National Consumer Disputes Redressal
New India Assurance Co. Ltd. vs Nanak Singla And Ors on 30 January, 2015
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 717 OF 2013 (From the order dated 20.12.2012 in Appeal Nos. 1258 and 1372 of 2012 of the Haryana State Consumer Disputes Redressal Commission, Panchkula) 1. The New India Assurance Co. Ltd., Having its registered Head Office At New Delhi Through its Divisional Manager Building no. 87 Mahatma Gandhi Road Fort, Mumbai 2. The New India Assurance Co. Ltd. Petitioners Near S D College, G T Road Panipat Through its Divisional Manager Vs 1. Nanak Singla Son of Shri Panna Lal 2. Shri Shila Singla Wife of Shri Nanak Singla Resident of House no. 657 Model Town, Panipat, Haryana Respondents 3. Raksha TPA Pvt. Ltd., 15/5 Mathura Road Faridabad Through its Authorised Signatory BEFORE: HON'BLE MR. JUSTICE AJIT BHARIHOKE PRESIDING MEMBER HONBLE MRS REKHA GUPTA MEMBER For the Petitioners Mr Vishal Yadav, Advocate For the Respondents Mr Aditya Vikram, Advocate for R 1 & 2 R 3 Already ex parte Pronounced on 30th January 2015 ORDER
REKHA GUPTA Revision petition no. 717 of 2013 has been filed against the order dated 20.12.2012 of the Haryana State Consumer Disputes Redressal Commission, Panchkula (the State Commission) in Appeal nos. 1258 and 1372 of 2012.
2. The facts of the case as per respondent nos. 1 and 2/ complainants are that the respondents had obtained a hospitalization and domiciliary hospitalization policy/ medical claim policy bearing no. 353900/ 48/ 20/ 70050324. The said policy was valid from 29.12.2004 to 28.12.2005. The said policy was in the name of Shri Nanak Singla and respondents were shown as insured persons. The said policy was renewed on various times, i.e., the respondents had taken the aforesaid hospitalization and domiciliary hospitalization policy/ medical claim policy no. 353900/ 48/05/20/70050358 and the said policy was renewed vide policy no. 353900/34/07/20/00000034 and policy no. 353900/34/08/11/00000334 which was valid from 09.09.2008 to 08.09.2009 and then had taken another policy no. 353900/34/09/11/00000452 which was valid from 09.09.2009 to 08.09.2010. All the aforesaid policies were in the name of Shri Nanak Singla - respondent no. 1.
3. The respondent no. 2 felt some trouble in the year 2009 in her uterus for which she consulted a doctor at Panipat and Delhi and various tests were conducted on respondent no. 2 and thereafter at Citizen Hospital. She consulted a Doctor at Sri Ganga Ram Hospital, Rajinder Nagar, New Delhi, where the respondent no. 2 was diagnosed as suffering from Uterine Fibroid with Hemorrhagic. The doctors at Ganga Ram Hospital, New Delhi advised the respondent no. 2 to get operated. The respondent no. 2 agreed to it and she was admitted in Ganga Ram Hospital, where she was operated upon by the competent doctors and was discharged from the said hospital on 04.11.2009.
4. The respondent no. 2 had to spent a huge amount of money at Ganga Ram Hospital, New Delhi and she lodged a claim of Rs.99,759/- with the New India Assurance Co. Ltd., (petitioner herein) and respondent no . 3 ( Raksha TPA Pvt. Ltd.,) regarding the aforesaid medical policy which the respondent no. 2 with her husband respondent no. 1 had taken from the New India Assurance Co. Ltd. The insurance company on receiving the claim from the respondents referred the claim case of the respondents to respondent no. 3 herein, i.e., Raksha TPA Pvt., Ltd. Respondent no. 3 the third party claim administrator Pvt. Ltd., which examines the medical claims lodged with the insurance company and decides whether to allow the medical claim or to repudiate the same.
5. After discharge from Ganga Ram Hospital, the respondent no. 2 was admitted to Citizen Hospital, New Delhi for further treatment of post operation. In the Citizen Hospital, also, the respondent no. 2 spent an amount of Rs.22,295.45 towards medical charges and claim to this effect was also lodged with the insurance company and respondent no. 3.
6. At the behest of the insurance company the respondents sent all the original documents including bills and all the reports to the insurance company and the respondent no. 3, i.e., Raksha TPA Pvt. Ltd., The respondents have been writing to the insurance company to release their aforesaid medical claim.
7. The respondents received a letter dated 07.07.2010 and vide this letter the respondent no. 3 had repudiated the aforesaid medical claims of the respondents without going into the facts of the case properly. It was wrongly mentioned that the medical claim of the respondent was not covered under the aforesaid medical claim policy of the respondents.
8. The repudiation claim by the insurance company was on false and flimsy grounds which amount to deficiency of service on the part of the insurance company. The insurance company has not gone through the complete records properly.
9. Respondents have prayed that the complaint of the respondents be accepted and the insurance company be directed to pay Rs.2,00,000/- to the respondents on account of deficiency in service along with interest of Rs.2500/- on account of mental agony and harassment suffered by the respondents due to deficiency in service on the part of the insurance company.
10. Petitioners/ OP no. 1 in the reply before the District Forum stated that the respondents took the medical policy, vide policy no. 353900/ 48/04/ 20/70056324, which was valid from 29.12.2004 to 28.12.2005, policy no. 353900/48/05/20/70050358 valid from 11.01.2006 to 10.01.2007, policy no. 353900/34/07/20/0000034 valid from 16.04.2007 to 15.04.2008, policy no. 353900/34/08/11/00000334 valid from 09.09.2008 to 08.09.2009, policy no.
353900/34/09/11/00000452 valid from 09.09.2009 to 08.09.2010 for the sum assured of Rs.2.00 lakh in favour of the respondents with the terms and conditions of the insurance policy.
11. Respondent no. 3, i.e., Raksha TPA Pvt Ltd., had registered the claim of the insured/ respondents vide claim no. 905101136467 after receiving the intimation from the insured/ respondents vide MAID no. N 9010216121. The Raksha TPA Pvt. Ltd., had immediately scrutinized the documents of treatment of the respondents no. 2 as well as the prescription of doctors, who had given treatment to the respondents no. 2/ insured. The respondents submitted the claim form of respondent no. 2 along with other relevant documents, i.e., treatment record of Ganga Ram Hospital, Delhi and treatment record of Citizen Hospital, Delhi along with cash memos etc. The Raksha TPA Pvt. Ltd., scrutinized the documents of the respondents and found that the claim of the respondents/ insured stand non-payable/ tenable due to the following reasons as under:
Claimant no. 2 admitted and diagnosed fibroid uterus with Menorrhagia LAVH with B/L Salpingo Oopherectomy done. Since, there is a gap of five months in the renewal of the policy from September 2008, hence, the policy considered on 2nd year according to T & C of the policy. Since Hysterectomy comes under 2 year exclusion hence, claim is not payable. Fibroid Uterus with Menorrhagia for Lavh with B/L Salpingo Oopherectomy.
12. Respondent no. 3 sent the denial letter through registered post to the respondents vide letter dated 07.07.2010. The said letter was duly received by the respondents, hence, respondent no. 3, i.e., Raksha TPA Pvt., Ltd., was not liable to pay any compensation/ claim to the respondents.
13. The District Consumer Disputes Redressal Commission, Panipat (the District Forum) vide their order dated 24.09.2012 while allowing the complaint has observed as under:
We have heard both the parties at length and have also gone through the entire evidence and relevant record available on file carefully. In the present complaint there is no dispute with regard to policy of insurance which was taken by the complainant known as hospitalization benefit policy. Policy was continuing from 29.12.2004. Last policy was taken by the complainant covering the risk from 09.09.2009 to 08.09.2010. Complainant Shila Singla remains admitted in Ganga Ram Hospital on 01.11.2009 and filed the claim for reimbursement of the expenses with the opposite parties. Opposite parties repudiated the claim vide letter dated 07.07.2010 on the ground that there was a gap of five months in the renewal of the policy from September 2008, hence the policy is considered in the second year. Since, Hysterectomy comes under 2 years exclusion hence claims is not payable. In order to prove his case opposite parties placed the copy of insurance policy which are continuing from 29.12.2004, copy of insurance policy is Ex. R4 which is covering the risk from 09.09.2008 to 08.09.209 and further policy Ex R 5 is covering the risk from 09.09.2009 to 08.09.2010. Hence, these two policies are continuing whereas prior to this policy covering the risk from 16.04.2007 to 15.04.2008. Discharge summary clearly shows that illness occurred to the complainant for the first time in April 2009 and she was admitted in hospital on 01.11.2009 and she was diagnosed with the disease of Symptomatic uterine fibroid with menorrhagia. She was operated on 02.11.2009. Laparoscopic Hysterectomy operation was done. Opposite parties filed the terms and conditions of the Mediclaim policy. Under exclusion clause 4 which is reproduced as under:
The company shall not be liable to make any payment under this policy in respect of pre-existing diseases: All diseases/ injuries which are pre-existing when the cover incepts for the first time. And clause 4.3 waiting periods for specified diseases is shown. As per the terms of policy this waiting period is for the disease which are pre-existing at the time of inception of the policy. Hence, the interpretation of the opposite parties that under the policy all these diseases are not covered as mentioned in schedule is not tenable. Opposite parties wrongly interpret the terms and conditions of the policy. Complainant was not suffered from any disease at the time of inception of the policy. Policy was continuing since 29.12.2004 and this exclusion is not applicable to the complainant and also in two continuing policies which start from 09.09.2008. Complainant was not suffering from any illness at the time. Hence, the repudiation of the claim by the opposite parties is unjustified and amounts to deficiency in service. Complainant incurred an expenses of Rs.99,759/- as the claim filed by the complainant and bills of expenses produced by the complainant. So the complainant is entitled for the sum of Rs.99,759/-.
In view of the above discussion, the present complaint succeeds. We hereby allow the present complaint with a direction to opposite parties to pay Rs.99,759/- to the complainant with interest @ 8% per annum from the date of filing the complaint till realization. Cost of litigation quantified at Rs.2200/- is also allowed to be paid by the opposite parties to the complainant.
14. Aggrieved and dissatisfied by the order of the District Forum, the petitioners/ opposite parties 1 & 2 filed an appeal no. 1258 of 2012 and respondent nos. 1 & 2, i.e., complainant nos.1 & 2 filed an appeal no. 1372 of 2012 before the State Commission. The State Commission vide its impugned order dated 20.12.2012 dismissed the appeal. While dismissing the appeal the State Commission had observed as under:
Having considered the facts and circumstances of the case as well as the observations made by the District Forum, as mentioned above, we are of the view that since the opposite parties have not disputed the treatment taken by the complainant Shila Singla therefore, the complainants are entitled for insurable benefits under the above mediclaim policy. The plea of the opposite parties that the policy in question was not run two years and comes under the exclusion clause, is not acceptable for the reasons that the complainants have purchased the policy on 29.12.2004 and continued the policy till 2010 and therefore, the complainant are entitled for insurable benefits under the policy. The District Forum after considering each and every aspect of the case has rightly accepted the complaint and issued directions to the opposite parties as mentioned above. Learned counsel for the complainants failed to prove on the record any case for enhancement of compensation.
Accordingly both the above appeals bearing nos. 1258 and 1372 of 2010 are dismissed.
15. We have heard the learned counsel for the petitioners and respondents 1 and 2.
Respondent no. 3 was ex parte.
16. Learned counsel for the petitioner has argued that the District Forum has erroneously allowed the complaint ignoring the waiting period and awarded Rs.99,759/- with interest at 8% from the date of filing of complaint with costs of Rs.2200/-. The petitioner has issued and renewed hospitalization policy from 2004 to 2009 which was renewed by paying premium with breaks of 13 days, 3 months and 5 months. Hospitalization policy also provided terms and conditions. That on 07.07.2010 respondent no. 3 repudiated the claim of respondent nos. 1 and 2 stating that there is a gap of five months in the renewal of policy from September 2008.
17. On the other hand, the learned counsel for the respondent states that the State Commission had rightly dismissed the appeal of the petitioner and the District Forum had rightly allowed the complaint.
18. We have given our thoughtful consideration to the case. We note that the first policy was with effect from 29.12.2004. No doubt the respondent nos.1 and 2 had taken the Hospitalization and Domiciliary Hospitalization Benefit Policy for themselves since 29.12.2004 but we observe that they were not vigilant and prompt in renewing the policies. There have been gaps of 13 days, 3 months and 5 months, hence, the petitioners as per their terms and conditions have treated these policies as new policies and not as a renewal. Learned counsel for the respondent nos. 1 and 2 cold not show any provision which allows grace period for renewing this policy which covers such gaps. The claim has been repudiated on the ground that since, there is a gap of five months in the renewal of the policy from September 2008, hence, the policy is concerned in the second year according to the terms and conditions of the policy. Since Hysterectomy comes under two year exclusion hence, the claim is not payable. We have then perused the terms and conditions of the said policy. Clause 4.3 reads as under:
Waiting period for specified diseases/ ailments/ conditions:
From the time of inception of the cover, the policy will not cover the following diseases/ ailments/ conditions for the duration shown below. This exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with our company without any break.
19. In the tabular chart indicates the diseases which are not covered for the first two years as item no. 12, which reads as under:
Hysterectomy for menorrhagia/ Fibromyoma, Myomectomy and Prolapse of uterus.
20. Here, it may note that clause 4.3 states that this exclusion will be deleted after the duration shown provided the policy has been continuously renewed with our company without any break. There is no dispute that the policy was not continuously renewed as mentioned in paragraph above, hence, the Fora below have committed a grave error in concluding that the plea of the opposite parties that the policy in question was not run for two years and comes under the exclusion clause is not acceptable for the reasons that the complainants have purchased the policy on 29.12.2004 and continued the policy till 2010 and therefore, the complainants are entitled for insurance benefits under the policy.
21. Hence, the revision petition is allowed and the impugned orders of the State Commission as also the District Forum are set aside and the complaint is dismissed, with no order as to cost.
Sd/-
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[ Rekha Gupta ] Sd/-
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[ Ajit Bharihoke, J.] Satish