Delhi

West Delhi

CC/03/562

Narender Narang - Complainant(s)

Versus

Branch Manager New India Assurance Co. Ltd - Opp.Party(s)

29 Jul 2017

ORDER

CONSUMER DISPUTES REDRESSAL FORUM (WEST)

                            GOVERNMENT OF NCT OF DELHI

  150-151 Community Centre, C-Block, JanakPuri, New Delhi – 110058

 

                                                                                     Date of institution:11.08.2003

Complaint Case. No. 562/2003                                     Date of order:29.07.2017

IN  MATTER OF

NarenderNarangS/o Sh. K.D. Narang R/o D-1/8, RajouriGarden , New Delh-27.

Complainant

VERSUS

Branch Manager New India Assurance Co. Ltd., S-1, Ajay  Enclave, Near Ajanta Cinema, New  Delhi.

                                                                                                                             Opposite party

ORDER

R.S. BAGRI,PRESIDENT

             Sh. NarenderNarang named above hearein  the complainant  has filed  the present  consumer complaint  under section 12 of the Consumer Protection Act against Branch Manager, New India Assurance  Co. Ltd.  herein after in short referred  as the opposite party  for directions to the opposite party  to pay  medical expenses of Rs. 38081/- , Rs. 25,000/- compensation for harassment , mental agony and wastage  of time and Rs. 11,000/-  towards cost of  legal notice  and litigation.

The brief  relevant  facts necessary for disposal of the present complaint as

 

stated  are that the complainantis a mediclaim policyholder no. 4832020305903  for the period  from 25.04.1999 to 24.04.2000 for  assured sum ofRs. 1,50,000/-  of the opposite party.

            That the complainant in March-April  1999 had  acute headache.  He was diagnosed acute ethmoidsinusitieand  maxillarysinusitie.Doctors  suggested and advised him  surgery .  On21.05.1999  he was admitted inSitaramBhartiaInstitute of Science and Research,  New Delhi .   Where he was operated.  He paid total sum of Rs.  38,081/- towards  expenses of the operation and medicines.  He also incurred more expenses on medicinesand investigationsetc.  The complainant filed claim no.99/00/0017 under the insurance policy with the opposite party  with all details.

            That the opposite party vide letter dated 16.07.1999 asked the complainant  to furnish detail regarding tenure of the  disease. The complainant replied the letter with certificate from the doctor, who performed the operation of the complainant.   The opposite party  vide letter dated 28.09.1999 again asked the complainant to provide the same details.  The complainant vide his letter dated 04.10.1999 again supplied the details.  The opposite party did not considerhis letterand certificate ofthe  doctor and closed  claim of the complainant without assigning any reason  and even did not send intimation to the complainant.   The

 

complainant when on 28.07.2000  approached the opposite  party with  certificate

of his doctor who had gone abroad  during the   intervening period,  to  know about closure of his claim.  The opposite party on written request of the complainant reopened his case.  The opposite party vide letter dated 14.09.2000 again repeated  the same story.  The complainant  again requested his doctor  to give opinion as required by the opposite party.  Who  gave opinion on 13.10.2000.Which was submitted to the opposite party  with letter dated 17.10.2000. The complainant  several times visited  office of the opposite party  in connection with his claim.But to no effect and lastly in January 2001 received letter dated 02.01.2001 from the opposite party of repudiation of his claim on flimsy and illegal  ground without any valid reason with malafideintention just to harm andharass the complainant .  Therefore,  the complainant  sent  legal notice dated 12.12.2002 to the  opposite party.  The opposite party without considering the legalnotice gave long and detailed reply suggesting for a certificate specifying duration of cronicsinusitie and DNS  from the doctor.  The opposite party failed  to pay the mediclaim  of the complainant and repudiated  his claim on flimsy and illegal  grounds.Hence the present complaint for directions to the opposite party to pay Rs. 38,081/- of medical expenses ,Rs. 25,000/- for compensation for harassment, mental agony and wastage  of time  and Rs. 11,000/-  towards cost of legal notice and litigation  expenses. 

            Notice of the complainant wassent to the opposite party.  The opposite party appeared.  But did not file reply to the complaint.  However, the opposite party  filed written submissions  admitting  that the complainant  is holding mediclaim  insurance policy no. 4832020305903 for  the period from 25.04.1999 to 24.04.2000 for insured sum of Rs. 2,00,000/-. The opposite party received claim papers of the complainant on 10.06.1999 with discharge summary etc. from SitaramBhartia Institute of Science and Research,  New Delhi confirming that the complainant was  suffering from Rhino  Pan Sinusitis  and  FESS and septoplasty were done  under  General Anaesthesia  on 21.05.1999. But asserted thatclaim  papers of the complainant  were sent by the opposite party to their paneldoctor  Batra for his opinion on admissibility .  Dr. Batra opined that claim could be further processed  on receipt of following documents from the complainant:-

1.        Certificate from the treating  doctor regarding  duration of illness.

2.        Nasal  Endoscopy Report  dated 22.04.1999.

3.        Certain medical prescriptions.

            The complainant submitted certain papers with certificatedated 03.08.1999 of Dr. Kacker.But the Certificate did not show duration of his illness.  The complainantwasagain requested to send fresh certificate with the information.  The panel doctor in hisreport dated 16.10.1999 opined that usually deviated Nasal Septum is Congenital  unless it took place after Trauma to the nose.Endoscopy  report of the complainant  confirm that the complainant  had marked  Nasal   Deviated  Septum   probably  caused  frequent headache and report from

Dr. Kacker  regarding   duration of illness was required.  The opposite party send the claim papers of the complainant to panel doctor for opinion four times and on all the occasions the simple question was not answered.  Therefore,  the opposite party  vide  letter  dated  02.01.2001  advised the complainant  that in view of his willful refusal  to  obtain certificate from the treating doctor regarding  duration of illness, the claim is not tenable.   Therefore, the claim of the complainant was rightly  repudiated.

WhenSh. NarenderNarangcomplainant wasasked to file evidence by way of affidavit he filed affidavit narrating facts of the complaint.  He also relied upon policy no. 4832020305903, receipt no. 228318 dated 22.04.1997, letter  dated 10.06.99 written by the complainant  to the opposite party of intimation of the surgery , bill dated 03.08.1999, certificate of Dr. Indar S. Gupta,  prescription slip  dated 27.3.1999,discharge summary from SitaramBhartia Institute of Science and ResearchNew Delhi dated 22.05.1999, prescription slip dated 17.04.1999,  report dated 26.03.1999 with treatment record, Bill no. 1479 dated 22.05.1999, letter dated  16.07.1999 written by the opposite party to the complainant, reply of the complainantdated 19.08.1999, letter  dated 28.09.1999written by the

 

opposite party to the complainant,  reply dated 04.10.1999  of the complainant, letter dated 05.11.1999 written by the opposite party  to the complainant,  reply dated 03.12.1999 of the complainant, letter dated 03.02.2000 written by the complainant to the opposite party  with certificate of Dr. Kacker, letter dated 28.07.2000  written by the complainant to  the opposite party  with certificate of Dr. Kacker dated 28.07.2000, letter dated 14.09.2000 written by the opposite party to the complainant, opinion dated 13.10.2000, letter dated 17.10.2000 written by the complainant to the opposite party  and repudiation letter dated 02.01.2000.

            When the opposite party was asked to file evidence by way of affidavit  they filed affidavit  of Sh. Vijay Anand  Additional Manager narrating facts of the written submissions.

            We have heard learned counsel for the parties and have gone through the material on record carefully and thoroughly. 

            From the complaint, affidavits, documents and written submissions of the party it is a common case of the parties that the complainant had medclaim policy   no. 4832020305903 of the opposite party for the period from 25.04.1999 to 24.04.20000 with assured some of Rs. 2,00,000/-.  The case of the complainant is that  he had acute headache in March-April  1999.   He was admitted and operated

 

inSitaramBhartia Institute of Science and Research,  New Delhi on 21.05.1999.   He was discharged on 22.05.1999.He paid Rs.38,081/- for the treatment.  The complainant submitted claim with  theopposite party.  The opposite party asked for following for processing his claim:-

1.        Certificate from the treating  doctor regarding  duration of illness.

2.        Nasal  Endoscopy Report  dated 22.04.1999.

3.        Certain medical prescriptions.

            The complainant asked the treating doctor to issue necessary documents.  Dr. Kacker, gave three certificates  dated 03.08.1999, 28.07.2000 and 13.10.2000. Dr.  Kackerinopinion  dated 27.08.1999 opined :-

“ Mr. NarenderNarang( CR No. 50429 dated4.5.99 ) was  admitted  for acute  headache of one and a half months duration.  The CA 1  scan hadshown evidence of  acute ethmiodsinusitie and  maxillary  sinusitie. He was treated for the same medically and surgically.  The diseasecanoccure after viral infection and allergy in a short period of few months.

Dr. kacker in in letter dated 28.07.2000 opined as under:-

“Mr.NarenderNarang (CR No.50429  dated04.05.1999) continuation clarification of certificated dated 03.08.99 and discharge summarydated

22.05.1999.  As clarified the FESS along withseptoplastywas done.   Septoplasty

is necessary as an approach to paranasalpansinus clearance by an endoscope  in cases who has associated Deviated Nasal Septum (DNS). The Biopsy report confirm presence of  enthiodsinusitie which is a part of Paranasalpansinusitie (PNS),(dated 24.05.99) ”

            Dr.  Kacker in opinion dated 13.10.2000 opined as under:-

            “MrNarenderNarang  was operated for  infection in ethmoidsinusitie was operatated. The instruments could not be introduced on the side because of deviated  septum.  In order to reach it a septoplasty was done to allow endoscope to be introduced for surgery of FESS Deviated Nasal Septum  was coincidental and primary cause of amplants was acute ethmoid sinus  infection  and other mucosal disease as already certified.”

            The Opposite partydid not satisfy with certificates dated 27.08.1999, 28.07.2000 and 13.10.2000 of Dr. Kacker, treating surgeon  of the complainant, and repudiated claim of the complainant  vide letter dated 02.01.2000 on the following ground :-

“The certificate provided  by you was  forwarded to our panel doctor   whose conclusion is this- the certificate  again does not provide the specific reply to a very simple query about  the duration for which the   patient  was having the duration for which the patient was having DNS.  Hence no further comments are possible.

            As such you claim is not tenable.”

            From the pleadings of the parties, documents and affidavits filed by the parties it is  admitted case of the parties  that the opposite party repudiated  claim of the complainant on the sole ground  that the complainant  failed to produce certificate from the treating doctor  regarding duration of  illness.  The complainant   from the affidavit   and treatment record has been able to prove  that  he was suffering from ethmoidsinusitie.  He was admitted in SitaramBhartia Institute of Science and Research,  New Delhi on 21.05.199, operated  and  discharged on 22.05.1999.  He paid a sum of Rs. 38081/- to SitaramBhartia Institute of Science and Research,  New Delhi for his treatment .  Dr. Kacker in certificates dated 04.05.1999, 28.07.2000 and 13.10.2000 has specifically  mentioned  that the complainant  was suffering  from ethmoidsinusitie.   The disease canoccure after viral infection, allergy in a short period of months.  Which shows that the treating  doctorhas given duration of  illness of the complainant  a few months.  Even otherwise there is no term or condition  in the insurance policy  according to which  duration of disease  is required for processing  medical claim of the complainant.  Therefore, the opposite party without any reasonable ground arbitrarily repudiatedclaim of the complainant .   Hence there is unfair trade practice and deficiency  in service on the party of the opposite party.

            Therefore we direct the opposite party to  pay Rs. 38081/- to  the complainant,  expenses  made on treatment  with interest  @ 9% p.a. from the date of  filing the present claim till actual realization of the  amount   and pay a sum of Rs. 11,000/- as cost of litigation.

            Order pronounced on :29.07.2017

• Compliance of the order be made within 30 days after receipt of the order.
• Copy of order be sent to the concerned parties free of cost.
• Thereafter, file be consigned to record.

                  

 

(PUNEET LAMBA)                                                              ( R.S.  BAGRI )

                         MEMBER                                                                        PRESIDENT