Haryana

Karnal

CC/761/2019

Amit - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

R.K. Karma

15 Sep 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 761 of 2019

                                                        Date of instt.14.11.2019

                                                        Date of Decision:15.09.2022

 

Amit son of Shri Subhash Chand, resident of House no.361, Sector-7, Urban Estate, Karnal.

                                               …….Complainant.

                                              Versus

 

1.     United India Insurance Company Ltd. through its Divisional Manager, Division Office, G.T. Road, Karnal.

 

2.     Safeway TPA Services Private Ltd. 815, Viswa Sadan Colony, District Centre, Janakpuri New Delhi-110058 through its Manager.

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

              Dr. Rekha Chaudhary…Member

 

 Argued by: Shri R.K. Kamra, counsel for complainant.

Shri Virender Adlakha, counsel for OP no.1.

OP no.2 given up.

 

                    (Jaswant Singh President)

ORDER:  

  

                 The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a Family Medi-care policy from the OP no.1 for so many years and lastly the complainant purchased the policy, vide policy no.1107052818P113360894, valid from 17.01.2019 to 16.01.2020. OP no.1 is tie up with OP no.2 and policy was issued by OP no.2 through OP no.1. In the said policy complainant, his wife Aarushi, two daughters namely Anshika and Harshika are covered under this policy. The said policy is cashless and sum assured was Rs.2,00,000/-. It is further averred that suddenly the complainant was suffering from Gullaina Barre Syndrome disease (Miscle Weakness Caused by Immune system which spreads to both upper and lower limbs since last two days). On 08.02.2019, complainant approached to the Doctors at Fortis Hospital and was admitted in Fortis Escorts Health Institute of New Delhi for further treatment, where he remained admitted for eight days. The complainant was discharged on 16.02.2019. Complainant spent Rs.4,91,542/- on his treatment. After discharge from the hospital, complainant lodged the claim with the OPs and submitted all the relevant documents, but OPs did not pay the claim and postponed the matter on one pretext or the other and lastly repudiated the claim of complainant, vide repudiation letter dated 12.07.2019 on the false and frivolous grounds. In this way there is deficiency in service on the part of the OPs. Hence, complainant filed the present complaint seeking directions to the OPs to release the insured amount of Rs.2,00,000/- alongwith interest @ 24% per annum, to pay Rs.50,000/- as compensation for mental pain, agony and harassment and Rs.22000/- as litigation expenses.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability and complainant is estopped by his own act and conduct to file and maintain the present complaint. On merits, it is pleaded that OP no.1 repudiated the claim of the complainant on the following ground:-

“On scrutiny of documents, it was observed that patient Amit, was admitted in Fortis Hospital from 08.02.2019 to 16.02.2019 and was diagnosed with Gullen Barre Syndrome, the patient presented with weakness of limbs, he managed with IVIG (IVIG are as replacement therapy in primary or acquired antibody deficiency disorders and as such immunomodulatory agents in patients with autoimmune or inflammatory conditions) treatment in ICU for five days, the treatment was only IVIG with other consultation (urology and optha). As per CMD guidelines, this claim is being recommended for repudiation”.

 

Thus, the complainant is not entitled for any amount as per Arogya Raksha Policy terms and conditions as per exclusion clause 4.9 of the policy. The claim of the complainant has rightly been repudiated on the basis of observations supplied by SAFEWAY Insurance TPA Private Limited, New Delhi. There is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied by the OP no.1 and prayed for dismissal of the complaint.

3.             OP no.2 given up by the complainant being unnecessary party, vide his statement dated 07.01.2022.

4.             Parties then led their respective evidence.

5.             Learned counsel for complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policies Ex.C1 and Ex.C2, copy of repudiation letter dated 12.07.2019 Ex.C3, copy of discharge summary Ex.C4, copy of MR Reports Ex.C5 and Ex.C6, copy of medical bill Ex.C7, copy of detail of bill Ex.C7A and Ex.C8, copy of receipts Ex.C9 to Ex.C12, copy of MNC record Ex.C13, insurance policy Ex.C14 and closed the evidence on 07.02.2022 by suffering separate statement.

6.             On the other hand, learned counsel for OP no.1 has tendered into evidence affidavit of Raj Kamal, Assistant Manager Ex.OPW1/A, copy of claim form Ex.OP1/1, copy of recommendation to insurer Ex.OP1/2, copy of intimation to complainant Ex.OP1/3, copy of discharge summary Ex.OP1/4 and closed the evidence on 22.07.2022 by suffering separate statement.

7.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

8.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a Family Medi-care policy from the OP no.1. In the said policy complainant, his wife Aarushi, two daughters namely Anshika and Harshika are covered. The said policy is cashless and sum assured was Rs.2,00,000/-. The complainant was suffering from Gullaina Barre Syndrome disease and on 08.02.2019, complainant approached to the Fortis Hospital and was admitted in Fortis Escorts Health Institute of New Delhi for further treatment, where he remained admitted for eight days. Complainant spent Rs.4,91,542/- on his treatment. After discharge from the hospital, complainant lodged the claim with the OPs and submitted all the relevant documents, but OPs did not pay the claim and lastly repudiated the claim of complainant, vide repudiation letter dated 12.07.2019 on the false and frivolous grounds.

9.             Learned counsel for OP no.1, while reiterating the contents of written version, has vehemently argued that the complainant is not entitled for any compensation as per exclusion clause 4.9 of the Arogya Raksha policy. The claim of the complainant has rightly been repudiated by the OPs and prayed for dismissal of the complaint.

10.           We have duly considered the rival contentions of the parties.

11.           Admittedly, complainant had availed the health insurance policy from the OPs. It is also admitted that complainant was admitted in Fortis Escorts Health Institute of New Delhi on 08.02.2019 and was discharged on 16.02.2019 during the subsistence of the insurance policy.

12.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C3 dated 12.07.2019 on the grounds which reproduced as under:-

“On scrutiny of documents, it was observed that patient Amit, was admitted in Fortis Hospital from 08.02.2019 to 16.02.2019 and was diagnosed with Gullen Barre Syndrome, the patient presented with weakness of limbs, he managed with IVIG (IVIG are as replacement therapy in primary or acquired antibody deficiency disorders and as such immunomodulatory agents in patients with autoimmune or inflammatory conditions) treatment in ICU for five days, the treatment was only IVIG with other consultation (urology and optha). As per CMD guidelines, this claim is being recommended for repudiation”.

 

13.           The onus to prove its case lies upon the OPs, but OPs have miserably failed to prove its version by leading any cogent and convincing evidence. The case of the OPs based upon the clause 4.9 of the Arogya Raksha Policy and CMD guidelines.  OPs have neither placed on file copy of terms and conditions of Arogya Raksha Policy nor copy of CMD guidelines to prove its version. There is nothing on the file to prove as to why the complainant was not entitled for the claim. The repudiation letter is based upon the presumption and assumption. It appears that OPs have repudiated the claim of the complainant without any cogent reason just to harass the complainant.

14.            Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

                It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

15.           Keeping in view that the ratio of the law laid down in the aforesaid judgment and the facts and circumstances of the present complaint, we are of the considered view that the insurance company has failed to prove the allegations, on the basis of which they have repudiated the claim of the complainant. Thus, the act of the OP no.1 while repudiating the claim of the complainant amounts to deficiency in service and unfair trade practice, which is otherwise proved genuine one.

16.           It is evident from the medical bill Ex.C7, complainant spent Rs.4,91,542/- on his treatment but as per insurance policy Ex.C2, the sum insured is only Rs.2,00,000/-(Rs.two lakhs only). Hence, complainant is entitled for Rs.2,00,000/- alongwith interest, compensation for mental pain, agony and harassment and litigation expenses.

17.   In view of our above discussion, we allow the present complaint and direct the OP no.1 to pay claim amount of Rs.2,00,000/- (Rs. two lakhs only) to the complainant alongwith interest @9% per annum from the date of repudiation of the claim till its realization. We further direct the OP no.1 to pay a sum of Rs.20,000/- as compensation for harassment and mental agony suffered by her and also to pay a sum of Rs.11,000/- as litigation expenses to the complainant. This order shall be complied with within 45 days from the date of receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:15.09.2022.                                                                       

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

       

                (Vineet Kauhik)                 (Dr. Rekha Chaudhary)      

                      Member                               Member