Haryana

Karnal

CC/113/2018

Om Parkash - Complainant(s)

Versus

Branch Manager Canara Bank - Opp.Party(s)

Gulshan Galhatra

11 Sep 2019

ORDER

 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                     Complaint No.113 of 2018

                                                         Date of instt. 09.05.2018

                                                         Date of decision:11.09.2019

 

Om Parkash son of Shri Ishar Dass resident of Dairy Mohalla Taraori.

                                                                      

…….Complainant

                                                  Versus

 

1. Branch Manager Canara Bank Sector 12 Karnal.

2. Apollo Munich Health Insurance Company Ltd. Central Processing Center 2^nd and 3^rd floor ILABS Centre plot no.404-405 Udyog Vihar Phase-III Gurgaon-122016.

                                                                       .…..Opposite Party.

 

           Complaint u/s 12 of the Consumer Protection Act. 

         

Before    Sh. Jaswant Singh……President. 

                Sh. Vineet Kaushik………Member

                Dr. Rekha Chaudhary……Member

 

 Present:  Shri Gulshan Galhotra Advocate for complainant.

                   Shri Rajesh Kumar Sachdeva Advocate for OP no.1.

                   Shri Rahul Bali Advocate for OP no.2.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that Smt. Shanti Devi purchased a health insurance policy from the OP no.1, vide policy no.120100/12001/2016/A005425/PE00394781 on 22.12.2016 and the agent of the OP no.1 assured that if Smt. Shanti Devi will be hospitalized for any illness/disease/injury the bill will be reimbursed by the insurance company upto 5,00,000/-. The policy in question was issued after completion of all necessary and requisite formalities and considering Smt. Shanti Devi fit and eligible for the same. On 28.03.2017 when Smt. Shanti Devi returned back from morning walk suddenly she felt pain in her chest and the pain become swear after sometime. She was taken by her son to the life care hospital Karnal where the doctor gave her medicine and some test were performed i.e. ECG and ECHO, after gone through the test reports the doctor said that as per the test condition is normal but he suggested ANGIOGRAPHY for the satisfaction. On the next day i.e. 29.03.2017 Smt. Shanti Devi alongwith his son went to G.B. Pant Hospital for ANGIOGRAPHY and she was got admitted. On 30.03.2017 the doctor done the ANGIOGRAPHY after going through the report the doctor advised the By Pass Surgery and told that near about 150 person are waiting for BY Pass Surgery in our hospital and its takes long time and suggested to go Max Hospital Padpatganj Delhi. On 30.03.2017 Smt. Shanti Devi admitted in the Max Hospital Padpatganj Delhi for By Pass Surgery and sent the information through hospital to OP no.2 for Cashless Claim. The agent of the OP no.2 came in the hospital and enquired about the admission of Smt. Shanti Devi in hospital. The office staff of the OP no.2 sent the information to the hospital department that the claim of Smt. Shanti Devi has repudiated. Bypass surgery performed upon the person of Smt. Shanti Devi went unsuccessful and she could not survive and expired on 2.4.2017. The complainant paid a sum of Rs.2,00,000/- to the hospital for the treatment of Smt. Shanti Devi. As per insurance policy the OPs are legally bound to pay the claim of treatment of Smt. Shanti Devi and because of the act of the OPs the complainant has sustained financial loss besides mental pain, agony etc. The OP is liable to make the payment of Rs.2,00,000/- the paid amount to the hospital and Rs.2,00,000/- suffered on account of deficiency in service and unfair trade practice on part of OPs. Thereafter, complainant requested the OPs so many times to reimburse the bill but OPs postpone the matter on one pretext or the other. Then complainant sent a legal notice dated 02.01.2018 to the OPs in this regard but it also did not yield any result. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, OP no.1 appeared and filed written version stating therein that OP no.1 is a corporate Agent of OP no.2. The OP no.1 is a corporate body under working Regulation Act and doing the business of Banking having its Head office at J.C. Road, Banglore and among other branches one of the Branch is situated at Sector-12, Urban Estate Karnal whereas the OP no.1 is solely Insurance Company and governed by Insurance Regularity Authority. Both the OPs are having different companies having different business. It is further stated that Gulshan Kumar son of Shri Om Parkash resident of House no.25 Dairy Mohalla, ward no.13, Taraori District Karnal is having a Saving bank account with OP and on 28.12.2016 a sum of Rs.4857/-+4857/- was paid to the OP no.2 and the said amount was debited to the said Gulshan Kumar except this OP no.1 is not at all  concerned with other affair by purchase of policy terms of policy and repudiation of claim if and by OP no.2 etc. It was not out of place to mention here that Smt. Shanti Devi might have purchased an Insurance Policy from the OP no.2 after providing full and correct information to OP no.2. There is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.2 filed his separate written version raising preliminary objections with regard to maintainability; locus standi; complaint is bad for mis-joinder and non-joinder of necessary parties and present complaint is not maintainability and liable to be dismissed for it has been lodged in the backdrop of a premature claim and also its false and incorrect. On merits, it is pleaded that on 31.03.2017, cashless receipt was received from Balaji Medical and Diagnostic Research Centre, Delhi for Shanti Devi  (age 66 years)  who was  got admitted with complaint on 30.03.2017 and estimated cost of Rs.2,46,650/-. Post receiving the documents, legal query was raised for:

“Kindly provide exact duration of present illness with first prescription when diagnosed, provide all previous treatment records related to present illness, provide investigation reports of the patient supporting the diagnosis, provide latest photo of the patient.” After reviewing reply, further query was made “Cardiac marker test reports. ECG and ECHO report. All past records of treatment taken for chest pain/heart ailment.” Further query was revised: “Cardiac market test reports. All treatment records pertaining to chest pain and breathless prior to 28.03.2017.” From the reply received, the facts were not clear, so the case was sent for verification, where it was observed from investigator’s report that to get PED rule out, deep investigation was needed and which was not possible at that point of time so case was rejected: “Cashless facility cannot be extended as possibility of the present ailment being of Pre-existing nature cannot be ruled out based on the available/provided documents. However, insured can file the claim for reimbursement post completion of the treatment with all medical and financial records. The admissibility of the claim would be decided post review of the documents and policy conditions” The complainant had not submitted the claim in reimbursement till now. There is no deficiency in service on the part of the OP no.2 and prayed for dismissal of the complaint.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C18 and closed the evidence on 27.03.2019.

5.             On the other hand, OP no.1 tendered into evidence affidavit of Pawan Kumar Senior Manager Ex.RW/A and closed the evidence 25.07.2019.

6.             OP no.2 tendered into evidence Deepti Rustagi Ex.RW1/A and documents Ex.R1 to Ex.R4 and closed the evidence on 19.08.2019.

7.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

8.             The case of the complainant, in brief, is that Smt. Shanti Devi purchased a health insurance policy from the OP no.1, vide policy no.120100/12001/2016/A005425/PE00394781 on 22.12.2016 and the agent of the OP no.1 assured that if Smt. Shanti Devi will be hospitalized for any illness/disease/injury the bill will be reimbursed by the insurance company upto 5,00,000/-. On 28.03.2017 when Smt. Shanti Devi returned back from morning walk suddenly she felt pain in her chest and the pain become swear after sometime and she was got admitted. On 30.03.2017 the doctor done the ANGIOGRAPHY after going through the report the doctor advised the By Pass Surgery. On 30.03.2017 Smt. Shanti Devi admitted in the Max Hospital Padpatganj Delhi for By Pass Surgery and sent the information through hospital to OP no.2 for Cashless Claim. Bypass surgery performed upon the person of Smt. Shanti Devi went unsuccessful and she could not survive and expired on 2.4.2017. The complainant paid a sum of Rs.2,00,000/- to the hospital for the treatment of Smt. Shanti Devi. Thereafter, complainant requested the OPs so many times to reimburse the bill but OPs did not pay the claim.

9.             The case of the OP no.2 is that that on 31.03.2017, cashless receipt was received from Balaji Medical and Diagnostic Research Centre, Delhi for Shanti Devi  (age 66 years)  who was  got admitted with complaint on 30.03.2017 and estimated cost of Rs.2,46,650/-. Kindly provide exact duration of present illness with first prescription when diagnosed, provide all previous treatment records related to present illness, provide investigation reports of the patient supporting the diagnosis, provide latest photo of the patient.” After reviewing reply, further query was made “Cardiac marker test reports. ECG and ECHO report. All past records of treatment taken for chest pain/heart ailment.” Further query was revised: “Cardiac market test reports. All treatment records pertaining to chest pain and breathless prior to 28.03.2017.” From the reply received, the facts were not clear, so the case was sent for verification, where it was observed from investigator’s report that to get PED rule out, deep investigation was needed and which was not possible at that point of time so case was rejected: “Cashless facility cannot be extended as possibility of the present ailment being of Pre-existing nature cannot be ruled out based on the available/provided documents. However, insured can file the claim for reimbursement post completion of the treatment with all medical and financial records. The admissibility of the claim would be decided post review of the documents and policy conditions” The complainant had not submitted the claim in reimbursement till now.

10.            Admittedly, on 22.12.2016 Smt. Shanti Devi (since deceased) purchased a health insurance policy from OP no.2 for the sum assured of Rs.5 lakhs. On 30.03.2017 Smt. Shanti Devi went to G.B. Pant Hospital for ANGIOGRAPHY and after going through the report Doctor advised Bypass surgery. On the same day she got admitted in Max Hospital Padpatganj Delhi for Bypass surgery and sent the information through hospital to OP no.2 for cashless claim. The Bypass Surgery performed upon the person of Smt. Shanti Devi went unsuccessful and could not survive and expired on 20.04.2017.

11.            The concerned hospital has issued patient bill Ex.C9 for the sum of Rs.2,66,850/- and the complainant had deposited Rs.2 lakhs and Rs.66,850/- left unpaid at that time. It is not disputed that Smt. Shanti Devi had not gone Bypass Surgery and the complainant had not paid treatment/medical expenses. It is also admitted that the policy in question was cashless policy.

12.            The claim of the complainant had denied by the OPs on the reasons mentioned as under:-

“Cashless facility cannot be extended as possibility of the present ailment being of Pre-Existing nature cannot be ruled out based on the available/provided documents. However, insured can file the claim for reimbursement post completion of the treatment with all medical & financial records. The admissibility of the claim would be decided post review of the documents and policy conditions.”

13.            There is nothing on the file to prove that deceased life assured was having any pre-existing disease. Onus to prove the pre-existing disease upon the OP no.2, but OP no.2 totally failed to prove the same. The cashless service denied by the OP only on the ground that possibility of the present ailment being pre-existing nature. The cashless service cannot be denied on the possibility ground. As per the version of the OP no.2, OP no.2 is ready to reimburse the claim. The purpose for purchasing the policy in question by the deceased life assured has been defeated. The complainant had spent the huge amount for the treatment of her mother from his pocket. As per the policy, it was the duty of the OP no.2 to provide the cashless facility to the complainant. Thus, in our views the acts of the OP no.2 amount to deficiency in services and unfair trade practice. The sum assured in policy is Rs.5 lakhs. The treated hospital issued the bill of Rs.2,66,850/-. Thus, the complainant is entitled for the Rs.2,66,850/- as the complainant has already paid Rs.two lakhs to the hospital and Rs.66850/- is still pending.

14.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP no.2 to pay Rs.2,66,850/- to the complainant with interest @ 9% per annum from the medical bill paid date i.e. 2.4.2017 till its realization. We further direct the OP no.2 to pay Rs.30,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:11.09.2019                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

 

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                           Member