Haryana

StateCommission

A/1180/2016

BAJAJ ALLIANZ GEN.INSURANCE CO. - Complainant(s)

Versus

KAMAL TYAGI - Opp.Party(s)

SACHIN OHRI

13 Jan 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :    1180 of 2016

Date of Institution:      08.12.2016

Date of Decision :       13.01.2017

 

Bajaj Allianz General Insurance Company Limited having its office at Gurgaon through its authorised signatory, Navjeet Singh, Assistant Manager Legal, SCO 156-159, 2^nd Floor, Sector 9-C, Chandigarh.

 

                                      Appellant-Opposite Party No.1

Versus

 

1.      Kamal Tyagi s/o Sh. V.P. Tyagi, Resident of H.No.1820, Village Wazirabad, Tehsil and District Gurgaon.

Respondent-Complainant

2.      Mayom Hospital, D-Block, South City-1, Gurgaon.

3.      Dr. Saurabh Prakash, HOD Radio Diagnosis, Mayom Hospital, D-Block, South City, Gurgaon.

4.      Dr. Priyanka Jha (BAMS) R/o D-14/13, Ardee City, near Gate No.4, Gurgaon, Haryana.

5.      United India Insurance Company Limited 60, Janpath Connaught Place, New Delhi-110001 through its Divisional Manager Gurgaon, New Colony, near State Bank of India, Gurgaon.

6.      New India Insurance Company, Saxena Building, NH-24, Delhi Road, Gajraula, U.P. through its Gurgaon Divisional Manager, Divisional Office at Gurudwara Road,, Opposite Kamla Nehru Park, Gurgaon.

                                      Respondents-Opposite Parties No.2 to 6

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Argued by:          Shri Sachin Ohri, Advocate for appellant.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

          Bajaj Allianz General Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Party No.1 is in appeal against the order dated August 5^th, 2016 passed by District Consumer Disputes Redressal Forum, Gurgaon (for short ‘the District Forum’) whereby complaint was allowed and following relief was granted:-

“…we hold deficiency in service on the part of the OP-1 and thus, we direct OP-1 to reimburse the claim of the complainant to the extent of Rs.61,235/- as per terms and conditions of the policy along with interest @ 9% per annum from the date of filing of the present complaint i.e. 12.06.2012 till realization. The complainant is also entitled to compensation as well as litigation expenses to the tune of Rs.10,000/-. The OP-1 shall make the compliance of the order within 30 days from the date of receipt of the copy of this order.”   

2.                Kamal Tyagi-complainant (respondent No.1 herein) purchased health insurance policy known as Critical Illness Insurance Policy (Annexure A-1) from Bajaj Allianz General Insurance Company Limited-Opposite Party No.1/appellant with effect from 14^th October, 2011 to 13^th October, 2012. The sum assured was 10.00 lacs. The complainant suffered stroke on 11^th March, 2012 and was admitted in Mayom Hospital-Opposite Party No.2 on the same day. Dr. Shailesh Sahay, Senior Sonsultant Internal Medicine of Mayom Hospital after carrying out necessary tests diagnosed it as Stroke-Acute Infract in left Periventricular region. The complainant was shifted to Intensive Care Unit (ICU) and remained admitted in that hospital from 11^th March, 2012 to 16^th March, 2012. The complainant alleged to have spent Rs.61,235/- on his treatment.

3.                The complainant filed complaint claim with the Insurance Company but the Insurance Company repudiated the same vide letter dated 23^rd April, 2012 (Annexure A-2) on the ground that the complainant only suffered from Transient Ischemic attack (stroke-Acute Infract in left periventricular region) and recovered fully within 24 hours of admission. Therefore, the complainant was not entitled to the hospitalization expenses.  Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed.

4.                Notice being issued, the opposite parties contested the complaint. Opposite Party No.1 – Insurance Company/appellant in its written version stated that it (Insurance Company) received a letter from Dr. Saurabh Prakash, Head of Department, Radio Diagnosis Mayom Hospital, as per whom the disease did not fall under the category of critical illness and that the patient recovered within 24 hours. Therefore, the complainant was not entitled to the benefit of insurance policy. The other allegations were denied.

5.                Opposite Parties No.2 to 4 (Dr. Saurabh Prakash and Dr. Priyanka Jha) in their joint written version denied the allegations of complainant and prayed for dismissal of the complaint.

6.                Opposite Parties No.5 and 6 (United India Insurance Company Limited and New India Insurance Company) in their separate written version denied having any cause of action arisen against them.

7.                After evaluating the pleadings and evidence of the parties, the District Forum vide impugned order allowed complaint and issued direction to the appellant-opposite party No.1 as detailed in paragraph No.1 of this order.

8.                Learned counsel for the appellant- Insurance Company while assailing the order of the District Forum referred to letter of Dr. Saurabh Prakash (Annexure A/3) to state that the stroke which the complainant suffered did not fall under the category of critical illness. Counsel for the appellant submitted that the complainant had only suffered Transient Ischemic attack which fall within exclusion clause and therefore the complainant was not entitled to the benefits of insurance.

9.                The Insurance Policy has been placed on the file as Annexure A-1. It is not disputed that the complainant purchased critical illness insurance policy commencing from 14^th October, 2011 to 13^th October, 2012 with the coverage up to Rs.10.00 lacs. Critical illness has been defined in Section B of the policy under heading ‘Definitions’ reproduced as under:-

                   “Section B: Definitions

The following words or terms shall have the meaning ascribed to them wherever they appear in this policy, and references to the singular or to the masculine shall include references to the plural or to the female wherever the context so permits:

1.      xxx

2.      xxx

3.      xxx

4.      xxx

5.      Critical Illness

Means an illness, sickness or a disease or a corrective measure as specified in Section C of this Policy.”

10.              Sub heading 3 “Stroke Resulting in Permanent Symptoms” of Section C: Critical Illness reads as under:-

                   “3.     Stroke Resulting in Permanent Symptoms

I.        Any cerebrovascular incident producing permanent neurological sequelae. This includes infaraction of brain itssue, thrombosis in an intracranial vessel, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist medical practioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.

II.       The following are excluded:

          i.        Transient ischemic attacks (TIA)

          ii.       Traumatic injury of the brain.

         iii.       Vascular disease affecting only the eye or optic nerve or vestibular functions.”

11.              Annexure A-4 is the Case Summary/Discharge Slip. The complainant remained under the treatment of Dr.Shailesh Sahay, who has given final diagnosis as “Stroke-Acute Infract in Lt. Periventricular region”. There is no word of complainant having suffered from Transient Ischemic attack (stroke-Acute Infract in left periventricular region) or that he recovered fully within 24 hours of admission. Reliance has been placed upon the letter written by Dr. Saurabh Prakash, Head of Department, Radio Diagnosis Mayom Hospital.

12.              Neither the complainant remained under the treatment or Dr. Saurabh Prakash nor Dr. Saurabh Prakash had any occasion to issue such a letter to the Insurance Company. The Insurance Company apparently managed the certificate from the doctor who was not the treating doctor of the complainant. Besides the letter is contrary to the final diagnosis given by the treating doctor (Dr. Shailesh Sahay, Senior Sonsultant Internal Medicine of Mayom Hospital. As per the Discharge Slip even the consultant neurologist was Dr.Anurag Trivedi. No advice was sought by the Insurance Company from any of the treating doctors. Otherwise, the opposite parties do not dispute the complainant having been suffered disease and hospitalization for the period from March 11^th, 2012 to 16^th March, 2012.

13.              In view of the above, it cannot be said that the disease for which the complainant remained admitted in the hospital and treated, falls under exclusion clause. So, the impugned order does not require any interference.

14.              Hence, the appeal fails. It is dismissed.

15.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced 13.01.2017

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL