State Consumer Disputes Redressal Commission
M/S Universal Sompo General Insurance ... vs Gulbir Singh Anand on 29 March, 2017
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No.03 of 2016
Date of institution : 04.01.2016
Date of order reserved : 23.01.2017
Date of decision : 29.03.2017
M/s Universal Sompo General Insurance Co., SCO No.72,
First Floor, Swastik Vihar Sector-5, Sector-5, MDC
Panchkula (Haryana).
...Appellant/OP No.4
Versus
1. Gulbir Singh Anand, PPO No.11774, resident of House
No.155, New Mehar Singh Colony, Tripuri, Patiala
(Punjab).
Respondent No.1/Complainant
2. Indian Overseas Bank a body corporate duly constituted
under the Banking Companies (Acquistion and Transfer of
Undertakings) Act, 1970 having its Central Office at 762,
Anna Salai, Chennai.
3. Indian Overseas Bank through its Manager, Tripuri Branch,
Tripuri Tower, Patiala (Punjab).
4. M/s E-Meditech TPA Services Ltd., SCO 56, 1st Floor,
Sector 30-C, Chandigarh.
....Respondents/OP No.1,2 & 3
First Appeal against the order
dated 19.10.2015 passed by the
District Consumer Disputes
Redressal Forum, Patiala.
Quorum:-
Mr. Gurcharan Singh Saran, Presiding Judicial Member
Mrs. Surinder Pal Kaur, Member
F.A. No. 03 of 2016 2
Present:-
For the appellant : Sh. Rajeev Abhi, Advocate
For respondent No.1 : None
For respondent No.2,3&4: Ex-parte
MRS. SURINDER PAL KAUR, MEMBER
ORDER
Appellant/Opposite Party No.4 (hereinafter referred as "OP") has filed the present appeal against the order dated 19.10.2015 passed by District Consumer Disputes Redressal Forum, Patiala (hereinafter referred as "District Forum") in Consumer Complaint No.15/78 dated 20.04.2015 was allowed and OP No.4 was directed to pay Rs 1,50,000/- with interest @ 9% per annum from the date of repudiation i.e. 29.04.2014 till realization. It was also directed to pay Rs.10,000/- as compensation for harassment and Rs 7500/- as litigation costs within 30 days from the receipt of the copy of the order.
2. Complaint was filed by the complainant/respondent (hereinafter referred as complainant) under Section 12 of the Consumer Protection Act, 1986(in short the Act) wherein complainant averred that OP No.1 (Indian Overseas Bank) had launched a Group Health Insurance Scheme for its retired employees i.e Retired Employees Medical Assistance Scheme (REMAS) vide circular dated 26.07.2012 covered the employees and their spouse for a sum of Rs.1,50,000/- by way of medical assistance. After paying Rs.11,650/- a policy bearing No.2816/52396325/01/000 for the period 01.07.2013 to F.A. No. 03 of 2016 3 30.06.2014 was issued by OP No.4. Complainant was suffering from knee problem and he was admitted in Fortis Hospital, Mohali on 16.02.2014 and was discharged on 23.02.2014. After replacement of both the knees the said hospital charged a sum of Rs.3,32,162/-. The complainant raised a claim of Rs.1,50,000/- under the mediclaim policy bearing no 2816/52396325/01/000 through said hospital. The hospital sent the claim under the REMAS scheme but OP No.3 namely E-Meditech Services Ltd (TPA) had repudiated the claim of the complainant vide letter dated 29.04.2014 on the ground that three years waiting period for the ailment of osteoarthritis as per terms and conditions of the policy whereas, this condition was not disclosed to complainant at the time of issuing the policy. Repudiation of his genuine claim amounted to deficiency in service on the part of OPs. Hence, complaint was filed before the District Forum seeking directions against OPs:-
(i) to pay Rs. 1,50,000/- with interest @ 24% per annum from the date of lodging of the claim;
(ii) to pay Rs.50,000/- as compensation for mental tension and harassment;
(iii) to pay Rs. 11,000/- as litigation costs.
3. At the time of admission of complaint District Forum observed that complainant had challenged the repudiation of claim Rs.1,50,000/- against OP No.3 & 4. Vide order dated 22.04.2015 District Forum issued the notice to OP No.3 & 4 only. F.A. No. 03 of 2016 4 However, OP No.3 did not appear before the District Forum inspite of due service therefore, proceeded against ex-parte on 08.07.2015.
4. Complaint was contested by OP No.4 who filed written reply by taking the preliminary objections that the claim of the complainant did not fall under the policy, therefore, claim was rightly repudiated vide letter dated 29.04.2014. Complainant obtained Group Health Insurance Policy No.2816/52396325/01/000 for the period 01.07.2013 to 30.06.2014 subject to the terms and conditions of the policy. Claim of the complainant was registered at Serial No.100041408048. Complainant remained admitted in Fortis Hospital at Mohali, for the treatment of osteoarthritis both knees from 16.02.2014 to 23.02.2014. He was diagnosed with bilateral knee replacement on 17.02.2014. There is three years waiting period for the ailment of osteoarthritis in the policy and the same commenced from 01.07.2013. The claim was rightly repudiated vide letter dated 29.04.2014 as the complainant had not completed with three years waiting period as per terms of the policy. There is no deficiency in service on its part. On merits, it was pleaded that no premium was paid by the complainant to this OP as such complainant is not its consumer. OP No.1 had obtained the said policy alongwith terms and conditions. Complainant was intimated with regard to the claim in question by this OP. Complainant remained admitted in Fortis Hospital at F.A. No. 03 of 2016 5 Mohali, for the treatment of osteoarthritis both knees from 16.02.2014 to 23.02.2014. The claim of the complainant was rightly repudiated as three years waiting period for the ailment of osteoarthritis as per Exclusion No.2 of terms and conditions of the policy was not completed as the policy commenced from 01.07.2013 to 30.06.2014 and insured got the knees replacement on 17.02.2014 within a period of one year. It prayed for dismissal of the complaint with costs.
5. The parties produced evidence in support of their respective averments before the District Forum, after going through the same and hearing learned counsel on their behalf, allowed the complaint, vide aforesaid order.
6. In support of their allegations, the complainant tendered into evidence as affidavit C-A alongwith documents i.e. Ex.C-1 to Ex.C-16 and closed his evidence. On other hand OP No. 4 tendered into evidence affidavit of Sh. Piyush Shankar as Ex.OPA alongwith documents i.e. Ex.OP-1 to Ex.OP-7 and closed the evidence.
7. Aggrieved against the order passed by the District Forum appellant/OP No.4 has filed the present appeal.
8. We have heard learned counsel for appellant/opposite party No.4 and have carefully gone through the record of the District Forum.
F.A. No. 03 of 2016 6
9. It was argued by the learned counsel for the Appellant/OP that District Forum failed to consider the terms and conditions of the policy. Complainant remained admitted in the Fortis Hospital for the treatment of osteoarthritis both knees from 16.02.2014 to 23.02.2014. The policy commenced w.e.f 01.07.2013 and was upto 30.06.2014. Insured first admitted in Fortis Hospital on 16.02.2014 within a period of one year. He had not completed three years waiting period for the ailment of osteoarthritis as per Exclusion Clause No.2 of the policy. It prayed for to set aside the impugned order and to accept the appeal.
10. Complainant/insured Gurpreet Singh had taken Group Health Insurance Scheme with appellant/OP No.4 for the period 01.07.2013 and was upto 30.06.2014 after paying the premium of Rs.11650/- for sum assured Rs.1,50,000/-. Complainant was admitted in Fortis Hospital on 16.02.2014 to 23.02.2014 for knees replacement and he spent Rs.3,32,162/- on his treatment. The claim of the complainant was repudiated vide letter dated 29.04.2015 (Ex.OP-1) on the following grounds:
"You were admitted for treatment of osteoarthritis both knee admitted from 16.02.2014 to 23.02.2014 presented with c/o pain in both knees associated with walking in difficulty & climbing stairs diagnosed with osteoarthritis both knee managed with bilateral knee replacement on 17/2/14. Policy inception Date: 01-07-2013. There is 3 years F.A. No. 03 of 2016 7 waiting period for osteoarthritis. Hence under Basic Coverage Exclusion (2) this claim is repudiated. We invite your attention to the following exclusions in the policy. 1)Basic Coverage Exclusions (2)-(The waiting period for the ailments of Joint Replacement due to degenerative conditions and Age related osteoarthritis and osteoporosis is 3 years under this policy.)
11. The core question, which falls for consideration, is, as to whether, case of the complainant falls under terms and conditions of the policy.
Policy terms and conditions have been placed on the record Ex.OP-6 and in the coverage there is a column WHAT WE EXCLUDE : Exclusion clause 3 reads as under:
1. Xxxxxxx
2. xxxxxxx
3. "Hospitalization/Domiciliary Hospitalization expense incurred in the first year of operation of the insurance cover on treatment of the following Diseases • Xxxxxxx • Xxxxxxxx • xxxxxxxx • Arthritis, Gout, Rheumatism • Joint replacement unless due to accident. F.A. No. 03 of 2016 8
However, when the policy schedule was issued by the OPs, on the back of the policy OPs referred Clauses/Endorsements attached to the policy which read as under:-
Clause 6 :- 30 days waiting period and first year exclusions are waived off under the Policy and Exclusion number 2 and 3 of Section (What we exclude stands-deleted).
Therefore, according to these conditions Exclusion number 2 and 3 of Section (What we exclude stand deleted). Therefore, once these clauses were deleted, counsel for the OPs was not able to refer to any other provision how there is a waiting period for three years for the treatment of joint replacement. The objections raised by the counsel for the OP about the waiting period of three years will not applicable. Moreover, the counsel for the OP was unable to refer any clause whereas, there is waiting period of three years for joint replacement.
12. In these circumstances, the order passed by the District Forum is perfectly justified and we affirmed the same.
13. No other point was argued.
14. Sequel to above we don't see any merit in the appeal. The same is hereby dismissed.
15. The Appellant/OP No.4 has deposited Rs.25,000/- at the time of filing of the appeal and Rs.1,33,768/- in compliance with order dated 11.01.2016. Both the amounts along with interest which had accrued thereon, if any be remitted by the registry to the Respondent/Complainant by way of cheque/demand draft F.A. No. 03 of 2016 9 after the expiry of 90 days of the sending of certified copies of this order to the parties.
16. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
17. Order be communicated to the parties as per rules.
(Gurcharan Singh Saran) Presiding Judicial Member (Mrs. Surinder Pal Kaur) th March 29 , 2017 Member SK