| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 38 of 05-02-2020 Decided on : 27-05-2022 Krishan Kumar son of Yash Pal, resident of House No.24521, Gali No. 01, Hajji Rattan, Bathinda, Tehsil and District Bathinda. .........Complainant Versus The Oriental Insurance Company Limited, having its Divisional Office at # 4501, First Floor, Bank Bazaar, Bathinda through its Manager/Senior Manager. Raksha Health Insurance TPA Pvt. Ltd., SCO 122, 5th Floor, Feroze Gandhi Market, Ludhiana through its Manager/Authorized Person.
.........Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh. Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member Smt. Paramjeet Kaur, Member Present :- For the complainant : Sh. Jagdish Kumar Gupta, Advocate. For opposite party no.1 : Sh.Manohar Lal Bansal,Advocate Opposite party no.2 Ex-parte. ORDER Kanwar Sandeep Singh, President:- Complainant Krishan Kumar (here-in-after referred to as complainant) has filed this complaint under section 12 of the Consumer Protection Act 1986 (hereinafter referred as ‘Act’ before this Commission against the Oriental Insurance Company and other (hereinafter referred as Opposite parties). Briefly stated, the case of the complainant is that complainant purchased one mediclaim insurance policy bearing no.233200/48/2018/1574 from Opposite party no.1 valid from 24.07.2017 to 23.07.2018 for a sum of Rs.3,00,000/-. Premium for the said policy was Rs.4852/-. Second premium was for Rs.7200/- and third premium was for Rs.7258/- and that was also duly paid by him. On 21.07.2018, complainant suffered from heart attack and was taken to Pulse Hospital, Bathinda where he remained admitted from 21.07.2018 to 23.07.2018. There, he underwent treatment from Dr.Sharad Gupta and during this period several tests and scans were conducted upon him and he was diagnosed as suffering from Double Vessel Disease/Mid RCA showing 99% thrombus containing stenosis with distal TIMI (2) flow. About Rs.1,35,000/- were spent by complainant on his treatment. It is alleged that after getting discharged from the hospital, complainant submitted his claim alongwith relevant bills and documents to Opposite party no.1 on 20.08.2018, in response to which Opposite party no.1 vide letter dated 15.09.2018 asked complainant to submit Treating Doctor’s certificate; break up of Rs.1,00,000/-charged on account of TPD bill; original pre numbered, pre printed duly signed and stamped receipt against final bill of said hospital; clarification regarding discrepancy in date of admission and discharge and discharge summary and final bill from hospital and original detailed discharge summary of hospital. These documents were duly submitted by complainant in original. It is further alleged that though these documents were furnished to Opposite parties in original but, Opposite party no.1 again wrote letter to complainant to provide Treating doctors certificate mentioning history of DM, HTN, CAD alongwith previous treatment record clearly specifying the duration in response to which complainant submitted opinion of doctor IPD No.264/18 stating that patient has no diabetic and non HTN and no past history of CAD, but Opposite parties did not pass his genuine claim. It is further alleged that thereafter, complainant requested Opposite parties through letters dated 22.09.2018 and 26.04.2019 to make payment of claim, but Opposite parties did not pay single penny for said claim. Opposite parties kept lingering on the matter on one pretext or the other and then flatly refused to admit the claim, which amounts to trade mal practice. All this act and conduct of Opposite parties in not making payment of genuine insurance claim of complainant, amounts to deficiency in service and has caused harassment and mental tension to complainant. On this backdrop of facts, the complainant has prayed for directions Opposite parties to make payment of his genuine insurance claim and to pay compensation to the tune of Rs.3,00,000/- for harassment and mental agony suffered by him alongwith litigation expenses of Rs.21,000/-. Hence, the present complaint. The counsel for complainant was heard with regard to admission of the complaint and vide order dated 06.02.2020, complaint was admitted and notice was ordered to be issued to the Opposite parties. On receipt of the notice, the Opposite party no.1 filed written statement wherein asserted that there is no deficiency in service on the part of Opposite party. It is averred that present complaint is false, frivolous and vexatious and has been filed only to injure the reputation of answering Opposite party. It involves complicated questions of law and facts requiring voluminous evidence that is not permissible in the summary procedure of consumer act and moreover, complainant has concealed the material facts and documents from this Forum and therefore, he is not entitled for relief sought by him. It is further averred that on receipt of claim of complainant, answering Opposite party forwarded the same to Opposite party no.2, who after getting done some formalities and processing the claim, observed that claim of complainant is not payable as per Clause 4.1 vide which Pre-existing health condition or disease or ailment/injuries that are pre-existing and which are not declared in proposal form, in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person up to 3 years of this policy in force continuously. In present case, policy is in first year. Complainant is having liver-32-34% which means heart disease is chronic. CAD is pre existing and PED are payable after three years. Claim of complainant is not payable and therefore, same was repudiated by competent authority and complainant was duly informed about it vide letter dated 10.01.2019. However, on merits, Opposite party no.1 has denied all the allegations of complainant being wrong and incorrect and reiterated the same pleadings as taken in preliminary objections. It is further averred that there is no deficiency in service on the part of Opposite parties and prayer for dismissal of complaint with costs is made. Notice containing copy of complaint alongwith relevant documents was sent to Opposite party no.2 through registered post, but it did not receive back undelivered. Acknowledgment might have been mis-laid or lost in transit. Statutory period expired. No body appeared in this Commission on date fixed on behalf of Opposite party no.2 either in person or through counsel, therefore, after long waiting till 4.00 O’clock, Opposite party no.2 was proceeded against ex parte vide order dated 05.11.2020. Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence documents Ex C-1 to C-29 and affidavit of complainant Ex.C-30 and then, closed the same on behalf of complainant. In order to rebut the evidence of the complainant, Counsel for Opposite party no.1 tendered in evidence affidavit of Ashwani Kumar Ex OP-1/1 and document Ex OP-1/2 to Ex OP-1/13 and then, closed the evidence on behalf of Opposite party no.1. We have heard the ld counsel for complainant as well as Opposite parties and have carefully gone through evidence and documents placed on record by respective parties. The case of the complainant is that he was insured under the policy in question and during the subsistence of said policy, he suffered from cardiac arrest on 21.07.2018. He was immediately hospitalized and there he remained admitted from 21.07.2018 to 23.07.2018. He paid Rs.1,35,000/- to hospital authorities for his treatment and after getting discharged therefrom, he submitted his claim with Opposite parties alongwith relevant bills and documents, but Opposite parties repudiated his claim on false grounds which amounts to deficiency in service. In reply, plea taken by Opposite parties for repudiating the claim of complainant is that as per Clause 4.1 claim is not payable for pre-existing chronic disease during first year of inception of the policy. As per Opposite parties, claims are excluded for such insured person up to 3 years of this policy in force continuously. Complainant is suffering from heart disease that is chronic. CAD is pre existing and PED are payable after three years. They have rightly repudiated the claim and there is no deficiency in service on their part and complainant was duly informed about it vide letter dated 10.01.2019. It is reiterated that there is no deficiency in service on their part and prayed for dismissal of case. From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with Opposite parties. Opposite party no.1 has admitted that complainant was insured with them for under the policy in question. It is also admitted that complainant suffered from cardiac arrest and he underwent treatment from hospital for the period from 21.07.2018 to 23.07.2018. It is also not denied that he paid Rs.1,35,000/- for his treatment. Plea taken for denying the claim is that claim cannot be payable for pre-existing diseases. Opposite party no.1 has forwarded no plausible reason to justify that why they have not made payment of claim amount. Ld Counsel for complainant argued that the Opposite parties cannot deny the amount in dispute regarding claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are interested only in earning the premiums and find ways and means to decline the claims. He further placed reliance on citation 2008(3) RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon'ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The ld counsel for complainant further argued before issuance of Policy, medical check up is got done by Insurance Company and now, they cannot deny payment to complainant on the ground of any pre-existing disease. He further put reliance on citation 2016 (4) CLT 372 titled as SBI General Insurance Company Ltd Vs Balwinder Singh Jolly & anr wherein our Hon’ble Chandigarh State Consumer Disputes Redressal Commission, U T, Chandigarh held that Consumer Protection Act, 1986, Section 2(1) (g) – Insurance claim (Mediclaim) – Hypertension – Pre-existing disease – Age of insured when Mediclaim insurance policy was issued was more than 45 years – Held – In that event, as per instructions issued by Insurance Regulatory & Development Authority of India (IRDA), it was duty of the insurer to put insured to thorough medical examination – Claim raised after issuance of insurance policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained. Now, at this stage, they cannot repudiate the claim of complainant on false grounds. Further perusal of discharge summary, (Ex.C-2) reveals that the complainant was admitted in the hospital on 21.7.2018 with severe chest pain since few hours and was diagnosed with Coronary Artery Disease (CAD). Opposite parties repudiated the claim of the complainant vide letter dated 10.1.2019 (Ex.C-12) under clause 4.1 i.e. for pre-existing disease. But opposite parties failed to bring on file any evidence in the shape of documents or evidence of any treating doctor to establish pre-existing disease. On the other hand, the complainant brought on file certificate issued by treating doctor to prove that the complainant was non Diabetic, Non HTN and having no past history of CAD. From the above discussion, we are fully convinced with the arguments and case law produced by complainant and we are of considered opinion that Opposite parties have wrongly and illegally repudiated the claim of complainant. Hence, complaint in hand is hereby partly allowed. Opposite parties are directed to make payment of insurance claim of Rs.1,35,000/- to complainant on account of expenditure incurred by him on his treatment during hospitalization for the period from 21.07.2018 to 23.07.2018 alongwith interest at the rate of 9% per anum from the date of filing the claim till final realization. Opposite parties are further directed to pay Rs.10,000/-to complainant for harassment and mental agony suffered by him besides Rs.5,000/-as litigation expenses. Compliance of this order be made within 45 days of receipt of the copy of the order. The complaint could not be decided within the statutory period due to covid pandemic and heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 27-05-2022
(Kanwar Sandeep Singh) President (Shivdev Singh) Member (Paramjeet Kaur) Member
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