Delhi

New Delhi

CC/1036/2010

Binay Kumar Sadh - Complainant(s)

Versus

M/S. Royal Sundaram Alliance Insurance Company Ltd. - Opp.Party(s)

10 Dec 2019

ORDER

 

 

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110001

 

Case No.C.C./1036/10                                                             Dated:

            In the matter of:                                                                                                        Binay Kumar Sadh

Son of late  Nakul Sadh

A-14, 1^st Floor ,

New Friends Colony

New Delhi – 110065

 

    …..Complainant

VERSUS

1.         Royal Sundaram Alliance Insurance

Company Limited

                   Corporate Claims Department.

Sundaram Towers

45 & 46, Whites Road,

Chennai – 600014

 

Also at :

1505-6 Ambadep Building, 15^th Floor,

14, Kasturba Gandhi Marg,

Connaught Place,

New Delhi – 110001

 

2.              CITI Bank

Insurance Operations,

PB No. 4830, Anna Salai PO

                       Chennai-600002

                                                                                                                                                        …...Opposite Party

 

 

 

 

 H.M. VYAS -  MEMBER

                                                      ORDER

 

The gist of the complaint is that the complainant had a CITI Bank card (OP-2) where under Health Shield Insurance was provided by OP-1. The complainant was issued  master policy no. H L CITI 0016 and certification No. HCE 0019641000100 for the insurance period  11/07/2009 to 10/07/2010 “The Health Forever” plan was opted and the complainant was insured for a sum of Rs. 5,00,000/- and the premium of Rs. 10,583/- was payable. In September, 2009 the complainant started suffering from swelling on the right side of the scrotum and went to Indraprastha Apollo Hospital, New Delhi for treatment on 20/09/2009. He was admitted on same day and discharged on 23/09/2009. He was diagnosed of Right Testicular NHL. He was operated for high right orchedectomy and advised chemotherapy. During the treatment he was diagnosed malignancy of right testicular mass as there was swelling. Thereafter the complainant was admitted during 01/12/2009 to 02/12/2009, 22/12/2019 to 23/12/2009 and 28/01/2010 to 19/02/2010 for chemotherapy treatment and the total expenses incurred for the treatment was Rs. 5,06,379.64/-.

The complainant filed his claims for the said amount under the plan “The Health Forever” claiming the expenditure amount for payment. The OP rejected the claim vide letter 25/03/2010 on the ground that the claim was not payable due to pre-existing disease. It is stated that the Lymphomass measuring 4.4  cm would  have shown signs and symptom much prior to the policy inception and hence is pre-existing . Hospitalization of the pre-existing disease was beyond the scope of the policy. The complainant has also stated that as per the expert opinion of the senior consultant  Sh. Harsh Dua in the field of oncology on Indraprastha Apollo Hospital the complainant was diagnosed as a case of NHL right testis in September2009 and he could not be suffering  from this problem for a period of 4 years. Prayer to pay Rs. 16,06,379.64/- on various factors viz in hospitalization expenses, for mental and physical harassment and cost of litigation has been made.

The OP filed written statement/ version after notice the OP has stated that the  opinion of TPA, a medical speacialist opinion has been relied wherein it is stated that

“ After scrutinizing the additional documents our panels of doctors are of the opinion that policy incepted from 11/07/2009. A 4X4CM testicular mass cannot develop over 2 months and is pre-existing claim not admissible and not payable.

Reference to the ultrasound indicating the pre-existing ailment such as enlarged mass in right testicle. It is also stated that  under the exclusion clause the complainant’s claim is not admissible and accordingly, it has been rightly repudiated. Prayer to dismiss the complaint has been made.

The OP-2 i.e. CITI Bank also filed written statement/ version stating that  the complaint is based on misrepresentation, totally efficacious and misconceived. Relief sought by the complainant  in the present complaint is in violation of the terms and conditions contained in the Card Member Agreement executed between the complainant and the OP .It is also stated that the claim sought by the complainant was repudiated by the OP-1 on 25/03/2010 and as such there is no role of OP-2 so far the repudiation of the claim by OP-1 is concerned. The complainant opted for the Insurance plan and signed the insurance policy of OP-1. The complainant was billed  the Health Forever Policy with transaction fee.

All the parties filed their respective evidence by way of affidavit. Oral arguments were also addressed.

The main argument on behalf of OP (Insurance Company) is that the claim of complainant is not covered under the policy since he had been suffering from pre-existing disease. Admittedly, the complainant  was diagnosed of as a case of right testicles, NHL ( Non-Hodgin Lymphoma) and was operated  for high right orchedectomy. The complainant has not placed on record the entire documents showing the treatment between  20/09/2009 and 23/09/2009, nor the discharge summary thereof. The complainant has mainly referred to the chemotherapy treatment which was advised after surgery carried out between 20/09/2009 and 23/09/2009. The claim of the complainant is in respect of post operative treatment (chemotherapy) and not for surgery/ diagnosis expenses when the complainant allegedly  first approach the Apollo Hospital on 20/09/2009. The issue as per the OP revolves around exclusion clause where under the claim of the complainant is not considerable.

Per contra the complainant alleges to have not been suffering from any problem nor there was any symptom  for which any treatment was ever taken prior to first entire treatment during 20/09/2009 and 23/09/2009. The size of right testicles measuring 9.2X506X6.8 is not been disputed by the complainant.

We have given consideration to the material placed before us and the submissions of the parties.

The reliance of the complainant that B-cell Lymphoma testis is fast growing and that the complainant  started feeling the scrotum  enlargement of right testis only in September and thereafter on 20/09/2009 he visited the Apollo Hospital  and got admitted. Surgery was carried out and thereafter on 23/09/2009 he was discharged.

In our considered view, around 4 times of growth of the right testicle as evident from the treatment record cannot appear with a negligible period of 10-20 days.  As per complainant’s own averment he alleges to have started suffering from swelling on the right testicle and the scrotum in September itself. In other words, it is only a period of 15 days wherein the complainant alleges to have acquired such large growth of right testicle/ scrotum which is not convincing more so, for the reason that the complainant himself  has not placed  the entire treatment record / discharge summary of hospitalization during the period 20/09/2009 – 23/09/2009 during which period the surgery was carried out.

We therefore, hold that the complainant at the time of taking the policy covered under this CITI Bank credit card did not declare the material facts at the relevant time and is covered under exclusion clause of the Policy / pre-existing disease and the repudiation of claim by OP is justified. The complainant is, therefore, dismissed in view of above discussion.

Copy of the order may be forwarded to the parties to the case free of cost as statutorily required. 

Announced in open Forum on: 10/12/2019.

The orders be uploaded on www.confonet.nic.in

File be consigned to record room.

 

 

 

 

                                                (ARUN KUMAR ARYA)

                                                                   PRESIDENT

 

              (NIPUR CHANDNA)                                                                    (HM VYAS)

             MEMBER                                                                                 MEMBER