District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.207/2020.
Date of Institution: 21.07.2020.
Date of Order: 09.12.2022.
Amit Dagar S/o Shri Mannu Dev, R/o village Jharsently, Ballabgarh, Faridabad.
…….Complainant……..
Versus
1. M/s. United India Insurance Company Limited, Registered Office: 24, Whites road, Chennai – 600014.
2. M/s. United India Insurance Company Limited, Head Office: 19, Lane-4 (IV), Nungambakkam High road, Chennai – 600 034.
3. M/s. United India Insurance Company Limited through its General Manager, Divisional Office: SCO – 106, 2nd floor, Commercial Complex, Green Channel Road, Sector-16, Faridabad, Haryana - 121002.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Gautam Narain Singh and Shri Vikas , counsel for the complainant.
Sh. Ravinder Chandila, counsel for opposite parties Nos.1 to 4.
ORDER:
The facts in brief of the complaint are that the complainant purchased an insurance policy from United India Insurance Company Limited initially in 2011 and the same remained continued uninterruptedly till date. On 12.07.2016 the complainant blessed with a baby boy and in the year 2016, the minor son of the complainant namely Preet Dagar was incorporated in the array of insured persons on 19.12.2016 at the age of 3 months. At the time of birth of master Preet Dagar, he was in a healthy condition and no disease was diagnosed at that time. Just to save his family for any unexpected illness of health, the complainant also included his son in the insurance policy and the all particulars pertaining to the health of the child were duly communicated to the insurance company. Since the birth of the child till 11.07.2019, the child was living a healthy life apart from the minor tender age related and seasonal illnesses but he was never diagnosed or suffered any critical disease. On 11.07.2019, the child was admitted to Sarvodaya Hospital, Sector-8, Faridabad, due to fever, cough-cold and vomiting. At the time of his admission, he was 3 years. The doctors of Sarvodya Hospital, Sector-8, Faridabad, after the report of X-ray MCU on 15.07.2019, noticed Bilateral grade V VUR and discharged the minor child when found symptomatically better and accepting oral feeds well with direction to follow up further. Thereafter the minor child on 20.07.2019 taken to Appolo Hospital for second opinion & upon their direction he was medically examined on 23.07.2019 at M/s. Focus Diagnostics: Faridabad and then on 30.07.2019 with Dr. Parvinder Singh, M.D.(Radio-Diagnosis), at his clinic situated at Shop NO. 19-20 , B.K.Chowk, Faridabad, for another opinion to remove any doubt over the findings of Sarvodaya Hospital, but unfortunately the findings was same. In this hapless situation and for the better medical treatment, the minor child got admitted to Apollo Hospital, Delhi, for further medical examination and treatment. During the treatment at Apollo Hospital, Delhi on 21.08.2019 vide the MCU Procedure, the minor child was diagnosed with a disease called Bilateral Vessicoureteric Reflux (Grade-IV), and the minor child underwent Cystoscopy, REtyrograde Prelogram, bilateral DJ stent removal, robotic bilateral ureteric reimplantation on 22.8.2019. For the above mentioned surgery an amount of Rs.2,50,000/- was initially deposited by the complainant to the hospital. The insurance company was duly informed within the stipulated time and initially a part approval for Rs.1,65,000/- was issued by the insurance company to the Apollo Hospital, Delhi. Thereafter the entire procedure related to the treatment was successfully completed and the minor child was discharged from the hospital on 28.8.2019. After the discharge the all relevant and necessary documents were submitted with the insurance company. The minor kid was again admitted with Apollo Hospital for one day on 27.09.2019 for post surgery observation/clinical evaluation and investigation. At this time an amount of Rs.29,500/- was also deposited by the complainant. The complete documentation as per the necessary detections were submitted to the insurance company for a an total Rs.2,79,500/-, but it was highly shocking to the complainant that his claim was ejected under the policy clause 4.1 Congenital Disease Internal and External vide letter dated 24.01.2020. The insurance company wrongly interpretated clause 4.1. of the policy while considering the disease as congenital, which states “Any pre-existing condition(s) as degined in the policy, until 48 months of continuous coverage of such insured person had elapsed since inception of his/her first policy as mentioned in the schedule attached to the policy.” But the insurance company overlooked the clause 4.5(a) which manifestly covers the congenital disease as “clause 4 page No. 13 para 4.5 congenital internal disease or defect of anomalies. However, if not known to the insured as pe-existing at the time of inception of first policy with us, these diseases would be covered after 24 months of continuous coverage. If the insured was aware of the existence of congenital internal diseases before inception of the policy, the same would be cover after 48 months . (B) Congenital external diseases of defects of anomalies. As per the forgoing paras it was evident that the complainant as well as the minor child was not aware about this disease till it was firstly diagnosed on 15.07.2019 when the minor child was three years above of age. The entire medical record was obtained by paying Rs.1340/- as charge for the copies of record. Theinsurance company had wrongly rejected the claim of the complainant as the disease did not come under the definition of congenital disease and also this was the clear violation to its own clause 4.5.(a). The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the claimed amount of Rs.2,79,500/- alongwith 24% interest P.a. till the disposal of the complaint.
b) pay Rs.2,50,000/- as compensation for causing mental agony and harassment .
c) Any other relief which this Hon’ble Forum deem fit and proper may also be awarded to the complainant.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the complainant neither had any cause of action or locus standi to file the present complaint reason being, as a matter of record the complainant had loded his mediclaim vide under claim form dated nil by enclosing entire treatment papers by alleging indoor treatment we.r. 21.08.2019 to 28.08.2019 therein with Indraprastha Apollo Hospital, Faridabad as to treatment of her child, so received with the opposite party No.4 – M.s, Vipul Med Corp TPA Private Limited being the authorized agency of the opposite party No.1 During processing of the claim a the end of the opposite party No.4 being the authorized agency of the opposite party No.1, it was revealed that the claim of the complainant stands non payable as per exclusion clause 4.1 (Treatment for diagnosed with Recurrent Urinary Tact Infection & Bilateral Vesicoureteric reflux (Greade IV) (Congenital Diseases (In TerNal and External) of the insurance policy. As such, the opposite party No.1 had treated the subject claim as repudiated by closing the file in terms of “letter of intimation” dated 18.12.2019 which decision could not be termed unconscionable at all. As per discharge summary Master Preet Dagar a 3 years old toddler presented with history of Recurrent episodes or Urinary tract infection for since infantile period and each time treated with antibiotics. Further investigation were carried out. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– M/s. United India Insurance Company Limited & Others with the prayer to: a) pay the claimed amount of Rs.2,79,500/- alongwith 24% interest P.a. till the disposal of the complaint. b) pay Rs.2,50,000/- as compensation for causing mental agony and harassment . c) Any other relief which this Hon’ble Forum deem fit and proper may also be awarded to the complainant.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Amit Dagar, insurance policy, Ex.C-2 – birth certificate, Ex.C-3 – discharge summary, Ex.C-4 – Focus Diagnostics report, Ex.C-5 – Whole Abdomen Scan report, Ex.C-6 – Examination performed:Genito- Urinary MCU Ex.C-8 & 9 – Doctor prescription, Ex.C-10 – discharge summary, Ex.C-11 – repudiation letter, Ex.C-12 OP Cash Bill – Bill of supply.
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties, Ex.RW1/A – affidavit of Ankit Bhadana, Admin. Officer, M/s. United India Insurance Company Limited Divisional Office, DO-21, SCO-Complex, Sector-16A, Faridabad , Annx.A – details of hospital, Annx.B – Discharge summary, Annx.-C – In patient Bill – Bill of supply, Annx.D – letter dated 18.12.2019, Annx.E – insurance policy for the period 19.12.2018 to 18.12.2019.
6. In this case, the complainant purchased an insurance policy from United India Insurance Company Limited initially in 2011 and the same remained continued uninterruptedly till date. On 12.07.2016 the complainant blessed with a baby boy and in the year 2016, the minor son of the complainant namely Preet Dagar was incorporated in the array of insured persons on 19.12.2016 at the age of 3 months. Since the birth of the child till 11.07.2019, the child was living a healthy life apart from the minor tender age related and seasonal illnesses but he was never diagnosed or suffered any critical disease. On 11.07.2019, the child was admitted to Sarvodaya Hospital, Sector-8, Faridabad, due to fever, cough-cold and vomiting. At the time of his admission, he was 3 years. The doctors of Sarvodya Hospital, Sector-8, Faridabad, after the report of X-ray MCU on 15.07.2019, noticed Bilateral grade V VUR and discharged the minor child when found symptomatically better and accepting oral feeds well with direction to follow up further. Thereafter the minor child on 20.07.2019 taken to Appolo Hospital for second opinion & upon their direction he was medically examined on 23.07.2019 at M/s. Focus Diagnostics: Faridabad and then on 30.07.2019 with Dr. Parvinder Singh, M.D.(Radio-Diagnosis), at his clinic situated at Shop NO. 19-20 , B.K.Chowk, Faridabad, for another opinion to remove any doubt over the findings of Sarvodaya Hospital, but unfortunately the findings was same. In this hapless situation and for the better medical treatment, the minor child got admitted to Apollo Hospital, Delhi, for further medical examination and treatment. During the treatment at Apollo Hospital, Delhi on 21.08.2019 vide the MCU Procedure, the minor child was diagnosed with a disease called Bilateral Vessicoureteric Reflux (Grade-IV), and the minor child underwent Cystoscopy, REtyrograde Prelogram, bilateral DJ stent removal, robotic bilateral ureteric reimplantation on 22.8.2019. For the above mentioned surgery an amount of Rs.2,50,000/- was initially deposited by the complainant to the hospital. Opposite party repudiated the claim of the complainant on the ground that “under the policy clause 4.1 Congenital Disease Internal and External vide dated 24.01.2020 vide Ex.C-11.
7. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 09.12.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
