BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.237 of 14

Date of Institution: 05-05-2014

Date of Decision: 12-05-2015

Balwinder Singh son of S.Joginder Singh, resident of VPO: Dashmesh Nagar, Tehsil: Baba Bakala, District Amritsar.

Complainant

Versus

1. Bajaj Allianz General Insurance Company Limited, Registered Office: GE Plaza, Airport Road, Yerwada, Pune-411006, through its Managing Director/ General Manager/ Principal Officer.
2. Bajaj Allianz General Insurance Company Limited, Branch Office: SCO-31, K.K.Towers, District Shopping Complex,  Ranjit Avenue, Amritsar-143001, through its Branch Manager/ Principal Officer. 

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act, as amended upto date.

Present: For the Complainant: Sh. S.S.Channa, Advocate.

              For the Opposite Parties: Sh.R.P.Singh, Advocate.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member 

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Balwinder Singh under the provisions of the Consumer Protection Act alleging therein that he obtained a Star Extra Care medical policy bearing No.OG-12-1210-6009-00000010 issued on 23.2.2012 valid upto 22.02.2013 from the Opposite Parties and paid the premium of Rs.23,415/-. Complainant alleges that in the said policy, star package of critical illness, health guard and extra care benefits were given to the complainant including his wife Smt.Sukhjinder Kaur and one child Baldeep Singh. On 19.5.2012 the complainant fell ill and got himself admitted in KD Ganesha Hospital Private Limited, Amritsar where various tests were got conducted by the doctors and it was found that the complainant was suffering from cirrhosis of liver  and it was also diagnosed that the complainant is suffering from HCV Positive, therefore, the treatment was prescribed and initial treatment was given in the hospital and after taking treatment, the complainant discharged from the said hospital on 20.5.2012 and an amount of Rs.3800/- was paid. As the complainant was suffering from HCV Positive, therefore, he was recommended to administer injections weekly and as per the advice, the complainant started getting injections administered. The cost of one injection is Rs.10,000/- and cost of medicines is more than Rs.2,000/- per week and till date 48 injections have been injected and the complainant has to pay more than Rs.5,00,000/- on his treatment. After that, the complainant submitted all the medical bills to the Opposite Parties for its reimbursement, but till date, neither the medical expenditure has been reimbursed nor any reason has been given why the medical expenditure has not been reimbursed. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to refund the amount of Rs.5,01,113/- alongwith interest @ 12% per annum. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Parties  appeared and filed written version in which it was submitted that the complainant has not come to this Forum with clean hands. In this case, as per verification of the documents, reveals that the complainant was hospitalized for the treatment of cirrhosis of  liver with  portal hypertension, space occupying lesion of liver with speenomegaly on 19.3.2012. The policy was incepted on 23.2.2012 and it does not cover the expenses incurred on the treatment of any illness which was diagnosed or was diagnosable during the first 30 days of the first  policy year. As such, the claim of the complainant was rightly repudiated vide letter dated 17.2.2014. It is admitted that  the complainant  obtained a Star Extra Care medical policy bearing No.OG-12-1210-6009-00000010 issued on 23.2.2012 valid upto 22.02.2013 from the Opposite Parties and paid the premium of Rs.23,415/-. Complainant alleges that in the said policy, star package of critical illness, health guard and extra care benefits were given to the complainant including his wife Smt.Sukhjinder Kaur and one child Baldeep Singh. However, it is denied that the officials of the Opposite Parties had specifically told to the complainant at the time of issuance of policy that all the diseases are covered under the policy. It is submitted that alongwith the policy, the terms ad conditions were also provided to the complainant ad the complainant is bound as per the terms and conditions of the policy. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.CW1/A alongwith documents Ex.C1 to Ex.C163 besides copies of admission and discharge register Ex.CX to CZ and closed the evidence on behalf of the complainant.
4. Opposite Parties tendered into evidence affidavit of Sh.Navjeet Singh, Senior Executive Legal Ex.OP1,2/1 alongwith copies Ex.OP1,2/2 to Ex.OP1,2/5 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant obtained  medical insurance policy bearing No.OG-12-1210-6009-00000010 issued  by the Opposite Parties  on 23.2.2012 for the period from 23.2.2012 to  22.02.2013 namely Star Extra Care Ex.OP1,2/2.   On 19.5.2012, the complainant fell ill and was admitted in KD Ganesha Hospital Private Limited, Amritsar where various tests of the complainant were got conducted by doctors and it was found that the complainant was suffering from cirrhosis of liver  and HCV Positive. Initial treatment of the aforesaid disease was given  to the complainant in the hospital and the complainant was discharged from the said hospital on 20.5.2012. The complainant paid an amount of  Rs.3800/- to the hospital authorities. As the complainant was suffering from HCV Positive, therefore, he was recommended to administer injections weekly. The cost of one injection is Rs.10,000/- and cost of medicines is more than Rs.2,000/- per week and till date, the complainant has got  48 injections injected and he has to pay more than Rs.5,00,000/- on his treatment. The complainant submitted all the medical bills to the Opposite Parties for reimbursement, but the Opposite Parties  did not settle the claim of the complainant and the complainant was forced to file the present complaint.     Ld.counsel for the   complainant  submitted that all this amounts to deficiency of service on the part of the opposite parties.
7. Whereas the case of the opposite party is that from the verification of the documents produced by the complainant, it is clear that the complainant was hospitalized for the treatment of cirrhosis of lever with portal hypertension, space occupying lesion of liver with speenomegaly on 19.3.2012, whereas the date of commencement of the policy  is 23.2.2012 and it does not cover the expenses incurred on the treatment of any illness which was diagnosed or was diagnosable during the first 30 days of the first year policy. So the claim of the complainant was rightly repudiated by the Opposite Parties  vide letter dated 17.2.2014. Opposite Parties  submitted that the complainant obtained medical policy on 23.2.2012 valid upto 22.02.2013 namely Star Extra Care   and extra care benefits were given to the complainant including his wife Smt.Sukhjinder Kaur and one child Baldeep Singh. Opposite Parties  denied that the complainant became ill on 19.5.2012 and admitted in KD Ganesha Hospital Private Limited, Amritsar on 19.5.2012, rather he was admitted in KD Ganesha Hospital Private Limited, Amritsar on 19.3.2012 whereas the Opposite Parties  denied all other averments of the complainant as alleged in the  complaint and ultimately submitted that the Opposite Parties  were justified in repudiated the claim of the complainant vide letter dated 17.2.2014 Ex.OP1,2/5.  Ld.counsel for the Opposite Parties  further submitted that as per the terms and conditions of the policy Ex.OP1,2/3, the liability of the Opposite Parties  is to pay a sum of Rs.159,589/- only because as per the policy, the Opposite Parties are liable to pay the expenses incurred by the insured within 90 days from the date of discharge from the hospital as per the clause 13 of the terms and conditions of the policy Ex.OP1,2/3.   On the other hand, ld.counsel for the complainant submitted that Opposite Parties  can not go beyond the pleadings because in the pleadings, no date has been mentioned that Opposite Parties  are liable to pay the medical expenses  of the insurance upto 90 days from the date of discharge from the hospital.    Ld.counsel for the Opposite Parties  submitted that there is no deficiency of service on the part of the Opposite Parties .
8. From the entire above discussion, we have come to the conclusion that the complainant got   medical insurance policy from the Opposite Parties  bearing No.OG-12-1210-6009-00000010  Ex.OP1,2/2 for the period from 23.2.2012 to  22.02.2013 named Star Extra Care.  The complainant became ill and he got various tests conducted from different labs and ultimately, he was  admitted in KD Ganesha Hospital Private Limited, Amritsar on 19.5.2012 and there also, various tests of the complainant were conduced and he was found suffering from cirrhosis of liver  and HCV Positive. After giving Initial treatment of the aforesaid disease, the complainant was discharged from   the hospital  on 20.5.2012 as is evident from the discharge card  Ex.C3/ Ex.OP1,2/4. The plea of the Opposite Parties that the complainant became ill on 19.3.2012 and he was admitted in KD Ganesha Hospital Private Limited, Amritsar on 19.3.2012 and discharged on 20.3.2012  is not tenable because the Opposite Parties could not produce any evidence to the effect that the complainant was admitted in KD Ganesha Hospital Private Limited, Amritsar on 19.3.2012. No doubt, there was correction in dates of admission and discharge in the discharge card of complainant Ex.C3/ Ex.OP1,2/4. So, this Forum vide order dated 9.2.2015 to clear this doubt, called the record of KD Ganesha Hospital Private Limited, Amritsar i.e. register of admission of patients  as well as complete treatment record of complainant Balwinder Singh. This record was produced by Sh.Suresh Kumar, Receptionist of KD Ganesha Hospital Private Limited, Amritsar on 19.2.2015, copy of admission and discharge register is Ex.CX and CY which proves that on 19.3.2012, one Balwinder Kaur wife of Chanan Singh was admitted in KD Ganesha Hospital Private Limited, Amritsar whereas Balwinder Singh son of Joginder Singh, insured complainant was admitted in that hospital on 19.5.2012 and was discharged on 20.5.2012. But inadvertently, KD Ganesha Hospital Private Limited, Amritsar authorities have wrongly mentioned the date of admission of Balwinder Kaur on the discharge card of complainant Balwinder Singh. Apart from this, this Forum has summoned the record of KD Ganesha Hospital Private Limited, Amritsar which has been produced by Suresh Kumar, Receptionist of KD Ganesha Hospital Private Limited, Amritsar i.e. copy of patient record, department of medicines (bill No. 372)  Ex.CZ which also proves that complainant was admitted in the aforesaid hospital on 19.5.2012 and discharged on 20.5.2012. So, it stands fully proved on the record that the complainant was admitted in KD Ganesha Hospital Private Limited, Amritsar on 19.5.2015 and was discharged on 20.5.2015 and he was diagnosed suffering from cirrhosis of liver  and HCV Positive and he was given  Initial treatment  and the complainant has to get injections administered for HCV Positive every week. The cost of one injection is Rs.10,000/- and cost of medicines is more than Rs.2,000/- per week and the complainant has got  injected 48 injections and has spent more than Rs.5,00,000/- on his treatment as per bills Ex.C5 to Ex.C48 and bills of medicines Ex.C59 to Ex.C125 and other tests, reports, copies of which are Ex.C132 to Ex.C160. The complainant has also paid Rs.3800/- to KD Ganesha Hospital Private Limited, Amritsar as per bill Ex.C4.
9. As per the terms and conditions of the policy i.e. condition No. 13, the insured is entitled to reimbursement of the amounts spent on medical treatment and essential investigations for a period upto 90 days after the discharge from the hospital. The complainant has produced bill of Rs.4,92,385/-, but the complainant is not entitled to the reimbursement of the amount spent by him on his medical treatment beyond 90 days from the date of discharge from the hospital as it is out of the scope of post hospital limits of the terms and conditions of the policy.
10. Ld.counsel for the complainant submitted that the Opposite Parties are not entitled to deduct the aforesaid amount on the ground that this plea was not taken by the Opposite Parties in their written version and the Opposite Parties  can not go beyond the pleadings. In this regard, ld.counsel for the complainant relied upon the ruling  of Hon’ble Supreme Court of India in case: Kalyan Singh Chouhan Vs. C.P.Joshi in Civil Appeal No. 870 of 2011 (Arising out of SLP © No. 16944 of 2010, decided on 24.1.2011, in which it has been held that the parties can not be permitted to travel beyond their pleadings.  We have gone through he aforesaid ruling of Hon’ble Supreme Court of India in case: Kalyan Singh Chouhan Vs. C.P.Joshi (supra) and have come to the conclusion that the facts of the present case are quite different from the facts of case decided by Hon’ble Supreme Court of India, because in that case, the parties have not pleaded the actual facts in their versions. But in the present case, the parties are bound by the contract of insurance between the parties and its terms and conditions of the policy. After going through the entire record, we do not agree with the contention of the ld.counsel for the complainant because the parties are governed under the terms and conditions of the policy and it is not necessary to mention the terms and conditions of the policy in the pleadings, particularly when the complainant has come to this Forum on the basis of policy as well as terms and conditions of the policy which are binding upon both the parties.
11. The Opposite Parties  have given the detail of deduction of the amount spent by the complainant on his medical treatment beyond 90 days from the date of discharge from the hospital which is reproduced as under:-

12. In the  arguments of the complainant, ld.counsel for the complainant  could not rebut these calculations, rather from the bills produced by the complainant, it shows that he has lodged claim of the bills with the Opposite Parties which are even beyond the period of coverage of policy because the policy of the complainant was for the period from 23.2.2012 to 22.2.2013, but the complainant has claimed the amount of  bill dated 9.3.2013 (Ex.C42), bill dated 23.2.2013 (Ex.44) ; bill dated 10.3.2013 (Ex.C45) and dates of most of the bills are not legible such as bills on Ex.C16 to Ex.C35, Ex.C43, Ex.C46 to Ex.C48. So from the entire above discussion, we are of the opinion that the complainant is entitled to reimbursement of the amount, he has spent on his medical treatment for the period he remained admitted in aforesaid KD Ganesha Hospital Private Limited, Amritsar and upto 90 days from the date of discharge from the hospital which amounts to Rs.1,59,589/-. The complainant is therefore, held entitled to reimbursement of Rs.1,59,589/-.
13. Resultantly, the complainant is partly allowed with costs and the Opposite Parties  are directed to pay this amount of Rs.1,59,589/- alongwith interest @ 9% per annum from the date of filing of the complaint till the payment is made to the complainant. The Opposite Parties  are also directed to pay the costs of litigation to the complainant to the tune of Rs.2000/-.   Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 12-05-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                 (Kulwant Kaur Bajwa)    (Anoop Sharma)

              Member                         Member