State Consumer Disputes Redressal Commission
Ashish H Prajapati vs The United India Ins Co Ltd on 29 September, 2023
Details DD MM YY
Date of disposal 29 09 2023
Date of filing 25 05 2017
Duration 04 04 06
BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION
GUJARAT STATE AHMEDABAD.
COURT NO: 02
APPEAL NO. 330 of 2017
Ashish H. Prajapati
Res: C/34, Mangal Darshan Society,
Nr. Chanakyapuri Char Rasta,
New Sama Road,
Vadodara. ....Appellant
V.s
1. The State of Gujarat
2. United India Insurance Co. Ltd.
Office at: 1st floor, Wakaskar Chambers,
Raopura, Baroda -390001.
3. Vipul Medicorp Pvt. Ltd.
Office at: 449-450, Phoenix Complex,
Near Suraj Plaza, Sayajigunj,
Vadodara. ...Respondents
Before: Ms. A. C. Raval, Presiding Member
Appearance: J. R. Oza, Ld. Adv. for the appellant,
Mr. V. P. Nanavaty, L. A. for the respondent no.2.
ORDER BY MS. A. C. RAVAL, PRESIDING MEMBER.
JUDGMENT
1. The appellant/original complainant has preferred this fist appeal as per the provision of Section 15 of the Consumer Protection Act, 1986 against the impugned order passed by the Ld. District Consumer Disputes Redressal Commission, Vadodara (Main) (for short Ld. District Commission) in complaint no.40/2014 dated 29.04.2017 on the grounds stated in the appeal memo. Therefore, for the sake of convenience parties are referred to by their original nomenclature/status.
Akshay A/330/2017 Page 1 of 72. Brief facts of the case as narrated in the complaint are that the complainant had taken medi claim policy from opponent no.1 with policy no. 180500/48/12/06/00 006800 for the period 23.12.2012 to 22.12.2013 for sum insured of Rs.2,00,000/-. Complainant was hospitalized for 3 days from 06.03.2013 to 08.03.2013 in Shivam Surgical Hospital, Baroda. The total expense incurred was Rs.32,151/-. The complainant has lodged the claim and submitted all the requisite documents. Opponents had rejected the complainant's claim on the ground that "during the first two years of life operation the expense on this disease as satractr prostatic calciles, fistula etc are not payable so this claim is repudiated as per the policy clause no.4.3." Therefore, the complainant has filed the complaint.
3. I have heard the Ld. Adv. Mr. Darshil M. Parikh on behalf of Ld. Adv. Mr. V. P. Nanavaty for the respondent no.2.
Arguments of the appellant:
4. Appellant has filed written arguments which are considered for deciding the matter. It is stated by the appellant that the respondent no.2 and 3 had conspired and rejected the claim and had not taken into consideration the facts that though the policy being continuous policy since more than 5 years, the claim needs to be granted. It is further stated that the shifting of the policy from New India Insurance Company Limited to United India Insurance Company Ltd. during the period 23.12.2012 to 22.12.2013. The TPA Medicorp Pvt. Ltd. (respondent no.3) had informed the appellant that the appellant shall get all the benefits as the appellant is changing the company only, the mediclaim policy will be continuous policy. The conditions which are mentioned for the rejection were never declared, informed or instructed by the opponents to the complainant at any time before the filling up the form. The opponent no.2 had only informed that the complainant's policy shall cover all the disease and is in continuation of the Akshay A/330/2017 Page 2 of 7 existing medical policy, only the insurance company is changed. The insurance company failed to bring on record any of the documents/evidence which shall prove that the said conditions were known or informed or instructed to the complainant before filling of the mediclaim policy form. The insurance company has rejected the genuine claim of the opponent on the flimsy ground of waiting period of 2 years from the inception of the policy. The Ld. District Commission has also erred in concluding that the policy terms and conditions are binding to the complainant and the waiting period of 2 years will apply in case of the compliant and has erred in rejecting the genuine claim against the facts and law and is required to quashed and set aside and the appeal may be allowed. Arguments of the Respondent:
5. Ld. Adv. appearing for the respondent argued that the complainant has produced certain documents with his reply which are not part of the record of the Ld. District Commission hence those documents cannot be looked into consideration. Even otherwise, the appellant has not produced the additional document with the application for production of additional document at admission stage hence, this cannot be considered at this stage. The argument of the appellant that the policy is continuous policy is not tenable, there is no mentioning in the policy about the portability. The policies on which the reliance has been made are united health care insurance policies issued by New India Insurance Co. Ltd., in tie up with union bank, in the name of the complainant only. While the policy issued by the respondent company is family medi care policy where the appellant and his wife are covered under the policy. These are two different type of policies. The policy with the respondent company is different than the policy produced at Annexure K, L, M and N. The policy issued by the respondent insurance company has nothing to do with the policy produced at Annexure K to L. Unnecessarily the appellant has mixed up the two type of policies.
Akshay A/330/2017 Page 3 of 7There was no portability. The complainant has never raised the contention to the non-providing of terms and condition in his complaint and it is totally an afterthought while arguing the matter. The complainant has taken the treatment of Fistula can be seen from the discharge summary. Therefore, the insurance company has rightly repudiated the claim of the complainant relying upon the clause 4.3 of the terms and conditions of the policy. The order passed by the Ld. District Commission is just, proper and valid and does not required any interference and this appeal may be dismissed.
Merits of the case:
6. The period of policy, coverage and the sum insured are undisputed facts for deciding the present case. The complainant was admitted in Shivam Surgical Hospital from 06.03.2013 to 09.03.2013. the discharge summary is produced at page 22. The insured was operated for Fistula. The medical certificate to be filled up by the Doctor is produced at page 23 where in Column 10: nature of surgery it is mentioned that the patient was treated for Fistula. The repudiation letter is produced at page no.36. The relevant portion reads as under:
"Please note that your file stands closed, on account of Sr. No. 1 and 3 below :-
(1) Inspite of letters/ reminders sent to you, you have not complied with the required papers/documents. (2) As you have withdrawn your claim by giving your consent through your letter dated ___________ we are closing your claim -file as NO CLAIM (3) We are closing your claim - file, on account of the following reason:-
DURING THE FIRST TWO YEARS OF THE OPERATION THE EXPENSES ON THIS DISEASE AS CATRACR PROSTAITIC CALCILES, Akshay A/330/2017 Page 4 of 7 FISTULA ETC ARE NOT PAYABLE SO THIS CLAIM IS REPUDIATED AS PER POLICY CLAUSE NO 4.3."
7. While deciding the claim of the complainant, the reliance is made on clause no.4.3 of the policy condition. Clause 4.3 of the policy condition is produced at page no.43 which reads as under:
"4.3 During the first two years of the operation of the policy, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hyperthrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, piles, Sinusitis and related disorders, Gail Bladder Stone removal, Gout & Rheumatism, Calculus Disease, Joint Replacement due to Degenerative Condition and age-related Osteoarthiritis & Osteoporosis are not payable."
8. Now in the light of the aforesaid facts, if claim of the complainant being evaluated, it is the admitted position that the complainant has undergone the surgery during the second year of the policy with the respondent company. The copy of the policy schedule is produced at page 61 to 62. The first policy with the respondent insurance company was taken for the period 23.12.2011 to 22.12.2012. The policy was renewed for the period 23.12.2012 to 22.12.2013. The treatment is taken by the complainant in the second year of the policy and as per the policy condition clause no.4.3, it is very much clear that during the first 2 years of the operation of the policy, the expense of treatment of disease such as Fistula is not payable. I have gone through the discharge summary and claim form, the complainant was diagnosed and operated for Fistula, hence, he is not entitled for the reimbursement of the expenses incurred for the treatment. Terms and conditions of the policy are binding to both the parties.
9. It is the contention of the appellant/original complainant that the terms and conditions were never provided to the complainant before filling up the form. The complainant himself has produced copy of Akshay A/330/2017 Page 5 of 7 the policy with the respondent company at page 61 and 62, 2 pages of the policy booklet have been produced by the complainant. Even otherwise this contention is not raised by the complainant in the complaint. Perusing the order passed by the Ld. District Commission, it seems that the complainant has not taken this contention of non-providing of terms and conditions before filling up the form. This ground of non-providing of documents have been raised at the appeal stage, hence, this ground is not available to the complainant at this stage.
10. The another contentions of the complainant is that this policy is continuous policy, earlier the complainant has taken the policy from the New India Insurance Company through Union Bank of India. The complainant has produced the copy of the earlier policies at annexure k to n. Those policies are taken through the Union Bank of India. The subject policy issued through Union Bank and name is United Health care insurance policy. It was master policy and the certificate of policy was issued to its account holders. The certificate is issued in the name of Ashish H. Prajapati. Other family members are not included in the policy. The complainant has tried to mix up the two different policies, the policy taken from the respondent company is family medi care policy which is a personalised policy and not a master policy. There is no endorsement on the policy about portability or port-in-facility. Even otherwise these documents have been produced by the appellant first time at the stage of appeal without any application for production of additional evidence on record. There is no link between the two policies hence this documents are even otherwise not helpful to the case of the appellant. This commission of the view that the insurance company has rightly repudiated the claim of the complainant based on condition no.4.3 which is binding to both parties and the order passed by the Ld. District Commission is just, Akshay A/330/2017 Page 6 of 7 proper and fair and it is required no interference. Hence in the interest of justice, I pass the following order.
ORDER
1. The appeal No. 17/330 filed by the appellant/original complainant is hereby dismissed.
2. Impugned order passed by the Ld. District Consumer Disputes Redressal Forum, Vodadara (Main), in Consumer Complaint No. 40/2014 dated 29.04.2017 is hereby confirmed.
3. No order as to costs.
4. Registry is hereby instructed to send a copy of this order in PDF format by E-mail to Ld. District Forum, Vodadara (Main) for taking necessary action.
5. Office is directed to forward a free of cost certified copy of this judgment and order to the respective parties.
Pronounced in the open Court today on 29th September, 2023.
[A. C. Raval] Presiding Member Akshay A/330/2017 Page 7 of 7