Delhi

East Delhi

CC/552/2015

VIJENDER KR - Complainant(s)

Versus

U.I.C - Opp.Party(s)

18 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 552/2015

 

	Vijender Kumar Gupta then LR, Smt. Usha Rani Gupta, W/o Lt. Sh. Vijender Gupta R/o:- 511/1B, Gali No. 1, Vishwas Nagar, Shahdara Delhi-110031.	….Complainant
Versus
	United India Insurance Co. Ltd. Scope Minar Complex, Core 1 & Core 4, 2, Laxmi Nagar, District Centre, Delhi-110092.	……OP

 

Date of Institution: 29.07.2015

Judgment Reserved on: 17.04.2023

Judgment Passed on: 18.04.2023

               

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

 

Order By: Ms. Rashmi Bansal (Member)

 

JUDGMENT

               

The present complaint was filed by the complainant against the rejection of his insurance claim by OP alleging misrepresentation by OP and praying for the release of the insurance claim, compensation for his sufferings due to deficiency of service on the part of OP and litigation cost.

1. It is the case of the complainant that during his employment, he was covered under a ‘Group Medical Insurance Scheme’ of his employer since 2006, which continued till June 2013, i.e. till his retirement from the service. The last group medical insurance policy as issued by the office of OP, was bearing number 32030034120400000002 from 06.06.2013 to 30.06.2013. The complainant submits that OP’s assistant manager has sold him a cashless medical insurance policy bearing number 2504002813P133354023, (NS no. 250400/48/13/06/00000098) for the sum assured of Rs. 1,00,000/- for a period from 00:00 Hrs of 01.07.2013 to midnight 30.06.2014 stating that the same is in continuation of the existing group/medical insurance policy number 32030034120400000002 with same TPA and the new policy was issued with all benefits of previous group medical insurance policy and accordingly payment of premium was made by the complainant. The same has also been confirmed by the OP vide its internal official email dated 04.12.2017.
2. The complainant submits that OP was aware of the complainant’s medical condition as the complete information has been disclosed in the proposal form, in the previous group policies given to the OP by the complainant. The complainant developed ailment & was admitted to the hospital on 08.07.2013 and a request for cashless treatment was sent to OP but was declined by TPA. The complainant submits that the TPA sought some information from OP which was not provided to TPA and thus OP acted negligently because of which TPA refused the cashless facility to the complainant. The complainant had to pay the entire bill, amounting to Rs.81,317/- and Rs.  26,000/- on medicine taken from the outside market during the treatment.
3. The claim form for reimbursement of the amount of Rs. 1,00,000/- was submitted by the complainant along with all the original documents to OP in July 2013 but no response was received from OP. The complainant had to file RTI to know the status of his claim and was informed by the OP that they have received no claim form from him, however, TPA confirmed that they have received the claim form, and asked the complainant for the submission of the documents in duplicate again, which were filed by the complainant accordingly.
4. The complainant submits that vide email dated 12.06.2017, the TPA recommended denial of the claim of the complainant to the OP but OP had already sent a letter to the complainant on 15.05.2017 even before the recommendation by TPA, informing him w.r.t. denial of the claim which establishes that OP did not wait for the report from TPA and acted in violation of IRDAI rules and principle of natural justice in rejecting the claim of the complainant.
5. The legal notice dated 19.06.2015 of the complainant was not replied to by OP. The complainant alleged that the OP has used the tactics of non-payment of medical bills to the genuine policy holders by ignoring the genuine claim on one pretext or the other. The complainant claims a sum of Rs.1,00,000/- towards the insurance value of the medical bill, including the cost of medicines purchased from the outside market. The complainant also submits that he has been led to great inconvenience, mental torture and harassment in order to contact the OP officials to get the payment of his genuine claim. The complainant, therefore, also claims compensation amounting to Rs.50,000/- for the said mental agony and harassment caused to him due to deficiency of services on the part of OP.
6. OP has filed its reply, and denied its liability to pay the claim or any compensation to the complainant and submits that complaint does not disclose any cause of action against the OP and the complaint is liable to be dismissed. The OP submits that the policy was issued subject to terms and conditions contained therein and the claim of the complainant is not sustainable as on scrutiny of the claim document and various investigations and vide its letter dated 15.05.2017 has rejected the claim of the complainant stating that the patient was admitted for treatment of diabetic foot and was having a history of diabetes for last 8–9 years since the inception of the first policy is w.e.f. 01.07.2013 with OP and it is running in its first year, the disease is not covered in this policy and as per the policy clause number 4.1, the pre-existing disease is covered only after 48 months of continuation of the policy and since the policy is running in the first year, the claim is not payable.
7. The complainant has filed its rejoinder reiterating its version taken in the complaint. Both parties have filed their respective evidence and related documents in support of their respective case.
8. The complainant has filed the following documents:
   1. Copy of medical insurance policies issued by OP from 2007 to 2013, till the retirement of the complainant
   2. The copy of the insurance policy from 01.07.2013–30.06.2014
   3. Communication between the insurance company and TPA regarding the premature claim
   4. Family Medicare proposal form
   5. Repudiation letter dated 15.05.2017
   6. Copy of bill and receipt of the hospital,
   7. Copy of RTI application in its reply received from OP
   8. Claim form
   9. Document from the hospital
   10. Copy of the letter received from TPA regarding submission of the documents,
   11. Copy of the legal notice
9. OP has filed the following documents,
   1. The requisition letter of the documents, Ex. DW1/A;
   2. The letter of TPA informing the complainant about the closure of the claim, Ex. DW1/B;
   3. The copy of the letter received from the head office, and the regional office of the OP from Dehradun and Saharanpur, respectively, Ex. DW1/C;
   4. The copy of the summons issued to the OP at different, Ex. DW1/D;
10. During the course of the hearing, unfortunately,the complainant passed away on 04.01.2021, and his legal heirs were brought on record vide order dated 17.08.2022 and all the legal heirs gave their authority to their mother i.e. the wife of complainant & as such a fresh amended memo of parties was filed.
11. The Commission have heard the Ld.  Counsels for the parties and perused the documents. There are two questions for the determination first, whether the complainant has concealed the pre-existing disease of diabetes and second, whether the new policy dated 01.07.2013 as issued by the OP was in continuation of the earlier policy or it was a new policy.
12. The perusal of the Records shows that the proposal form dated 28.06.2014 filed by the complainant with OP at its clause 13 para (n) related to the question to past disease has written ‘yes’ against the question ‘diabetes or any other urinary disease’. Therefore, this cannot be said that the complainant has concealed the information with respect to the past disease from the OP.
13. So far as the second question is related, it is noted from the documents on record that certain emails were exchanged within the office of the OP in pursuance of the order dated 30.11.2016 of this commission vide which  OP was directed tosettle the claim of the complainant.
    1. The email dated 12^th April 2017 from OP Assistant Manager, Shri Sanjeev Mittal from Divisional Office, Saharanpur, sent to Ms. Shauqiya Firdaus, Administrative Officer, Regional Office, Dehradun admitted that policy was issued to the complainant in continuation of the old one, stating under the subject “DCDRF East – CSC, Sani enclave, Delhi CC number 552/2015 – Vijendra Kumar Gupta versus UIIC, 545221314062236,” stating that “the policy number 2504002813P 133354023 – NS no. 250400/48/13/06/0000 0098 were issued in continuation of new India policy vide no. 020300/34/12/04/0000 0002 with the same TPA.
    2. Another email dated 13^th April 2017 also mentioned that “communication was given to TPA only that we have issued the policy in continuation of the previous policy which was issued by New India Assurance with the same TPA as requested by insured but no confirmation was given by us to insured and TPA for continuation benefits because the previous insurer was different.”
    3. The other email of the same day dated 13^thApril 2017 from the administrative officer to another officer Shri SC Giri, the Regional Manager, New Delhi, also admitted that no written communication was given to the insured by their operating office.
    4. The email dated 21^st February 2017, this has also mentioned that the complainant has submitted all the related papers.
14. The above-said email communications clearly show that OP was not having a clear intention and misrepresented the complainant and in view of the admitted case, this Commission is of the view that OP has issued policy no. 2504002813P133354023, (NS no. 250400/48/13/06/00000098) in continuation of policy no. 32030034120400000002. Now, for the applicability of clause 4.1, the date for consideration is the date on which the insurance policy was taken by the insured from a particular insurer for the first time. It is not disputed that the first policy taken from United India was taken by the complainant on 31.07.2006 and any disease acquired by the complainant after 31.07.2006, cannot be said to be a pre-existing disease/condition, excluded in terms of the said clause. Considering that the new policy is in continuation of the old policy, therefore clause 4.1 of the new policy, has no applicability in the present case. Moreover, the complainant has filed the insurance policies from 2006 to 2013 and the policies of 2009–2010, 2011–12, and 2013–14 specifically mention “pre-existing disease covered”. 
15. Therefore, in view of the admitted case of the OP that the new policy was issued in continuation of the previous policy with the same TPA, this Commission is of the view that OP is not able to prove that there was a concealment of the material fact, and that concealment had misled the OP in accepting the proposal for the grant of the insurance cover held that the repudiation of the claim is not justified and is a clear-cut case of deficiency of services on the part of OP and directs OP to pay to the complainant the claim amount of Rs. 1,00,000/- along with interest of 9% per annum to be paid from the date of filing of the complaint i.e. 19.07.2017 and a compensation of Rs.15,000/- towards causing mental agony, physical discomfort and harassment to the complainant and litigation cost of Rs. 10,000/-.
16. The above-said order be complied with by the OP within 30 days from the date of receiving the order, failing which the entire amount  including compensation & legal expenses accrued till the 30^th day shall also carry interest @9% per annum till its actual realization.
17. A copy of the order be given to the parties free of cost as per CPA rules and orders be uploaded to the website. Thereafter the file be consigned to the Record room.
18. The complaint case could not be decided within time due to the heavy pendency of the cases before the commission.
19. The order contains 09 pages for each beer our signatures.
20. Pronounced on 18.04.2023.