State Consumer Disputes Redressal Commission
Oriental Insurance Company Ltd. vs Rakesh Kumar on 22 January, 2016
1
2nd Additional Bench
PUNJAB STATE CONSUMER DISPUTES REDRESSAL
COMMISSION,
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
Misc. Application No. 3160 of 2015
In/and
First Appeal No. 1194 of 2015
Date of institution: 10.11.2015
Date of decision : 22.01.2016
The Oriental Insurance Company Limited, Branch Office-II, Ground
Floor, Jeevan Rakshak Building, S.C.O. No. 50, PUDA Complex,
Jalandhar, through its Branch Manager, through its Regional Office at
SCO No. 109-110-111 Sector 17 D Chandigarh-160017
.....Appellants/OPs
Versus
1. Rakesh Kumar Arora son of Jiwan Lal R/o H.No. 393-R, Model
Town, Jalandhar.
.......respondent No. 1/complainant
2. E-Meditek Service Limited, Corporate Office, Plot No. 577,
Udhyog Vihar, Phase-V, Gurgaon (Haryana)-122016
. .......Proforma Respondent
Appeal against the order dated 29.09.2015
passed by the District Consumer Disputes
Redressal Forum, Jalandhar.
Before:-
Sh. Gurcharan Singh Saran, Presiding Judicial Member
Sh. Jasbir Singh Gill, Member Mrs. Surinder Pal Kaur, Member Present:-
For the appellant : Sh. Pradeep Kumar, Advocate GURCHARAN SINGH SARAN (PRESIDING JUDICIAL MEMBER) This appeal has been preferred by appellant/OP No. 1(hereinafter referred as 'OP') under Section 15 of the Consumer Protection Act, 1986 (hereinafter referred to as 'Act') against the First Appeal No. 1194 of 2015 2 order dated 29.09.2015 in C.C. No. 377 of 27.10.2014 passed by the learned District Consumer Disputes Redressal Forum, Jalandhar (in short the 'District Forum') vide which the complaint filed by the respondent/complainant (hereinafter referred as 'complainant') was allowed with directions to OP No. 1 to pay Rs. 2,00,000/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till the date of payment and further directed to pay Rs. 3000/- on account of litigation expenses. Misc. Application No. 3160 of 2015 (Delay):-
2. There is an application under section 5 of the Limitation Act moved by the appellant for condonation of delay of just 5 days in filing the appeal. Keeping in view of the reasons, given in the application, duly supported by an affidavit and that delay is just of 5 days in filing the appeal. Therefore, this application is accepted and delay of 5 days in filing the appeal is hereby condoned.
Misc. Application stands disposed of.
Main Case
3. Complainant Rakesh Kumar Arora had filed the complaint under section 12 of the Act against the OPs on the averments that he obtained Happy Family Floater under the Silver Pan insurance policy hospitalization benefit covering risk to reimburse/indemnify expenses for any illness/ailment, disease or injury sustained from OP No. 1 vide cover note 783532 dated 18.06.2012 followed by renewal effective from the period 28.06.2012 to 27.06.2013 covering himself and his wife Smt. Sudesh Arora and son Sunil Arora for sum assured of Rs. 2,00,000/- after payment of premium of Rs. 6922/-. He had been taking the policy since 2008 without any gap/break. Complainant had First Appeal No. 1194 of 2015 3 pain in his chest and on examination he was diagnosed as a case of inferior valve MI and was admitted on 10.03.2013 and discharged on 12.03.2013 from Tagore Hospital and Care Centre Pvt. Ltd., Jalandhar after successful primary PTCA+Stent and he paid Rs. 2,01,000/- besides Rs. 2720.20 incurred on medicines. He lodged a claim with OPs. However, to the utter surprise and dismay of the complainant, OP No. 2 vide their letter dated 05.07.2014 unilaterally, and arbitrarily intimated that the claim was not payable. OP No. 2 wrongly, perversely and unilaterally invoked exclusion clause 4.3 to repudiate the claim. This act of OPs amounted to deficiency in services. Hence, the complaint with directions to OPs to pay/reimburse the amount of Rs. 2,00,000/- alongwith interest @ 12% per annum from the date of lodging the claim till date of actual payment, Rs. 50,000/- as compensation and Rs. 10,000/- as litigation expenses.
4. The complaint was contested by OP No. 1 whereas presence of OP No. 2 was dispensed with. OP No. 1 in its written reply/version took preliminary objections that the complaint was not maintainable as the complainant had got no locus standi to file the complaint.; the complainant was barred by his own act, conduct and negligence from filing the complaint. On merits, issuance of the Mediclaim policy was admitted. It was denied that the policy conditions were not supplied to the complainant. On scrutiny of the claim submitted by the complainant alongwith documents for taking treatment in Tagore Hospital, Heart Care Centre, Jalahdhar, the disease had two years waiting period, therefore, cannot be paid because there was no policy prior to 28.06.2011. The claim of the complainant was repudiated on First Appeal No. 1194 of 2015 4 valid ground. There was no deficiency in service on the part of OP No. 1. The complaint was without merit and it be dismissed.
5. Before the District Forum, parties adduced evidence in support of their contentions. Complainant tendered into evidence his affidavit Ex. C/A, copy of policy Ex. C-1, covering letter of the policy Ex. C-2, information under RTI Ex. C-3, letter dated 13.03.2013 Ex. C-4, claim form Ex. C-5, claim intimation dated 14.03.2013 Ex. C-6, policy Ex. C-7, policy schedule Ex. C-8, discharge summary Ex. C-9 (colly), receipt Ex. C-10 to Ex. C-15, cover note Ex. C-16, affidavit of the complainant Ex. CB, Doppler Study Ex. C-17 & Ex. C-18, report dated 25.12.2012 Ex. C-19, Exercise Stress Test Report Ex. C-20, medical reports Ex. C-21 to Ex. C-23 and closed the evidence. On the other hand OPs tendered into evidence affidavit of Sandeep Thapa, Senior Divisional Manager Ex. OP-A, copy of cover note Ex. O-1, proposal form Ex. O-2, copy of dispatch register Ex. O-3, repudiation letter Ex. O-4, claim form Ex. O-5, discharge summary Ex. O-6, PA individual policy schedule Ex O-7, Happy Family Floater policy schedule Ex. O-8 and closed the evidence.
6. After going through the allegations as alleged in the complaint, written reply filed by OPs, evidence and documents on the record, the learned District Forum allowed the complaint in terms stated above.
7. Aggrieved with the order of the District Forum, the appellant/OP No. 1 has filed this appeal.
8. In the appeal, it has been argued by the counsel for appellant/OP No. 1 that there was no evidence brought on record by the complainant that Inferior Valves MI was not direct consequence of hypertension. If there was pre-existing disease, then exclusion First Appeal No. 1194 of 2015 5 clause 4.3 shall be applicable according to which treatment for hypertension was not payable for two years. Accordingly, clause 4.3 was rightly made applicable to repudiate the claim. This fact was not properly appreciated by the District Forum. Mediclaim policy issued by OP No. 1 in favour of the complainant is admitted. He was admitted in Tagore Hospital, Jalandhar on 10.03.2013 and had undergone primary PTCA+Stent and was discharged on 12.03.2013. Hospital charged Rs. 2,01,000/-, apart from medicine charges 2720.20. The claim was lodged, whereas OPs repudiated the claim under clause 4.3. Repudiation letter is Ex. O-4 dated 05.07.2013. Repudiation clause 4.3 reads as under:-
4.3 The expenses on treatment of following ailment/disease/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy. If these diseases are pre-existing at the time of proposal the exclusion No. 4.1 for pre-existing conditions SHALL be applicable in such cases.
I. Benign ENT disorders and surgeries i.e. Tonsillectomy, 1 year Adenoidectomy, Mastoidectomy, Tympanoplasty etc. II. Polyscistic Ovarian diseases 1 year III. Surgery of Hernia 2 years IV. Surgery of Hydrocele 2 years V. Non Infective Arthritis 2 years VI. Undescendent testes 2 years VII. Cataract 2 years VIII. Surgery of Benigin-Prostatic hypertrophy 2 years IX. Hysterectomy for menorrhagia or fibromyoma or myomectomy or 2 years prolapse of uterus X. Fissure/Fistula in anus. 2 years XI. Piles 2 years XII. Sinusitis and related disorders 2 years XIII. Surgery of gallbladder and bile duct excluding malignancy 2 years XIV. Surgery of genitor-urinary system excluding malignancy 2 years XV. Pilonidal sinus 2 years XVI. Gout and Rheumatism 2 years XVII. Hypertension 2 years XVIII. Diabetes 2 years XIX. Calculus diseases 2 years XX. Surgery for Prolapsed inter vertebral disk unless arising from 2 years accident XXI. Surgery of varicose veins and baricose ulcers 2 years XXII. Joint replacement due to degenerative condition 4 years XXIII. Age related osteoarthritis and Osteoporosis 4 years First Appeal No. 1194 of 2015 6 As is clear from the discharge summary on the record as Ex. C-9, the patient had undergone successful primary PTCA+Stent. According to this clause, expenses of the above referred disease was not payable for a specific period. It includes only hypertension, not any part disease Primary PTCA+Stent. Therefore, it cannot be a pre-existing disease. Counsel for the appellants has argued that hypertension was direct result of heart disease for which the complainant had to undergone primary PTCA+Stent and summary disclosed that patient was suffering from hypertension. It is pertinent to mention here that the period from which he was suffering from hypertension has not been referred. Counsel for OP No. 1 has not been able to refer any document on record that hypertension was direct result of heart disease from which insured was suffering. District Forum has referred that the heart problem can be due to various factors, which fact has not been denied by the counsel for the appellant. So far as the expert evidence is concerned, in case, appellant/OP No. 1 is repudiating the claim saying that hypertension was the direct result of heart disease, then onus was upon the appellant/OP No. 1 to bring such evidence. But no such evidence was brought on record. Therefore, we are of the opinion that the order passed by the District Forum is justified. Counsel for the appellant/OP No. 1 was unable to make out any point for admission of the appeal. The same is hereby dismissed in liminie.
9. The appellants had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal. The amount of Rs. 25,000/- with interest accrued thereon, if any, be remitted by the registry to respondent No. 1/complainant by way of a crossed First Appeal No. 1194 of 2015 7 cheque/demand draft after the expiry of 45 days of sending the certified copy of the order to the parties, subject to stay, if any, by the higher Fora/Court.
10. Remaining amount shall be paid by the appellants to respondent within 30 days from the receipt of the copy of the order.
11. The arguments in these appeals were heard on 19.01.2016 and the order was reserved. Now the order be communicated to the parties as per rules.
(GURCHARAN SINGH SARAN) PRESIDING JUDICIAL MEMBER (JASBIR SINGH GILL) MEMBER (SURINDER PAL KAUR) MEMBER January 22, 2016.
Rupinder