| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 308 of 23-10-2017. Decided on : 24-01-2022. Jagjiwan Kumar @ Jagjiwan Garg aged about 44 years son of Sh. Gian Chand R/o Street No. G-13, Paras Ram Nagar, Bathinda. ........Complainant Versus The New India Assurance Co. Ltd, 2090, The Mall, Bathinda, through its Divisional Manager. Raksha Health Insurance TPA Private Ltd, C/o Escorts Corporate Center, 15/5, Mathura Road, Faridabad, Haryana-121003 through its Manager. .......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member. Smt. Paramjeet Kaur, Member Present For the complainant : Sh. Naresh Garg, Advocate For the opposite parties : Sh. Sunder Gupta, Advocate. OP No. 2 exparte. ORDER Kanwar Sandeep Singh, President The complainant Jagjiwan Kumar @ Jagjiwan Garg (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against The New India Assurance Co. Ltd and another, (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that the opposite party No.1 at Bathinda issued one continuous Medi-claim insurance policy No. 36060134162800000044 w.e.f. 14-08-2016 to 13-08-2017 under cashless scheme with TPA opposite party No.2. In the said policy Jagjiwan Kumar, Anjali Garg and their children are duly insured for Rs. 2.00 lacs each. The above said insurance is continuous insurance for the last 10-12 years firstly with NIC and then shifted to NIA after 2-3 years and the complainant is having in possession only Insurance since 2012 and the said policies were issued by opposite party No.1. The opposite parties never issued any complete policy to the complainant till date, rather they have issued insurance certificate only. The said insurance is cashless insurance with the opposite parties. The opposite parties assured the complainant that in case of any emergency the claim can be lodged anywhere in India with the nearest offices of the opposite parties and insured can be got admitted in any hospital in India. The opposite parties also assured that this insurance is cashless and the opposite parties will pay the entire claim up to the sum assured i.e. Rs. 2,00,000/- directly to the hospital. It is alleged that the complainant first time, detected the problem of right Thyroid cystic lesion on 16-2-2017. He immediately got himself checked from Dhillon Hospital Bathinda. Thereafter, complainant was admitted in DMC Ludhiana on 08-03-2017 and discharged on 13-03-2017. Dr. Rohit Verma and others at DMC Ludhiana done the right hemithyroidectomy under GA on 09-03-2017 upon the complainant and and the complainant spent about Rs, 1,00,048/- on his treatment including hospital bills and medicine etc. The claim of the complainant was lodged by DMC Hospital with the opposite parties on the same day as DMC hospital is under network hospitals but the opposite parties did not pay the claim amount under cashless insurance scheme and finally the complainant spent huge amount from his own pocket. The complainant provided all the necessary documents i.e. original bills, claim form, cancelled cheque, original prescriptions, original reports etc on 24-04-2017 with opposite party No.1 at Bathinda. The amount of Rs. 1,00,048/- is still pending with the opposite parties. The complainant visited opposite party No. 1 several times and requested to pay the claim, but to no effect. It is further alleged that the opposite parties vide letter dated 14-06-2017, finally rejected the claim of the complainant amounting to Rs.1,00,048/- without any reason on the ground that “ claim is not payable as per clause 4.3” (Two year exclusion). No such policy or its terms and conditions supplied by the opposite parties till date to the complainant or his family members. Moreover the insurance is with the opposite parties for the last 12 years. The said no claim of Rs. 1,00,048/- is illegal and the claim is still pending with the opposite parties. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay total claim amount of Rs.1,00,048/- along with interest @ 18% p.a. and Rs, 50,000/- as compensation on account of mental agony and pains besides Rs, 25,000/- as litigation expenses. Upon notice, the opposite party No. 1 put in appearance through counsel and contested the complaint by filing written reply. In written reply, the opposite party No.1 raised legal objections that the complainant obtained New India Floater mediclaim policy from opposite party No.1. Firstly, vide policy No. 36060134162800000034 w.e.f. 14-08-2015 to 13-08-2016 and thereafter the same was renewed vide policy No. 36060134162800000044 for further period from 14-08-2016 to 13-08-2017. As per record submitted by the complainant, complainant has suffered right thyroid cystic lesion on 16-02-2017 i.e. in the second year of renewal of aforesaid Medi-claim policy. As per clause 4.3.1 of the aforesaid policy, no claim is payable under the aforesaid policy” unless the insured person has continuous coverage in excess of 24 months. It is pleaded that claim of the complainant was rightly repudiated by opposite party vide dated 14-06-2017, as per aforesaid exclusion clause 4.3. After receipt of intimation regarding aforesaid ailment of the complainant the cashless facility was not provided as the complainant was suffering from disease right thyroid cystic lesion and aforesaid disease is not covered during first 24 months of inception of aforesaid insurance policy.. The complainant has neither disclosed nor has mentioned in the proposal form that he is suffering from aforesaid disease. The said medi-claim policy obtained by the complainant is not continuous policy. The complainant has firstly obtained family floater medi-claim policy w.e.f. 20-04-2012 to 19-04-2013 and got renewed from 26-04-2013 to 25-04-2014 and thereafter from 06-05-2014 to 05-05-2015. The complainant could not get his aforesaid medi-claim policy renewed within stipulated period and got the fresh mediclaim policy effective from 14-08-2015 to 13-08-2016 vide policy No. 36060134162800000034. As per exclusion clause of said policy, aforesaid disease is not covered within first 24 months of inception of policy. The other legal objections raised by the opposite party No.1 are that the complainant is stopped by his own act and conduct to file the present complaint; that the complainant has not come to this Commission with clean hands, rather has suppressed true and material facts and documents; that the complainant has got no locus standi or cause of action to file the present complaint; that the amount of compensation claimed is highly excessive and exorbitant one and that the complaint is false, frivolous and vexatious to the knowledge of the complainant. On merits, the opposite party No. 1 admitted that complainant has obtained mediclaim insurance policy No. 36060134162800000044 w.e.f. 14-08-2016 to 13-08-2017. The said medi-claim policy is not continuous rather complainant has failed to get his Medi-claim policy renewed within stipulated period after 05-05-2015. It is specifically denied that aforesaid Medi-claim insurance policy is continuous since the last 10-12 years. Detailed terms and conditions of Insurance policy were duly supplied to the complainant. The Medi-claim policy is cashless insurance policy for the penal hospital of TPA and cashless facility is not provided to the hospital which are not on the penl of TPA. It is pleaded that complainant was suffering from pre-existing right thyroid cystic lesion disease. Moreover, complainant has not placed on file the treatment slip of Dr. Dhillon and discharge summery of DMC Ludhiana. Since claim of the complainant has been repudiated vide letter dated 14-06-2017, so the complainant is not entitled for any compensation from the opposite parties. No claim of the complainant is pending with opposite parties. After controverting all other averments, the opposite party No. 1 prayed for dismissal of complaint. The opposite party No. 2 in separate written reply pleaded that the insurance contract is between the insured and the insurer i.e. The New India Assurance Co. Ltd, As per privity of contract, the insurance company by itself or its TPA (opposite party No.2) is obliged to process the claim as per terms and conditions of the policy laid down by opposite party No.1. Opposite party No.2 is nominated as third party administrator for arranging to process the claim filed by the insured as per terms and conditions laid down by opposite party No.1. It is further pleaded that the complainant was covered under the medi-claim policy No. 36060134162800000044 w.e.f. 14-08-2016 to 13-08-2017 issued by the New India Assurance Co. Ltd, and the claim in respect of Mr. Jagjiwan hospitalized in Dayanand Medical College and Hospital Ludhiana, during 09-03-2017 to 13-03-2017 was processed and not paid in accordance with the policy terms and conditions laid by the opposite party No.1. The claim stands diagnosed with RT Thyroid Cystic lesion since one month as per discharge summary of the hospital, but as per clause No. 4.3 of the policy terms and conditions, this ailment falls under two years exclusion list and insured's policy is running in second year. Hence, the claim is recommended to Insurer as non tenable as per terms and conditions of policy. It is further pleaded that the opposite party No.2 is just a third party administrator who acts facilitator for the processing of the claims as per the policy terms and conditions laid down by respondent No.1. After controverting all other averments, the opposite party No. 2 also prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence affidavit of Jagjiwan Kumar dated 09-01-2018 (Ex.C-1), photocopy of policy schedules (Ex.C-2 to C-6), photocopy of medical bills containing pages 1 to 39 (Ex.C-7), photocopy of letter dated 24-04-2017 containing pages 1 to 2 (Ex.C-8), photocopy of no claim letter dated 14-06-2017 (Ex.C-9) and closed the evidence. In order to rebut the evidence of complainant, the opposite party No. 1 tendered into evidence affidavit of Ashish Paul dated 26-03-2018 Sr. Divisional Manager (Ex.OP1/1), photocopy of Floater mediclaim policy (Ex.OP1/2) and closed evidence. The opposite party No. 2 also tendered into evidence affidavit of Vinay Batra, GM dated 11-01-2018 ( Ex.OP-2/1) and closed evidence. We have heard learned counsel for the parties and gone through the record. In the case in hand, the complainant purchased New India Floater Medi-claim Policy of the opposite parties for himself and for his family members for the period from 20-4-2012 to 19-4-2013 (Ex. C-2) thereafter, complainant got the said policy subsequently renewed for the period from 26-4-2013 to 25-4-2014 (Ex. C-3), from 6-5-2014 to 5-5-2015 (Ex. C-4) from 14-8-2015 to 13-8-2016 (Ex. C-5) and from 14-8-2016 to 13-8-2017 (Ex. C-6). The complainant suffered problem of Right Thyroid Cystic Lesion on 16-2-2017 and his right hemithyroidectomy under GA was done on 9-3-2017 at DMC, Ludhiana where he remained admitted from 8-3-2017 to 13-3-2017. The complainant filed his claim with the opposite parties for reimbursement of medical expenses to the tune of Rs. 1,00,048/- incurred for the said treatment but the opposite parties repudiated his claim vide letter dated 14-6-2017 (Ex. C-9) on the ground that claim falls under first two year exclusion clause 4.3, hence claim stands repudiated and file closed as No Claim. As detailed above, complainant purchased first policy Ex. C-2 in the year 2012. A perusal of aforesaid Insurance Policies Ex. C-2 to Ex. C-6 reveals that Customer ID on all the policies is mentioned as P007149309 meaning thereby that complainant kept on making payment of premium to get the policies renewed but lapse/delay took place on the part of the opposite parties in not issuing the policies in time to complainant. Ex. C-2 & Ex. C-3 show date of issue as 11-3-2017 whereas on Ex. C-4 & Ex. C-5 no date of issuance of policy is mentioned. Only Policy for the period from 14-8-2016 to 13-8-2017 (Ex. C-6) under which claim of the complainant falls, reveals date of issue as 17-8-2016. Thus, it is proved on file that opposite parties did not issue and supply policy alongwith terms and conditions to complainant. The terms and conditions which are not supplied to the complainant are not binding on the complainant. Moreover, in the present case policy IRDA Registration Number is 190 and terms and conditions relied upon by opposite party No. 1 pertains to product IRDA/NL-HLT/NIA/P-H/V.I/467/13-14. Therefore, The opposite parties cannot deny genuine claim of the complainant on the ground that claim is not payable as it falls under first two year of exclusion clause specifically when complainant has been paying premium for the same policy since from the year 2012 under the same customer ID and he filed claim in the year 2017 i.e. after nearly about five years. The gap in renewal of insurance policy in question, if took place, it is only due to fault on the part of the opposite parties. Moreover, if complainant was made aware of the terms and conditions of the policy, he must have made follow-up in this regard. Moreover, terms and conditions relied upon by opposite party No. 1 pertains to some other product. Hence, repudiation of claim of complainant amounts to deficiency in service on the part of the opposite parties. Now the question is regarding amount for which complainant can be reimbursed. Of course the complainant has placed on record bills and receipts ( Ex. C-7) to prove that he has spent Rs. 1,00,048/- and has claimed reimbursement of this total amount. The opposite parties have placed on record terms and conditions of policy (Ex. OP-1/2) which has no relevancy with the policy in hand and the opposite parties have not brought on file terms and conditions pertaining to policy in hand for the reasons best known to them. Therefore, the complainant is entitled to reimbursement as prayed for. In view of what has been discussed above, this complaint is partly accepted with Rs. 10,000/- as cost and compensation against the opposite parties. The opposite parties are directed to reimburse to complainant the claim amount of Rs. 1,00,048/- with interest @9% p.a. from the date of repudiation of claim i.e. 14-6-2017 till realization. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 24-1-2022 (Kanwar Sandeep Singh) President (Shivdev Singh) Member (Paramjeet Kaur) Member
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