Punjab

Ludhiana

CC/16/211

Darshan Singh - Complainant(s)

Versus

Cholamandalam MS Gen.Ins.co.Ltd. - Opp.Party(s)

compl.in person

09 Jan 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No.211 of 16.03.2016

Date of Decision          :   09.01.2017

 

Darshan Singh Reehal, 811, Phase II, Urban Estate, Focal Point, Ludhiana-141010.

….. Complainant

Versus 

1.Cholamandlam MS General Insurance Company Limited, Dare House, 2^nd Floor, N.S.C.Bose Road, Chennai-600001, registered office.

2.Cholamandlam MS General Insurance Company Limited, 132/3, 2^nd Floor, K.L.Plaza, Opp.DIG Residence, Rani Jhansi Road, Civil Lines, Ludhiana.

 

..…Opposite parties

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.PARAM JIT SINGH BEWLI, MEMBER

 

COUNSEL FOR THE PARTIES:

For Complainant                     :       In person

For OPs                         :       Sh.Vyom Bansal, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Shorn of unnecessary details, the case of the complainant is that he purchased Chola Swasth Parivar Pearl Policy from Ops on 14.8.2012, which was duly renewed for next years on 14.8.2013, 14.8.2014 and 14.8.2015 against policies bearing Nos.2855/00100274/000/02(for the period from 14.8.2014 to 13.8.2015) and 2855/00100274/000/03 (for the period from 14/8/2015 to 13.8.2016). Mrs.Harpal Kaur Reehal, wife of the complainant was co-assured in the said policy and she was admitted in Fortis Hospital, Ludhiana on 19.10.2014 after pre-authorization clearance for cashless facility. Said Harpal Kaur Reehal was operated upon for both knees replacement on 20.10.2014. When she was convalescing well in the ward, then she suddenly suffered from breathlessness and after ECG changes, she was shifted to ICU for treatment. Finally, she was discharged from the hospital on 28.10.2014. Hospital prepared the final bill of amount of Rs.3,62,458/- which included the amount of Rs.33,520/-, the charges on account of breathlessness treatment. Insurance company cleared an amount of Rs.1 lac with deductions of 15% by claiming that Rs.85,000/- is payable. Complainant had to pay the balance amount of Rs.2,77,458/-. It is claimed that amount of Rs.85,000/- paid arbitrarily against the terms of the policy, despite the fact that the sum assured under the policy was for amount of Rs.5 lac. Claim for Rs.1 lac with deductions of 15% allowed by alleging that same is in accordance with clause 3.1.4(16) of the policy. TKR is a total knee replacement, which comes under the purview of Implant and not covered by the clause of fracture/dislocation/surgery mentioned in the policy. On repudiation of claim vide letter dated 22.01.2015 followed by detailed letter of date 24.2.2015, complainant lodged complaint with the office of Insurance Ombudsman, Chandigarh and he after hearing the case, passed award for sum of Rs.33,520/- on 14.9.2015. As that amount was not paid and as such, Ombudsman again had to serve notice upon Ops on 14.12.2015. It is claimed that Ombudsman has not touched the claim of the complainant with respect to the full amount of the total knee replacement. Reimbursement of balance amount of Rs.2,77,458/- claimed by filing this complaint.

2.                In joint written statement filed by Ops, it is admitted that the complainant and his wife were insured under the policy in question for a maximum sum of Rs.5 lac vide policy No.2855/00100274/000/02 for the period from 14.8.2014 to 13.8.2015. Benefits under the policy are governed by the terms and conditions of the policy. Liability of Ops is limited to the insured perils occurring within the policy period, subject to the conditions and exceptions as mentioned in the terms and conditions of the policy. Admittedly, after receipt of the health claim form and documents from the complainant, claim was registered regarding treatment of Smt.Harpal Kaur Reehal in Fortis Hospital, Ludhiana on 19.10.2014 for bilateral total knee replacement. Ops approved cashless treatment for hospitalization and paid amount of Rs.85,000/- after settlement. The final hospital bill of Rs.3,62,458/- also included the amount of Rs.33,520/- towards the intensive care unit charges incurred for treatment on account of breathlessness and problem of heart functioning. Ops repudiated the claim filed by the complainant and communicated the terms and conditions of the policy to the complainant vide letter dated 24.2.2015. Thereafter, the complainant approached the office of Insurance Ombudsman, Chandigarh, who upheld the decision of the insurance company qua settlement of the claim as per the terms and conditions of the policy, but by directing Ops to pay Rs.33,520/- more towards the intensive care unit charges incurred on account of breathlessness and problem of heart functioning. Insurance company has paid amount of Rs.33,520/- to the complainant vide NEFT dated 24.5.2016. As per coverage (B) Section 1(d) of the specific conditions of the insurance policy, each and every admissible claim is subject to a co-payment of 15%. Admissible cost for the claim was of Rs.1 lac in view of disease sub limit applicable as per policy coverage and after deducting 15% of the co-payment, an amount of Rs.85,000/- was duly paid. It is claimed that this Forum has no territorial jurisdiction because the policy in question was issued from Chennai. Besides, complaint alleged to be frivolous, particularly when the complainant has not approached this Forum with clean hands. Suppression of material facts alleged with intention of extorting unjust money. Complaint alleged to be filed after expiry of limitation period of two years. It is further claimed that voluminous evidence required to be adduced, due to which, Civil Court is competent to decide the controversy. Complaint alleged to be filed without any cause of action.

3                 Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C13 and thereafter, closed the evidence.

4.                On the other hand, counsel for OPs tendered in evidence affidavit Ex.RA of Sh.Ashutosh Kumar, Assistant Manager Claims(Legal) along with documents Ex.R1 to Ex.R4 and then closed the evidence.

5.                Written arguments not submitted by any of the parties. Oral arguments alone addressed and those were heard. Records gone through minutely. 

6.                Undisputedly, the policy in question was purchased by the complainant for self and wife for the period from 14.8.2014 to 13.8.2015 and treatment by Smt.Harpal Kaur Reehal (the insured-cum-wife of the complainant) got from the Fortis Hospital, Ludhiana on 19.10.2014 for bilateral total knee replacement. An amount of Rs.85,000/- for this treatment alone paid to the complainant as per the case of both the parties. Bone of contention remains as to whether the complainant entitled to full paid amount of Rs.3,62,458/- including treatment of breathlessness in ICU unit or not?

7.                Letter Ex.C1=Ex.R2 produced to establish that approval for cashless treatment for amount of Rs.85,000/- was granted by Ops by holding that as per the terms and conditions of policy, under coverage (B) Section I(d), disease sub limits are applicable. That sub limit for treatment of fracture/ dislocation/knee surgery is Rs.1 lac. As per coverage (B) Section I(d) of the terms and conditions of policy Ex.R1, the claim amount payable per person towards the treatment of fracture/dislocation/knee surgery is Rs.1 lac. That claim has been allowed as per this term mentioned at page no.7 of the terms and conditions annexed with Ex.R1 correctly are the submission of the counsel for Ops. However, complainant vehemently contends that it was a case of total replacement and as such, it was a case of Implant and not of dislocation or of fracture or of surgery. Reliance for the purpose is placed on meaning of words fracture/dislocation/surgery given in Dorland’s Pocket Medical Dictionary, copy of which produced on record as Ex.C7.

8.                Surgery is that branch of medicine which treats diseases, injuries and deformities by manual or operative methods is the meaning of the word surgery given in Ex.C7. It is not the contention of counsel for Ops that the present case is a case for treatment of fracture or dislocation of knee. As and when replacement of knee takes place, then the same also to take place for treating the deformities by manual or operative methods and as such, case of replacement of knee falls in the definition of surgery. Implant takes place by material insertion or grafted into the body for prosthetic-therapeutic, diagnostic or experimental purposes. Knee replacement is not an act of implant for grafting purposes or of experimental purposes or for diagnostic purposes and as such benefits of meaning of word of Implant given in Ex.C7 cannot be taken by the complainant. Question of replacement of knee to arise only after finding the deformity or some kind of problem or of improper functioning of the knee joint etc only. For curing all these aspects, surgery takes place for replacement of the knee joint and as such, it is not a case of implant, but it is a case of surgical treatment. If that be the position, then full insured amount of Rs.5 lac as stipulated through Ex.C11 is not payable. Rather, in Ex.C11 itself, it is mentioned that compulsory co-payment to the extent of 15% will be made in each and every eligible claim. Assured amount in this case even if may be Rs.5 lac, but the Cap of Rs.1 lac put on treatment of fracture/dislocation/knee surgery as per sub clause (d) of Section (B) of Coverage available at page no.7 of Ex.R1. So, allowing of the claim at Rs.1 lac with 15% Cap of co-payment is quite justified.

9.                Even after going through item No.59 of Ex.C12, same conclusion draw-able that in fact total replacement of knee was for correction of deformities or defects or for curing of disease. Total replacement of knee took place through surgical operation in hospital for giving relief from sufferance and as such, the present is a case, in which, surgical procedure was followed for the purpose of knee replacement. Being so, allowing of the amount of Rs.1 lac with condition of 15% co-payment is quite appropriate and inconsonance with the terms and conditions of the policy. That amount admittedly has been received by the complainant.

10.              The Insurance Ombudsman, Chandigarh vide orders Ex.R3 has allowed further amount of Rs.33,520/- on account of treatment for breathlessness and that amount allowed by keeping in view the terms and conditions of the policy and as such, complainant entitled to the amount of Rs.85,000/- referred above along with amount of Rs.33,520/- only.

11.              Therefore, as a sequel of the above discussion, complaint disposed of in terms that the paid amount of Rs.85,000/- to the complainant is appropriate in terms of the policy. However, complainant also entitled to the adjudged amount of Rs.33,520/- by the Insurance Ombudsman and if payment of the said amount of Rs.33,520/- earlier not made, then the same  be made within 30 days from the    date of receipt of copy of this order. No order as to compensation and litigation costs is passed. Copies of order be supplied to the parties free of costs as per rules.

12.                        File be indexed and consigned to record room.

 

                      (Param Jit Singh Bewli)                        (G.K.Dhir)

                                  Member                                        President

Announced in Open Forum

Dated:09.01.2017

Gurpreet Sharma.