State Consumer Disputes Redressal Commission
National Insurance Company Ltd., vs Anil Tandon on 5 February, 2018
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UNION TERRITORY, CHANDIGARH Appeal No. 151 of 2017 Date of Institution 31.05.2017 Date of Decision 05.02.2018 1. National Insurance Company Ltd. SCO 305-306, 3rd &4th floor, Sector 35, Chandigarh through its Senior Branch Manager. 2. National Insurance Company Ltd. SCO 57, 1st floor, Sector 26, Chandigarh through its Senior Divisional Manager. 3. M/s Park Mediclaim TPA Pvt. Ltd., 702 Vikrant Tower, Rajendra Place, New Delhi 110008 through its CEO. Now all through their authorised signatory, Puja Dhawan, Assistant Manager, Regional Office, SCO No.332-334, Sector 34-A, Chandigarh. .....Appellants/Opposite Parties Versus Anil Tandon resident of #No.29, Sector 27-A, Chandigarh. ..Respondent/Complainant. BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT MR. DEV RAJ, MEMBER.
MRS. PADMA PANDEY, MEMBER Argued by:
Sh. J.P.Nahar, Advocate for the appellants/Opposite Parties.
Sh. Ajmer Lal Pundeer, Advocate for the respondent/complainant.
PER PADMA PANDEY, MEMBER This appeal is directed against the order dated 03.04.2017, rendered by District Consumer Disputes Redressal Forum-II, UT, Chandigarh (in short 'the Forum' only), vide which, it allowed Consumer Complaint bearing No.800 of 2016, with the following directions :-
"14 In view of the above discussion, we find merit in the complaint and the same is allowed with the direction to the OPs to pay the amount of Rs.5 lakh to the complainant towards claim of reimbursement of medical expenses equivalent to sum insured of policy and Rs.20,000/- for compensation on account of mental harassment and Rs.5000/- towards litigation costs.
15 The above order shall be complied with by the OPs within 30 days of receipt of certified copy of this order failing which they shall be liable to pay additional compensatory amount of Rs.50,000/- to the complainant."
2. The facts, in brief, are that the complainant being an employee of Oriental Insurance Company opted 'Group Medi-claim' Policy since joining of his service and after his marriage, he also covered his wife and son under the aforesaid policy. It was stated that the complainant paid regular premium, as per the policy. It was further stated that in the year 2014-15, son of the complainant got employment and in this regard, he (complainant) informed Opposite Party No.1 and deleted name of his son from the list of dependents. The complainant took a separate policy in the name of his son from the same Insurance Company for sum insured Rs.5 lacs having coverage w.e.f. 11.03.2014 to 10.03.2015 by paying premium amount of Rs.5,194/-. It was further stated that due to dislocation of both hips, son of the complainant was admitted in M/s Max Super Specialty Hospital, Mohali from 15.12.2015 to 29.12.2015 and he had undergone surgery, on which, he spent an amount of Rs.6,04,762/-. Thereafter, the complainant submitted claim under mediclaim policy with Opposite Party No.3 on 21.1.2016 for reimbursement of medical expenses incurred on the treatment of his son but Opposite Party No.1 vide letter dated 26.02.2016 informed that the claim is not admissible as expenses incurred for the treatment of congenital external disease (Development Dysplasis of Hip) not covered under the policy, in view of Exclusion Clause 4.5. It was further stated that son of the complainant is member of Group Mediclaim policy since birth till attaining the majority and, thereafter, policy was taken from the same Company in his own name in continuation. It was further stated that the complainant visited Opposite Parties No.1 and 2 numerous times for settlement of his claim but nothing was done. Ultimately, the complainant served a legal notice upon the OPs, but to no avail. It was further stated that the Opposite Parties were deficient, in rendering service, as also indulged into unfair trade practice. When the grievance of the complainant was not redressed, left with no alternative, a complaint under the Consumer Protection Act, 1986 (hereinafter to be called as the "Act" only), was filed.
3. In their written statement, Opposite Parties No.1 & 2 while admitting the factual matrix of the case stated that the ailment suffered by the son of the complainant was not covered under the policy of insurance in any manner and hence excluded. It was further stated that as per history of ailment suffered by son of the complainant, couple of operations were performed upon him for dislocation of both the hip joints at PGI Chandigarh as well as L&JP Hospital in Delhi in his childhood, as such, the replying Opposite Parties rightly rejected the claim of the complainant. It was further stated that the replying Opposite Parties were neither deficient, in rendering service nor indulged into unfair trade practice.
4. Despite service, Opposite Party No.3 did not appear, as such, it was proceeded against exparte vide order dated 03.11.2016.
5. The complainant filed rejoinder to the written statements of Opposite Parties No.1 & 2, wherein he reiterated all the averments, contained in the complaint, and refuted those, contained in the written versions of Opposite Parties No.1 and 2.
6. The parties led evidence, in support of their case.
7. After hearing Counsel for the complainant, Counsel for Opposite Parties No.1 & 2 and, on going through the evidence, and record of the case, the Forum, allowed the complaint, as stated above.
8. Feeling aggrieved, the instant appeal, has been filed by the appellants/Opposite Parties.
9. We have heard Counsel for the parties and have gone through the evidence and record of the case, carefully.
10. Counsel for the appellants/Opposite Parties submitted that the Forum wrongly held in the impugned order that despite having continuous coverage of Nikhil Tandon, the Opposite Parties wrongly rejected the claim under the policy for the year 2014-15. Actually, the first policy was taken from 11.03.2014 to 10.03.2015 and renewed thereafter from 11.03.2015 to 10.03.2016 and under this policy, the claim was lodged for hospitalization from 15.12.2015 to 29.12.2015. He further submitted that the claim was lodged in the second year of the policy and not under the policy for the year 2014-15. He further submitted that the coverage of congenital disease was not available in the Group Mediclaim Policy taken prior to the policy from 11.03.2014 to 10.03.2015. He further submitted that the complainant himself admitted in para No.3 of the complaint that he purchased an independent separate policy for the period 11.03.2014 to 10.03.2015 for his son Nikhil Tandon, so there is no need to prove that it was the fresh policy. He further submitted that the coverage of congenital disease was not available even in the Group Mediclaim Policy. He further prayed for allowing the appeal and setting aside the impugned order
11. Counsel for the respondent/ complainant submitted that the Forum has rightly passed the impugned order and prayed for dismissal of the appeal filed by the Opposite Parties.
12. After going through the evidence and record of the case, we are of the considered opinion, that the appeal is liable to be dismissed, for the reasons to be recorded, hereinafter.
13. The core question, that falls for consideration, is, as to whether, the Forum has rightly passed the impugned order. The answer, to this, question is in the affirmative. It is, no doubt, true that the complainant opted 'Group Medi-claim Policy' and after extension of his family, he got his wife and son 'Nikhil Tandon' covered under the policy being dependent upon him. It is also the admitted fact that the complainant paid the premium regularly. Annexure C-1 is a certificate issued by The Oriental Insurance Company Limited. From this document, it is proved that son of the complainant i.e. Sh.Nikhil Tandon was covered under dependent family member under Group Mediclaim Policy, taken from National Insurance Company Limited upto 2013-14 with sum insured of Rs.5,00,000/-. Annexure C-2 is a copy of Duplicate Schedule issued by National Insurance Company Limited. From this document, it is proved that after employment, son of the complainant took a separate policy for the period from 11.03.2014 to 10.03.2015 for similar medical coverage, with sum insured of Rs.5 lacs by paying extra premium of Rs.5,194/-. It is also the admitted fact that due to dislocation of both hips, surgery was conducted upon the complainant in M/s Max Super Speciality Hospital, for which, he spent an amount of Rs.6,04,762/-. However, when the claim was lodged with the Insurance Company, they repudiated the claim of the complainant vide letter dated 26.02.2016 (Annexure C-8), which reads thus :-
"Reference above, this is to inform you that the above stated claim has not been admissible since Mr.Nikhil Tandon was hospitalized from 15.12.2015 to 27.12.2015 at Max Super Speciality Hospital with diagnosis Post DDH, Bilateral Hip Joint and Underwent bilateral Total Hip Replacement.
Further as per the information, the patient if covered under National Mediclaim Policy, which does not cover the expenses incurred for the treatment of Congenital External Disease (Development Dysplasis of Hip is Congential and patient has history of Bilateral operated Hip Joint 24 yrs. Back) vide exclusion clause 4.5, hence the claim is not admissible."
The aforesaid denial made by the Opposite Parties is not tenable in the eyes of law because the policy obtained by the son of the complainant is not a fresh policy, as no fresh proposal form has been placed on record. It is pertinent to note that son of the complainant i.e. Nikhil Tandon was already insured at the time of his birth under Group Mediclaim Policy and when he took employment, individual policy was obtained by the complainant for his son in the year 2014-15. It is not to be considered as a fresh policy and it is a continuous mediclaim policy. So, we are of the view that the Forum rightly held in para Nos. 11 to 13 of the impugned order, which reads thus :-
"11 The above contention raised by the OPs, is not tenable in the eyes of law for the reason recorded hereinafter. Record reveals that no fresh proposal form has been placed on record which was ever filled by the complainant or by his son to prove that the policy obtained by the complainant in his son's name is a fresh policy. Nothing has been placed on record by the OPs to corroborate the fact that the insured Nikhil Tandon is not entitled for the continuous coverage. On the contrary it is well proved on record that the son of the complainant was duly insured with the OPs since the time of his birth under Group Mediclaim Policy obtained by his father (the complainant) and remained covered under the said policy until an individual/separate mediclaim policy was obtained by the complainant for his son in the year 2014-15 by paying an extra premium of Rs.5,194/-
12 In the given circumstances, it is observed that the policy obtained by the complainant for his son is not to be considered as fresh policy but for all intent and purposes, it is a continuous mediclaim policy. So, the son of the complainant is duly entitled for the benefit of 48 months continuous coverage. It is duly mentioned in the policy issued in favour of the son of the complainant as under:-
"This insurance shall be extended after 48 months of continuous coverage has elapsed since inception of the first policy to pay any expenses incurred relating to the disease(s)/sickness/injury mentioned in the row "pre-existing disease/exclusions" and for consequences attributable thereto or accelerated thereby or arising therefrom, in respect on the respective insured person."
13 The fact is clear that the son of the complainant remained covered without break with the OPs since his childhood, so, it is the case of high-hand-ed-ness as well arbitrariness on the part of the OPs who wrongly denied the claim for the medical expenses incurred for the treatment of the insured i.e. the son of the complainant stating that the policy obtained in the year 2014-15 is fresh policy and insured is not entitled for continuous benefit of the policy."
We are of the opinion that son of the complainant remained covered without break with the Opposite Parties since his childhood, so the Opposite Parties wrongly repudiated the claim of the complainant. Hence, the order passed by the Forum, being based on the correct appreciation of evidence and law, on the point, does not suffer from any illegality or perversity.
14. For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same stands dismissed, with no order as to costs. The order of the Forum is upheld.
15. Certified Copies of this order be sent to the parties, free of charge.
16. The file be consigned to Record Room, after completion.
Pronounced.
February 5th, 2018.
[JUSTICE JASBIR SINGH (RETD.)] [PRESIDENT] [DEV RAJ] MEMBER (PADMA PANDEY) MEMBER rb