Haryana

Ambala

CC/116/2018

Arun Kumar - Complainant(s)

Versus

ICICI Lombard Gen Inss - Opp.Party(s)

11 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                          Complaint case No.: 116 of 2018.

                                                          Date of Institution         :  02.04.2018.

                                                          Date of decision   :  11.07.2019.

 

Arun Kumar, Advocate, aged about 39 years, r/o H.No.35, Palam Vihar, J-Block, Ambala Cantt (Haryana) - Pin Code:133001.

          ……. Complainant.

                                                Versus

 

1. ICICI Lombard General Insurance Co. Ltd.,

Registered Office/Policy issuing office at:

ICICI Lombard House, 414, Veer Savarkar Marg, near Siddhi Vinayak, Temple, Prabhadevi, Mumbai, Maharastra. Pin Code:400025.

2. ICICI Lombard Health Care,

Underwriting and Claims at: ICICI Lombard GIC, ICICI Lombard Health Care, ICICI Bank Tower, Plot No.12, Financial District, Nanakram Guda, Gachibowli, Hyderabad- Telangana. Pin Code: 500032.

Branch Office Ambala Cantt at:

ICICI Lombard General Insurance Co. Ltd.,

Triloki Chambers, First Floor, SCO-4307/4/21, Opposite Municipal Committee Road, Punjabi Mohalla, Sadar Bazaar, Ambala Cantt (Haryana) Pin Code: 133001.

(Through their authorized signatories/officers for 1 & 2).

3. J.D. Health Care Services, Corporate Office at #843, Sector-11, Garden Colony, Kharar, District Mohali (Punjab) – 140301 (Through its authorized signatory/officer).
4. Dhawan Orthopaedic Hospital, Arya Nagar, Jagadhri Road, Ambala Cantt (Haryana). Pin Code: 133001 (through its authorized signatory/officer).

 

               ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.                 

                            

Present:       Shri Anil Singla, Advocate, counsel for complainant.

Shri Rajesh Kumar, Advocate, counsel for the OPs No.1 & 2.

OPs No.3 & 4 ex parte.          

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) and prayed that directions may be issued to the OPs to pay the total sum of Rs.2,58,936/-, as per details given below:-

S. No.	Amount	Particulars
1	Rs.48,936/-	Being amount of medical bills accepted by OPs No.1 & 2 and OP No.3.
2	Rs.10,000/-	Cost of legal notice dated 13.02.2018 which was received by the OPs No.1 & 2 on 16.02.2018.
3	Rs.1,00,000/-	As compensation for metal agony and physical harassment suffered by him and loss of practice being illegally dragged into the litigation.
4	Rs.50,000/-	Being consolidated amount/cost of litigation of counsel, including all consequential and procedural expenses of litigation.
5	Rs.50,000/-	As rehabilitation expenses, to rehabilitate out of the grief, depression and stress, tension caused to him.
	Total	Rs.2,58,936/-.

 

382.  

                   Any other relief which this Hon’ble Forum may deem fit.

 

Brief facts of the case are that the complainant is an advocate and practising in Tax Laws and related procedures. On 17.04.2017, he had taken a health insurance policy bearing No.4125i/iH/89178878/03/000 from the OPs, vide which, he, his spouse and children were insured, having coverage period from 19.04.2017 to 18.04.2018 for a sum assured of Rs.3,00,000/-. On 01.11.2017, he met with an accident, due to which, his femur got fractured. He was admitted in the Dhawan Orthopaedic Hospital, Ambala i.e. OP No.4 on 02.11.2017 for treatment, wherein, he was operated upon and discharged on 05.11.2017. Meanwhile, his family and friends informed the insurance company i.e. OPs No.1 & 2, for the settlement of health insurance claim. He paid the amount of medical procedures in cash to OP No.4 and lodged the claim with the OPs No.1 & 2 for settlement and repayment. The OPs No.1 & 2 appointed an authorized the OP No.3 for collection of the requisite information and documents to process the claim. Vide letter dated 12.12.2017, the OP No.3, requested the OP No.4, to provide the required documents for the process of payment of claim amount and the OP No.3 submitted all the documents and required information in whole & full and completed all formalities. He requested the OPs No.1 & 2 to reimburse Rs.48,936/-, which was spent by him on medical operation and treatment including the relevant medical procedures cost. However, vide letter and email dated 02.02.2018, the OPs No.1 & 2 wrongly and illegally rejected his claim by stating the reason as “standard exclusion” with the remarks as:-

                   “As per Part II, of the Schedule, the hospital has to be registered with the local authorities under the Clinical Establishment (Registration and Regulations) Act, 2010 or under enactments specified under the Schedule of Section 56(1) of the said Act”.                 

                   The OPs No.1 & 2 have wrongly repudiated his genuine claim, because, the schedule on the basis of which they rejected his claim, is not applicable to Dhawan Orthopaedic Hospital i.e. OP No.4. The hospitals in Haryana are not required to be registered under the Clinical Establishments (Registration and Regulations) Act 2010 or under the enactments specified under the Schedule of Section 56 (1) of the Act, as this Act is not applicable to the State of Haryana. The complainant had paid all the medical expenses to the OP No.4, but the OPs No.1 & 2 had not reimbursed the said amount. The complainant sent a legal notice dated 13.02.2018 through his counsel which was received by the Ops No.1 & 2 vide acknowledgement dated 16.02.2018, but they failed to reply to the said legal notice. The OPs No.1 & 2, have wrongly repudiated the claim of the complainant on this flimsy ground, which amounts to deficiency in service. Hence, the present complaint.

2.                 Upon notice, OPs No.1 & 2 appeared through counsel and filed written version and have raised preliminary objections regarding maintainability; jurisdiction; bad for mis-joinder and non-joinder of necessary parties. It is stated that policy schedule alongwith terms & conditions was delivered to the complainant after the issuance of the policy. As per the terms and conditions of the policy, the definition of the hospital is:-

                    Hospital means any institution established for inpatient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulations) Act 2010 or under the enactments specified under the Schedule of Section 56 (1) of the Act of the said Act OR comply with all minimum criteria as under:-

1.      Has at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and 15 inpatient beds in all other places;
2.      Has qualified nursing staff under its employment round the clock;
3. Has qualified medical practitioner (s) in charge round the clock;
4. Has a fully equipped operation theatre of its own where surgical      procedures are carried out.
5.      Maintains daily records of patients and will make these accessible to the     insurance company’s authorized personnel.

                   According to the above definition/conditions, the Dhawan Orthopaedic Hospital ought to have fulfilled all the above referred conditions, but no such document has been produced to show that as to whether the said hospital has fulfilled the conditions, referred to above. The registration of the hospital and nursing home is necessary, as per the Indian Law, but no such document has been produced to establish that Dhawan Orthopaedic Hospital was registered with the local authorities. Hence, the claim was rightly repudiated and in this regard a letter No.891788 dated 07.05.2018 was sent to the complainant. On merits, rest of the allegations levelled by the complainant were denied for lack of knowledge and prayer has been made for dismissal of the present complaint.

                   Upon notice, none has turned up on behalf of OPs No.3 & 4, accordingly they were proceeded against ex parte vide order dated 28.05.2018.

3.                The complainant tendered his affidavit as Annexure CA alongwith documents as Annexure C-1 to C-26 and closed his evidence. On the other hand, learned counsel for OPs No.1 & 2 tendered affidavit of Shri Vikas Goyal, Authorized Officer/Manager Legal, ICICI Lombard General Insurance Co. Ltd., Chandigarh as Annexure OP/A alongwith document Annexure OP1 and closed the evidence on behalf of OPs No.1 & 2.

4.                We have heard the learned counsel of the parties and carefully gone through the case file and also the written arguments filed by the learned counsel for the complainant. 

5.                Admittedly, the OPs No.1 & 2, had rejected the claim of the complainant vide rejection letter dated 02.02.2018 (Annexure OP/1). At the outset, the ld. counsel for the OPs No.1 & 2 has vehementally argued that the insurance company has rightly rejected the claim of the complainant, because, the hospital, from where, he took the treatment, was not registered with the local authorities under the Clinical Establishments (Registration and Regulations) Act 2010 or under the enactments specified under the Schedule of Section 56 (1) of the Act.

6.                Contrary to it, the ld. counsel for the complainant has contended that the complainant had taken the treatment from the Dhawan Orthopaedic Hospital i.e. OP No.4, in the year 2017 and at that time, the Clinical Establishments (Registration and Regulations) Act 2010 or under the enactments specified under the Schedule of Section 56 (1) of the Act, was not in force in the State of Haryana, as is evident from Notification (Annexure 21). The said Act has not been made effective retrospectively. Even otherwise, the said hospital is less than 50 beds, therefore, it was not required to be registered with the local authorities under the said Act. In support of this contention, the learned counsel for the complainant has drawn our attention to the application Annexure C-25, vide which, the complainant sought information through R.T.I. from the office of Director General Health Services, Haryana, Panchkula. In response to the said application, the concerned office has given the information vide letter Annexure C-26. The concerned office has given answer in affirmative to the question No.6 “Whether the Clinical Establishments (Registration and Regulation) Adoption Act 2018, provides the relaxations to small & medium hospitals from the requirements of registration under the Act of 2018, for hospitals which are having less than 50 beds or having just 8-10 beds?” Since the OP No.4 hospital is a small hospital having less than 50 beds, therefore, there was no requirement to get it registered with the local authority, as per the above referred Act. The OPs No.1 & 2 by repudiating his genuine claim, have committed deficiency in services.

7.                The Haryana Government Gazette published on 25.01.2018, which provides for the ordinance of State of Haryana vide Part II, THE HARYANA CLINICAL ESTABLISHMENTS (REGISTRATION AND REGULATION) ORDINANCE, 2018 (HARYANA ORDINANCE NO.1 OF 2018), which clearly provides:

1. Short title, application and commencement
1.  
2.  
3.  
2. The State Government hereby adopts the Clinical Establishments (Registration & Regulations) Act 2010 (central Act 23 of 2010).

                   From the said Ordinance, it is clear that the State of Haryana, adopted the Clinical Establishments (Registration and Regulations) Act 2010, w.e.f. 25.01.2018. From Section 56 of THE CLINICAL ESTABLISHMENTS (REGISTRATION AND REGULATION) ACT, 2010, which reads as under:-

          56. (1) The provisions of this Act shall not apply to the States in which the enactments specified in the Schedule are applicable:

          Provided that the States in which the enactments referred to in sub-section (1) are applicable, and such States subsequent to the commencement of this Act, adopts this Act under clause (1) of article 252 of the Constitutions, the provisions of this Act shall, subsequent to such adoption, apply in that State.

          (2) The Central Government may, as and when consider necessary, by notification amend the Schedule.

                   It is evident that the said Act has no retrospective effect. Admittedly, the complainant took the treatment from OP No.4 hospital for the period from 02.11.2017 to 05.11.2017, i.e. prior to the enforcement of said Act in the State of Haryana, therefore, the aforesaid Act was not applicable to the OP No.4 hospital at the time when the complainant had taken treatment from it. The complainant has pleaded that the OP No.4 hospital is a small hospital having less than 50 beds. This fact has not been controverted by the OPs. As such, as per the information given by the Director General, Health Services, Haryana (Annexure-26), the OP No.4 hospital, being a small hospital, was not required to be registered with the local authorities under the said Act. Taking all these facts and circumstances into consideration, we are of the view that OPs No.1 & 2 were not justified in repudiating the claim of the complainant and are thus, liable to reimburse the amount, which the complainant had incurred on his treatment. From the receipts issued by the Dhawan Orthopaedic Hospital, OP No.4, Annexure C-9 to C-14, it is apparent that the complainant had incurred a total sum of Rs.48,236/- (Rs.38500 + 1100 + 3000+ 4148 + 1488), on his treatment. Therefore, the OPs No.1 & 2 are liable to reimburse the said amount alongwith interest. They are also liable to compensate the complainant for the mental agony and physical harassment suffered by him, alongwith litigations expenses. So far as, the complaint filed against OPs No.3 & 4 is concerned; it may be stated here that neither any specific allegation has been levelled by the complainant against them, nor it has been proved. Therefore, the complaint filed against them, is liable to be dismissed.

8.                In view of the aforesaid discussion, we hereby dismiss the present complaint against the OPs No.3 & 4 and allow the same against the OPs No.1 & 2. The OPs No.1 & 2 are directed in the following manner:-

1. To pay the claim amount Rs.48,236/- alongwith interest @ 7% per annum w.e.f. 02.02.2018 i.e. the date of the repudiation of claim, till its realization.
2. To pay Rs.3,000/- as compensation for mental agony and physical           harassment suffered by the complainant.
3. To pay Rs.2,000/- as litigation expenses.

 

                   The OPs No.1 & 2 are further directed to comply with the aforesaid directions within the period of 30 days from the date of receipt of the certified copy of this order, failing which, the awarded amount shall carry interest @ 9% per annum for the period of default. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :11.07.2019.

 

 

 

          (Vinod Kumar Sharma)           (Ruby Sharma)               (Neena Sandhu)

              Member                                  Member                       President