DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

BATHINDA

C.C. No. 181 of 17-07-2018

Decided on : 3-1-2022

1. Kewal Krishan Aggarwal aged about 67 years S/o Sh. Des Raj

2. Ravinder Aggarwal aged about 66 years W/o Kewal Krishan

   - Both R/o Kothi No. 4, Veer Colony, Amrik Singh Road, Bathinda. ........Complainants

Versus

1. Oriental Insurance Co. Ltd., 4501 Bank Street, Bathinda, through its Divisional Manager

2. Raksha Health Insurance TPA Pvt Ltd., First Floor, 14/3, Main Mathura Road, Faridabad 121 003, through its Manager/Authorized Signatory

.......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 opposite parties : Sh. M L Bansal, Advocate, for OP No. 1

Opposite party No. 2 exparte.

ORDER

Kanwar Sandeep Singh, President

1. The complainants Kewal Krishan and another (here-in-after referred to as complainants) 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 Oriental Insurance Co. Ltd., and another (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainants is that they are having one bank account with Oriental Bank of Commerce, Bathinda. The opposite party No.1 issued one Medi-claim Insurance policy No. 233200/48/2018/2859 w.e.f. 23-12-2017 to 22-12-2018 under cashless scheme through OBC, Bathinda with TPA opposite party No.2 under the scheme of Oriental Bank Medi-claim Policy of their account holders. Cashless card was also issued in this regard. In said insurance Kewal Krishan Aggarwal and Ravinder Aggarwal are duly insured for Rs. 5,00,000/- each. As per said medi-claim insurance, any person of the policy holder can avail insurance upto Rs, 5,00,000/- on Ist basis or both can use the said amount i.e. up to Rs. 5,00,000/-. The opposite parties never issued any complete policy to the complainants till date, rather they have issued insurance certificate only. The said insurance is continuous insurance since 2013. In 2014, medi-claim of complainant No. 2 was filed and the opposite parties denied the said claim and then after filing complaint, they paid the claim, through court. At that time, during the proceedings of the court, the opposite parties, renewed the insurance of the complainants and the medical treatment and condition papers of complainant No.2 were in the possession of the opposite parties at that time. The said insurance is cashless insurance with the opposite parities. The opposite parties assured the complainant that in case of any emergency, the claim can be lodged anywhere in India with the nearest office of the opposite parties and insured can be admitted in any hospital in India and also assured that this is the cashless insurance and the opposite parties will pay the entire claim upto the sum assured i.e. Rs, 5,00,000/- directly to the hospital.

3. It is alleged that complainant No.2, all of a sudden, started vomiting. The complainant No.1 and his son admitted the complainant No.2 in Max Hospital Bathinda on 24-03-2018 and he was discharged on 28-03-2018. The opposite parties denied the cashless facility when complainant No.2 was in hospital. The complainant No. 2 again started vomiting then she was again admitted in Max Hospital Bathinda on 12-04-2018 and was discharged on 14-04-2018. This time also, the opposite parties denied the cashless facility. The family of the complainant lodged cashless claim with the said hospital as the said Max Hospital Bathinda is duly network Hospital for cashless Treatment and the said hospital sent the information and registered the claim with the opposite parties under their system through e-mail.

4. It is alleged that complainants have already filed claim in the year 2014 and the opposite parties paid his entire claim. The complainant No.2 had same disease i.e. diabetic and hypertension at that time also.

5. It is further alleged that the complainants spent Rs. 1,91,439/- for treatment and medicine charges etc., and submitted all the original bills with the opposite parties on 23-04-2018 with the Claim Form for reimbursement, as per directions given by the opposite parties at the time of denial of cashless treatment. The opposite parties firstly not provided approval for cashless treatment from the above said hospital and thereafter they are not ready to reimburse the expenses incurred by complainants from their pocket.

6. It is also alleged that complainants again and again requested the opposite parties for releasing the claim of Rs, 1,91,439/- but finally on 03-05-2018 and 15-05-2018 the opposite parties rejected the claim on the flimsy grounds with exclusion clause No.4.1. The amount of Rs,1,91,439/- is still pending with the opposite parties and the original bills with original medical file is still in the possession of the opposite parties. Such exclusion clause neither supplied to the complainant at the time of insurance nor at the time of rejecting the claim. Due to non payment of Rs.1,91,439/- complainant suffered mental agony and pain for which he claims compensation to the tune of Rs,1,00,000/-.

7. On this backdrop of facts, the complainants have prayed for directions to the opposite parties to pay claim amount of Rs. 1,91,439/- along with interest @ 18% p.a from the date of payments to the hospital alongwith compensation to the tune of Rs. 1,00,000/- besides Rs. 50,000/- as litigation expenses.

8. Registered notice of complaint was sent to the opposite parties., None appeared on behalf of opposite party No. 2, as such, exparte proceeding were taken against it.

9. The opposite party No.1 appeared through counsel and contested the complaint by filing written reply raising legal objections that the present complaint has been filed by the complainants only to injure the goodwill and reputation of the opposite party and that the complainants have concealed material facts and documents from this Commission.

10. It is pleaded that on receipt of claim of the complainants, the same was forwarded by opposite party No. 1 to opposite party No. 2, which is deputed as TPA (Third Party Administrator), to decide the medi-claims. While processing the claim, opposite party No. 2 observed that the claim is not payable. As per the documents patient is a K/C/O (known case of) DM, HTN, CAD Post FTCA (In 2008). Policy is effective since 2015. Illness diagnosed was before policy inception. So, pre-existing. PED (pre-existing disease) are payable after 3 years of policy inception. Policy is in 3^rd year. Based on above observations, claim is recommended to be non payable as per clause 4.1 of the policy.

11. Further legal objections are that the complainants are estopped by their own act, conduct and acquiescence from filing the present complaint; that the complainants have no locus standi or cause of a action to file the complaint and that the complaint is not maintainable in its present form.

12. On merits, the opposite party No.1 pleaded that the cashless facility depends upon the circumstances of each case. The claim is payable strictly as per terms and conditions of the policy. Since the claim is not payable as per terms and conditions of the policy, the same has already been recommended by opposite party No.2 as Non payable and accordingly, the claim of the complainants has already been repudiated by the competent authority keeping in view exclusion clause 4.1 and an intimation in this regard has already been given to the complainants vide registered letter dated 15-05-2018.

13. It is further pleaded that the answering opposite party is a service oriented company and has already decided the claim of the complainants without any delay on its part. The complainants have not suffered any loss due to any act or conduct of the answering opposite party, as such the complainants are not entitled to any relief/claim/compensation. After denying all other averments of the complainant, opposite party No. 1 prayed for dismissal of the complaint.

14. In support of their complaint, the complainants have tendered into evidence affidavit of Kewal Krishan Aggarwal dated 17-07-2018 (Ex.C-1) affidavit of Ravinder Aggarwal dated 17-07-2018 (Ex.C-2) photocopy of cashless card (Ex.C-3 & C-4), photocopy of insurance certificate (Ex.C-5 to C-8), photocopy of medical file (Ex.C-9) photocopy of bills (Ex.C-10), photo copy of medical file (Ex.C-11), photocopy of bills ( Ex.C-12) photocopy of cashless denial letter (Ex.C-13 & C-14) photo copy of circular (Ex.C-15) photocopy of claim form (Ex.C-16 & C-17), photo copy of no claim letters (Ex.C-18 & C-19) affidavit of Kewal Krishan Agarwal dated 21-08-2019 (Ex.C-20), photocopy of application u/s 22 (Ex.C-21), photocopy of reply of application (Ex.C-22), photocopy of rejoinder (Ex.C-23), photocopy of proposal form (Ex.C-24), photocopy of discharge summary (Ex.C-25), photocopy of repudiation letter (Ex.C-26), photocopy of order dated 31-01-2015 (Ex.C-27), photocopy of application dated 21-01-2015 ( Ex.C-28), photocopy of reply of application dated 30-01-2015 (Ex.C-29) and closed evidence.

15. In order to rebut the evidence of the complainants, opposite party No.1 tendered into evidence affidavit of RL Baleem dated 20-08-2018 (Ex.OP-1/1), photocopy of form A (Ex.OP-1/2), photocopy of letter (Ex.OP-1/3& OP1/4), photocopy of claim form ( Ex.OP-1/5 & OP-1/6), photocopy of policy schedule (Ex.OP-1/7), photo copy of details (Ex.OP-1/8), photocopy of policy schedule (Ex.OP-1/9), photocopy of detail (Ex.OP-1/10) photocopy of policy schedule (Ex.OP-1/11), photocopy of detail (Ex.OP-1/12), photocopy of policy schedule (Ex.OP-1/13), photocopy of discharge summary (Ex.OP-1/14 & OP-1/15), photocopy of letters (Ex.OP-1/16 & OP-1/17) photocopy of details (Ex.OP-1/18) photocopy of letter (Ex.OP-1/19), affidavit of RL Baleem dated 12-09-2018 (Ex.OP-1/20) and closed evidence.

16. We have heard learned counsel for the parties and gone through the record.

17. These are undisputed facts between the parties that complainants obtained Medi-claim Insurance policy No. 233200/48/2018/2859 w.e.f. 23-12-2017 to 22-12-2018 from opposite party No. 1. Complainant No. 2 fell ill and she was hospitalized. She was admitted in Max Hospital, Bathinda, on 24-3-2018 and was discharged 28-3-2018 whereby she incurred expenses to the tune of Rs. 1,91,439/-. The complainants submitted claim with opposite party No. 1 for reimbursement of medical bills, but the opposite parties repudiated their claim vide letters dated 15-5-2018 (Ex. OP-1/3 & Ex. OP-1/4).

18. Ex. OP-1/3 reveals that opposite party No. 1 repudiated the claim of the complainants under clause 4.1 of the insurance policy on the ground of pre-existing disease as the complainant no. 2 was suffering from HTN and DM and this fact was not disclosed by complainants in the proposal form while obtaining policy as pre-existing diseases are covered only after the policy has been continuously in force for 36 months (3 years).

19. Admittedly the above said medi-claim insurance policy of the complainants was firstly obtained in the year 2013 and subsequently renewed and is in continuous period. The complainants have placed on record all the policies which were subsequently renewed upto the policy in question. Ex. C-5 is the first/initial medi-claim insurance policy of complainant for the period from 11-9-2013 to 10-9-2014. Thereafter complainants got renewed the policy from 11-9-2014 to 10-9-2015 (Ex. C-6) 22-12-2015 to 22-12-2016 (Ex C-7), 23-12-2016 to 22-12-2017 (Ex C-7) and 23-12-2017 to 22-12-2018 (Ex. C-8).

20. In the case in hand, the opposite parties have repudiated the claim of the complainants on the ground that complainant No. 2 is known case of DM, HTN, CAD Post PTCA (In 2008). As mentioned above, complainants obtained first policy in the year 2013.

21. The complainants have pleaded that earlier also, the opposite parties repudiated the claim of the complainant which was filed for reimbursement of medical expenses incurred at Apollo Hospital for the period from 31-5-2014 to 14-6-2014 on the treatment of complainant No. 2 under above mentioned medi-claim policy which was subsequently renewed upto policy in hand. Ex. C-25 is Discharge Summary of the hospitalization from 31-5-2014 to 14-6-2014 wherein also diagnosis is mentioned as Hypertension, Diabetes Mellitus The complainants filed application before Permanent Lok Adalat for redressal of their grievace and vide order dated 31-1-2015 (Ex. C-7) Permanent Lok Adalat, Bathinda ordered to the opposite parties to pay the claim amount of Rs. 3,88,425/- to complainants and as per complainants this amount was paid by the opposite parties. This fact was not specifically denied by the opposite parties.

22. Hon'ble National Commission in Revision Petition No. 2939 of 2011 decided on 15-11-2017 case titled Vipin Grover & anothers Vs. New India Assurance Co. observed :-

    “If Insurance companies co-relate each and every disease with pre-existing condition, under such circumstances, insured i.e. helpless consumers will never succeed to get his genuine claim from Insurance Company.”

23. Similarly Hon'ble State Commission, Punjab in the case :-

    (i) CC No. 100 of 2017 decided on 24-4-2018 case Rajesh Singla Vs. Max Bupa Health Insurance Co., observed :-

    “Hypertension is not a disease, which is required to be referred in proposal form.”

    (ii) First Appeal No. 673 of 2015 decided on 12-5-2017 case titled Life Insurance Corporation of India & Anr Vs. Sarabjit Kaur also observed :-

    “Hypertension is not serious disease. It is part of ordinary strain, stress of life.”

24. In the case of Virpal Nagar Vs. HDFC Standard life Insurance Co. Ltd., II (2019) CPJ 59 (Del.), Hon'ble Delhi State Commission after noticing the observations of Hon'ble National Commission and Hon'ble Supreme Court in various judgements, concluded that :-

    “Unless and until a person is hospitalised or undergoes operation for a particular disease in near proximity of obtaining insurance policy or any disease for which he has never been hospitalised or undergone operation is not a pre-existing disease.”

    It was also observed :-

    “Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in or out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for treatment of these disease or any other disease.”

25. The complainant proved on file that earlier too complainant filed claim qua policy for the year 2013-2014 and opposite parties repudiated the claim on the ground of pre-existing diseases of hypertension and Diabetes Mellitus CAD Post PCTA (in 2008). Complainant filed application before Permanent Lok Adalat and Permanent Lok Adalat vide order dated 31-1-2015 (Ex. C-27) allowed application and directed opposite parties to pay claim amount. So, once opposite parties paid claim qua these diseases and did not discontinue/cancel the policy, now they cannot deny claim to complainant. Thus, ground of repudiation is not sustainable as these disease were in the knowledge of opposite parties and they should not have issued policy to the complainant.

26. Therefore, keeping in view the above observation also, the conclusion is that the repudiation on the ground of pre-existing diseases of Hypertension and Diabetes Mellitus and CAD Post PTCA (In 2008) is not sustainable and repudiation of claim amounts to deficiency in service on the part of the opposite parties. As such, the complainants are entitled to claim amount of Rs. 1,91,439/- alongwith interest from the date of repudiation. They are also entitled to compensation for harassment and mental agony caused to them on account of non approval of cashless treatment and thereafter non-payment of claim.

27. Resultantly, this complaint is partly allowed with Rs. 10,000/- as cost and compensation. The opposite parties are directed to pay Rs. 1,91,439/- to complainants with interest @9% P.A. w.e.f. 15-5-2018 (date of repudiation) till payment.

28. 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.

29. The complaint could not be decided within the statutory period due to heavy pendency of cases.

30. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced :

    03-01-2022 (Kanwar Sandeep Singh)

    President

     

     

    (Paramjeet Kaur) (Shivdev Singh)

    Member Member