENT

           

            This complaint has been filed by Smt. Nita Kaushik against          Shri Vipin Gupta Authorized agent of Oriental Insurance Company (OP-1), Oriental Insurance Company Limited (OP-2) and Good Health Plan Limited (OP-3) under Section 12 of the Consumer Protection Act, 1986 with allegations of deficiency in service. 

 

2.         The facts in brief are that the complainant Smt. Nita Kaushik got a mediclaim policy in her name under Happy Family Floater Policy Schedule (Gold Plan) from Oriental Insurance Company Limited (OP-2) through its authorized agent Mr. Vipin Gupta (OP-1) vide policy no. 272500/48/2013/4451 dated 13.03.2013 for a premium of Rs. 12,650/- which was valid for the period 13.03.2013 to 12.03.2014.  After four months of issuance of mediclaim policy, complainant started fever with pain in abdomen and pain in both legs in July, 2013.  She consulted Dr. Vipul Jain on 15.07.2013 and 22.07.2013, Dr. Vijay Arora on 28.07.2013 and           Dr. Achal Dave who prescribed medicines and various blood tests, ultrasound CT etc. to the complainant.  The complainant could not get any relief. 

            Thereafter, she was admitted in Max super Specialty Hospital on 02.08.2013 under Dr. Ritwick Raj Bhuyan (Sr. Consultant of CTVS) with complaint of fever since past one month with pain in abdomen and pain in both legs since last 15 days with breathing difficulty.  She undergone various blood tests , CTVS, CT, MRI, Ultrasound etc. and finally was diagnosed with Pulmonary Thromboembolism, IVC Thrombus and was discharged on 12.08.2013. 

            During her hospitalization, a request for pre-authorization dated 03.08.2013 was sent by Balaji Medical & Diagnostic Research, I.P. Extension, Patparganj, Delhi, on behalf of complainant to M/s. Good Health Plan Limited (OP-3), who was authorized TPA of OP-1.  This request was refused due to pre-existing disease. 

            She deposited a sum of Rs. 30,000/- as advance with hospital for treatment on 02.08.2013, 03.08.2013 and balance was paid at the time of discharge on 12.08.2013.  She sent a claim for a sum of Rs. 2,15,055/- on 17.08.2013 to Oriental Insurance Company Pvt. Ltd. (OP-2) through Good Health Plan Limited (OP-3) for payment of treatment.  She submitted all the documents alongwith relevant treatment bills.  She received a letter of dated 14.02.2014 from Noida office of Oriental Insurance Company Pvt. Ltd. (OP-2) in reference to her claim no. 000905 and was shocked to know that they have repudiated/refused the claim giving the reason of fever with pain in abdomen and pain in both legs as pre-existing disease under clause 4.1 of terms and conditions of insurance policy. 

            She wrote letter to the insurance company on 07.03.2014 clarifying the period of her disease which was received by them on 11.03.2014.  She also sent a letter dated 26.03.2014, issued by Dr. Ritwick Raj Bhuyan (Senior consultant) and Dr. Neerav Bansal (Consultant-CTVS) of Max Super Specialty Hospital clarifying their inevident error of mentioning the bilateral legs pain for one year instead of 15 days. 

            The complainant again wrote a letter to M/s. Good Health Plan Ltd. (OP-3) enclosing the letter issued by the doctors which was received by their office on 03.04.2014.  She enquired from OP-1, OP-2 and OP-3 about the progress of her claim and finally she received a letter of dated 19.11.2014 from Oriental Insurance Company Pvt. Ltd. (OP-2) whereby they again refused her claim on the point of pre-existing disease. 

            It has been stated that Oriental Insurance Company Pvt. Ltd. (OP-2) arbitrarily/legally/unlawfully closed her claim on the basis of pre-existing disease.  Thus, it has been stated that they have been deficient and negligent in providing their services to the complainant which has resulted in mental pain and suffering as well as financial loss.  Thus, she has claimed an amount of Rs.2,36,995/- alongwith interest @ 18% p.a. since July, 2013; Rs. 50,000/- as legal charges and Rs. 2,00,000/- compensation on account of mental and physical harassment, mental shock, agony, pain and suffering. 

3.         During the course of proceedings, a representative appeared on behalf of Shri Vipin Gupta (OP-1).  Later on, they did not appear, though, no formal order was passed, but the fact that they have not appeared in the case, they also stands proceeded ex-parte.

            In the WS, filed on behalf of Oriental Insurance Company Pvt. Ltd. (OP-2), they have taken various pleas whereby they denied the claim of the complainant on the basis of pre-existing disease under Clause 4.1 of the terms and conditions of the policy.

            Notice of the present complaint was served upon OP-3.  No reply was filed on their behalf; hence they were proceeded ex-parte. 

4.         The complainant has filed rejoinder to the WS of OP-2, wherein he has controverted the pleas taken in the WS and reasserted his pleas. 

5.         In support of its complaint, complainant have examined herself.  She has deposed on affidavit.  She has narrated the facts which have been stated in the complaint.  She has got exhibited documents such as copy of mediclaim policy dated 13.03.2013 (Ex.CW1/1), copy of request for pre-authorization dated 03.08.2013 (Ex.CW1/2), copy of letter dated 03.08.2013 of OP-3 (Ex.CW1/3), copy of claim form dated 17.08.2013 for Rs. 2,15,055/- (Ex.CW1/4), copy of patient admission request form dated 02.08.2013 (Ex.CW1/5), copy of case summary, discharge summary dated 12.08.2013, hospital bills and test reports (Ex.CW1/6 colly.), copy of claim form dated 15.10.2013 alongwith discharge summary, bills and medical records (Ex.CW1/7 colly.), copy of letter dated 01.10.2013 (Ex.CW1/8),  copy of letter dated 09.10.2013 (Ex.CW1/9), copy of letter dated 14.02.2014 (Ex.CW1/10), copy of letter dated 07.03.2014 (Ex.CW1/11), copy of letter dated 26.03.2014 of Max Hospital (Ex.CW1/12), copy of letter dated 03.04.2014 (Ex.CW1/13) and copy of letter dated 19.11.2014 (Ex.CW1/14).

            In defence, Oriental Insurance Company Pvt. Ltd. (OP-2) have examined Shri Khem Chand, Sr. Divisional Manager, who have also deposed on affidavit.  He has also narrated the facts which have been stated in the Written Statements.  He has also got exhibited documents such as clinical progress notes (Ex.RW1/1), and copy of terms and conditions of the policy (Ex.RW1/2).

5.         We have heard Ld. Counsel for the complainant and Ld. Counsel for  Oriental Insurance Company Pvt. Ltd. (OP-2).  It has been argued on behalf of Oriental Insurance Company Pvt. Ltd. (OP-2) that claim of the complainant was rejected on the ground that complainant was suffering from pre-existing disease.  They have also argued that complainant was having leg pain for one year which comes under the Exclusion Clause being pre-existing disease.

            On the other hand, Ld. Counsel for complainant have argued that leg pain for one year which is said to be pre-existing disease on the basis of which Oriental Insurance Company Pvt. Ltd. (OP-2) have repudiated the claim cannot be said to be a disease.  He has also argued that the insurance company have failed to brought on record the proposal form to show that the complainant was suffering from any pre-existing disease.

            To appreciate the arguments of Ld. Counsel for the parties, a look has to be made to the repudiation letter as well as discharge summary of the hospital.  Firstly, the reference has to be made to Ex.RW1/1 which is clinical progress notes submitted in the testimony of Shri Khem Chand, Sr. Divisional Manager of OP.  In the clinical progress notes, which have been of 02.08.2013, it has been stated “Leg pain B/L–1 year”.  In the repudiation letter of dated 14.02.2014, they have stated that “As per policy exclusion 4.1, pre-existing diseases are not covered under policy condition”.

            Arguments of Ld. Counsel for the parties have rested on the point as to whether leg pain for one year amounts to pre-existing disease or not.  For this, reference has to be made to Oxford Medical Dictionary, where Pain has been defined as “an unpleasant sensation ranging from mild discomfort to agonized distress associated with real or potential tissue damage”.  Thus, from the dictionary meaning of the word Pain, it comes out that it is only a mild discomfort or extreme suffering.  Thus, the dictionary meaning of Pain does not suggest that Pain is a disease.

            When Pain is not a disease, the repudiation of claim by the Oriental Insurance Company Pvt. Ltd. (OP-2) on the basis of exclusion clause cannot be said to be justified.  Even otherwise also, if a look is made to the documents placed on record such as discharge summary under the column ‘Past History’, it has been stated “Not significant”. 

            Not only that, even during the course of proceedings, counsel for OP was directed to produce the proposal form, which they have failed to do so.  Though, this does not have any bearing, but the fact remains that OP have failed to put anything on record to show that complainant was having any pre-existing disease. 

            When they have failed to produce any material on record to show that the complainant was having any pre-existing disease, the repudiation of claim without any basis amounts to deficiency in service for which the complainant have not to suffer.  Therefore, we order that claim of the complainant be processed and passed as per policy terms and conditions within a period of 60 days.  If the claim is not processed/passed within a period of 60 days, the complainant shall be entitled to 9% interest on the amount passed.  In addition to that, we award a sum of 20,000/- on account of compensation which includes the cost of litigation. 

          Copy of the order be supplied to the parties as per rules.

            File be consigned to Record Room.

 

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member    

 

            (SUKHDEV SINGH)

             President