BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL
FORUM, MOGA.
Complaint No.146 of 2014
Instituted On: 01.12.2014
Decided On: 17.03.2015
Bhupesh Kumar aged about 43 years son of Shri Ram Partap resident of Main Bazar, Village Fatehgarh Panjtoor District Moga.
……..Complainant
Versus
1. ICICI Prudential Life Insurance through its Manager, Branch at Moga.
2. ICICI Prudential Life Insurance Co. Ltd., The Head Office, BSEL
TGECH-C-wind, 1st Floor, Vashi, Navi Mumbai, Maharastra, through its Divisional Manager.
……..Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
*****
Coram: Sh.S.S.Panesar, President
Smt Vinod Bala, Member
Smt.Bhupinder Kaur, Member
PRESENT
For the complainant : Sh.Dinesh Kumar Garg, Advocate counsel
For the opposite parties : Sh. Gurmeet Singh Dhaliwal Advocate counsel
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ORDER
(S.S.Panesar, President)
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (herein-after referred to as ‘Act’) against the ICICI Prudential Life Insurance through its Manager, Branch at Moga and another (herein-after referred to as ‘Insurance Company’)-OPs directing them to pay the hospitalization charges for a sum of Rs.1,88,229/- in lieu of the health insurance policy and to pay Rs.20,000/- as compensation for causing mental tension and harassment besides Rs.10,000/- as costs of litigation and also to grant any other relief to which this Forum may deem fit.
2. Briefly stated, the complainant had purchased Health Insurance Policy bearing No.12218255 from the opposite parties by paying Rs.10,000/- as annual premium, which was to commence from 17.07.2009. It has been pleaded that the said policy known as Health Solution Scheme covers various diseases as quoted in the policy. At the time of selling the said insurance policy, the opposite parties assured the complainant that if the complainant gets the medical treatment of any disease from any clinic or hospital, the expenses incurred on the treatment will be paid by the opposite parties. It has been further pleaded that the complainant has been regularly depositing the instalments with the opposite parties. In the month of January 2014, the complainant fell ill and remained under treatment in Dayanand Medical College & Hospital at Ludhiana, where various tests
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were conducted and it was detected that complainant was suffering from hepatitis C disease. He spent an amount of Rs.1,88,229/- on his treatment. The complainant approached the opposite parties and submitted all the requisite documents with opposite parties for re-imbursement of the medi-claim bill under the policy. But the opposite parties declined the claim of the complainant on the ground that the such disease fell under Clause 8.36 of the policy i.e. treatment or procedure customarily and usually performed by medical practitioner in out patient department or clinic or causality setting shall not be payable, even, if performed as day care procedure or hospitalization. The complainant served a legal notice upon the opposite parties, but all in vain. Due to the negligent act of the opposite parties, the complainant is suffering from mental and physical harassment and economic loss. Hence the present complaint.
3. Notice of the complaint was given to the opposite parties, who have appeared through their counsel namely Sh. Gurmeet Singh Dhaliwal Advocate and filed joint written reply contesting the same. They took up preliminary objections that the policy bearing No.12218255 was issued by the opposite parties on the basis of information provided by the life assured. The opposite parties sent policy documents including terms and conditions of the policy to the complainant and as per Section 6 (2) of the Insurance Regulatory and Development Authority ( Protection of Policyholders interests) Regulations, 2002, insured can avail free look cancellation or modifications within 15 days of the receipt of the policy
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documents. However, the complainant did not submit the free look request within fifteen days of the receipt of the policy documents; that after going through the terms and condition of the policy, the opposite parties have rejected the claim of the complainant on the ground that as the policy terms and conditions Clause 8.36, the claim is not payable to the complainant. On merits, the opposite parties took almost the same and similar pleas as taken up in the preliminary objections. All the allegations made in the complaint were specifically denied being incorrect and it is stated that the complaint deserves to be dismissed.
4. In order to prove his case, the complainant tendered in evidence his affidavit Ex.C-1 and copies of documents Ex.C-2 to Ex.C-74 and closed his evidence.
5. To rebut the evidence of the complainant, the opposite parties tendered affidavit Ex.OP1&2/1 of Sh. Rohit Thakil Working Manager and copies of documents Ex.O.P.1&2/2 to Ex. O.P.1&2/31 and closed the evidence on behalf of the opposite parties.
6. We have heard the learned counsel for the parties and have also carefully gone through the record.
7. It has been vehemently contended by the counsel for the complainant that the complainant purchased health insurance policy bearing No. 12218255 from the opposite parties on payment of Rs.10,000/- as annual premium, which was to be effective w.e.f. 17.07.2009. The complainant has been regularly depositing the instalments to the opposite
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parties since then. In the month of January 2014, the complainant fell ill and remained under treatment in Dayanand Medical College & Hospital at Ludhiana. It was detected that the complainant was suffering from hepatitis ‘C’ disease. The complainant spent an amount of Rs.1,88,229/- on his treatment. However, when the complainant approached the opposite parties and submitted all the requisite documents for re-imbursement of the medi-claim under the policy, the opposite parties declined the claim of the complainant on the ground that the disease fell under Clause 8.36 of the policy and no re-imbursement was allowable, even, if performed as day care procedure or hospitalization. The act and conduct of the opposite parties is not consonance with the provisions of the insurance policy and they are deficient in service. It is requested that the complaint may be allowed and an order for re-imbursement of insured amount of Rs.1,88,229/- alongwith compensation for causing mental tension and harassment besides costs of litigation to be assessed by this Forum, may be granted in favour of the complainant
8. On the other hand, the learned counsel for the opposite parties has vehemently contended that the claim of the complainant has rightly been turned down under Exclusion Clause 8.36. The only treatment to be provided by the doctor, in case of a person suffering from hepatitis C, was to administer injection for which no hospitalization was necessary as per Clause referred above. Copy of policy document Ex.O.P.1,2/3 on record clearly establishes that no re-imbursement of medical expenditure was
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allowable, even, if, hospitalization or day care hospital is provided in such like disease i.e. hepatitis C. There is no merit in the complaint. The opposite parties are not deficient in service and the complaint is nothing, but an abuse of the process of law. It is, therefore, contended that the complaint may be dismissed.
9. We have given thoughtful consideration to rival contentions.
10. There is no dispute that the complainant has been availing medical insurance health solution since 2009 and he has been paying the premium regularly to the opposite parties. It is also not disputed that the complainant suffered from disease known as hepatitis ‘C’ and he got himself treated in Dayanand Medical College & Hospital at Ludhiana in April/May 2014. The complainant is stated to have been admitted to the hospital on 19.04.2014 for the first instance and he was released on that very day. Thereafter, as per medical record, the complainant got himself admitted to hospital on 02.05.2014 and was discharged on 03.05.2014. There is absolutely no detail or actual stay in the hospital mentioned in the complaint from which it could be inferred that the complainant remained admitted in hospital for treatment purposes for a continuous period of 48 hours. Continuous admission in hospital for 48 hours as indoor patient is a condition precedent for grant of re-imbursement of medical expenses incurred by the insured person. Not only that, the complainant has not produced on record any certificate from concerned doctor of the hospital to bring home the point that the hospitalization was necessary for the
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treatment of the complainant or the treatment was required to be given to the complainant as Indoor Patient. However, the disease hepatitis ‘C’ was admittedly to be treated by administering injections only, which is an Out Door treatment. As per Clause 8.36 of the insurance policy, an insured is not entitled to re-imbursement of medical expenses in case of hospitalization regarding disease, which could be treated in the O.P.D. Clause 8.36 of the policy is reproduced as under for ready reference:-
“8. Exclusions for Hospitalization Insurance Benefit:
The company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by any insured person(s) in connection with or in respect of any of the following.
36). Treatments or procedures customarily and usually performed by Medical Practitioners in out patient department or clinic and causality setting shall not be payable even if performed as Day Care Procedure or hospitalized”.
Here in the case in hand, the insured has gone for hospitalization for the disease, which did not require admission in the hospital. Because only the injections were required to be administered to the patient, which could be administered in the O.P.D. Therefore, no consumer dispute is made out & the opposite parties are not deficient in service in declining the claim.
11. From the aforesaid discussion, it transpires that the claim of the complainant has been rightly repudiated by the opposite parties.
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Consequently, instant complaint fails and the same is ordered to be dismissed. Copies of the order be sent to the parties free of cost immediately and thereafter the file be consigned to the record room.
(Bhupinder Kaur) (Vinod Bala) (S.S.Panesar)
Member Member President
Announced in Open Forum.
Dated:17.03.2015.
