Chandigarh

DF-II

CC/695/2018

Yadvinder Singh Bhullar - Complainant(s)

Versus

Life Insurance Corporation - Opp.Party(s)

Adv. Kapil Kumar Bhardwaj

12 Jan 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	695 of 2018
Date  of  Institution	:	07.12.2018
Date   of   Decision	:	12.01.2022

 

 

 

 

 

Yadvinder Singh Bhullar, Aged 38 years, son of Dr.Sukhchain Singh Bhullar, R/o H.No.3004, Ajanta Co-operative Society, Sector 51, Chandigarh

             …..Complainant

 

Versus

 

1]  Life Insurance Corporation of India, through its Divisional Officer, Northern Zone, Divisional Office, Jeevan Prakash, Sector 17-B, Chandigarh 160017

2]  Mayo Healthcare Super Speciality Hospital, through its Senior Manager, Near Gurudwara Singh Saheedan, Sector 69, Mohali.

    ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                PRESIDENT

         SMT.PRITI MALHOTRA             MEMBER

         SH.B.M.SHARMA                      MEMBER

 

 

Argued by: -   Sh.Kapil Kumar Bhardwaj, Adv. for complainant

                Sh.Piyush Sharma, Adv. for OP No.1

                None for OP No.2.

 

PER  PRITI  MALHOTRA,  MEMBER

         Concisely put, the complainant obtained Health Insurance Policies No.165112448 & 165110677 from OP No.1 on 28.3.2012 and got the policies renewed yearly.  It is averred that the complainant got admitted in OP No.2 Hospital on 18.5.2015 at 1.37 PM for surgery of parotid tumor and discharged on 19.5.2015 at 7.00 PM.  Thereafter, the complainant lodged claim with OP Insurance Company for the reimbursement of an amount of Rs.72,505/- as per the bill issued by OP No.2 Hospital, but the OP Insurance Company made part payment of Rs.2400/- under Policy No.165110677 and Rs.7200/- under policy No.165112448  only and did not make payment of balance amount of Rs.62905/-. The complainant agitated the matter with OP Insurance company and clarified things, but still the OP Insurance Company rejected the balance claim per email dated 17.12.2016 & 27.12.2016.  The complainant also sent legal notice to OPs but to no avail.  Hence, this complaint.

 

2]       The OP No.1 has filed reply and while admitting the factual matrix of the case, stated that the policies in question are not a mediclaim policies which are being issued by the General Insurance Companies under which whole medical expenses are covered. Claimed that the payment depends upon actual expenses in hospital, rather the policies issued by OP Company are only Non-Linked Health Protection Plans which cover certain surgeries mentioned in the list of Major Surgery Benefits alongwith Daily Hospital Cash benefits if it fulfills the requirement per terms & condition of policy.  It is submitted that in the present case, the surgery having been undergone by the Complainant does not fall under the purview of either ‘Major Surgery Procedure’ nor ‘Day Care Surgery Procedure’. Therefore, in this eventuality Clause 2 (iv) of the Terms & Conditions of the Policy i.e. ‘Other Surgical Benefits’ come into play which provides double the amount of the daily hospital benefit which is Rs.3000/- under Policy No.165112448 and Rs.1000/- under Policy No.165110677.  It is also submitted that after perusing the claim of the complainant, it was found that the complainant was admitted in the Hospital i.e. OP No.2 on 18.5.2015 at 13.37 and was discharged on 19.5.2015 at 14.10., therefore, the complainant was not remained admitted in the Hospital for more than 28 hours as required under the terms & conditions of the Policies. It is further submitted that had the complainant remained admitted in the Hospital for more than continuous period of 4 hours, after exclusion of 24 hours of waiting period, then the complainant would have been entitled for the daily hospital cash benefit, but in present case, he does not fulfill the said requirement.  It is stated that the complainant has underwent a surgery for ‘parotid tumor’ which is not covered by the policy either under ‘Major Surgery procedure’ or under ‘Day Care Surgery Procedures’, therefore, the complaint has been given Rs.7200/- under policy No.165112448 and Rs.2400/- under policy No.165110677 under the head of ‘other surgical benefits’. Denying all other allegations and pleading no deficiency in service, the OP No.1 has prayed for dismissal of the complaint.

         OP No.2 has also filed reply and while admitting the factual matrix of the case in respect of treatment giving to the complainant, stated that the complainant was admitted with OP No.2 on 18.5.2015 at 1:37:33 PM for superficial Parotidectomy and was discharged on 19.5.2015 at 2:10:59 PM as per record of OP No.2.  It is denied that the complainant was discharged on 19.5.2015 at 7:00 PM.  It is stated that copy of medical record provided by the complainant vide page 19,20 & 21 of the complaint are forged one.  It is further stated that Inpatient Bill dated 19.5.2015 in the name of complainant has been forged as on the top of Right side shown written comment with Stamp (forged one) of OP No.2 with signature does not belong to any of staff of OP No.2, hence it is denied. It is submitted that the answering OP No.2 has nothing to do with the payment/reimbursement claim to be made by OP No.1 to complainant. Denying other allegations, OP No.2 has prayed for dismissal of complaint qua it.            

 

3]       Replications have been filed by the complainant thereby reiterating the assertions made in the complaint and controverting that of the OPs in their reply.

4]       The parties have led evidence in support of their contentions.

5]       We have heard the ld.Counsel for the complainant ld.Counsel for OP No.1 and have also perused the entire record including written arguments.

6]       Admitted facts that the complainant obtained two Jeevan Arogya (Non-linked Health Insurance Plan) bearing No.165112448 & 165110677 from OP No.1 Insurance Company and during the currency of said insurance cover, he has been treated at OP No.2 Hospital for Parotid Tumor on 18.5.2015 and thereby incurred expenses to the tune of Rs.72,505/-.  On filing claim for reimbursement by the complainant, the OP Insurance Company paid an amount of Rs.2400/- under Policy No.165110677 and Rs.7200/- under policy No.165112448 after deducting an amount of Rs.62905/- on the ground that the complainant failed to fulfill the condition to be remained admitted for more than 28 hours. 

7]       The thorough perusal of the record and in particular, the terms & conditions of the policy clearly reveals that the treatment undertaken by the complainant falls under ‘Day Care Procedure Benefit’.  That means the procedure underwent by the complainant is duly covered under this head of the policy i.e.’ Day Care Procedure Benefit’. 

8]       The record reveals that the complainant placed on record a certificate issued by OP No.2 Hospital (Page No.19 to 21) showing that he stayed in the Hospital for more than 28 hours, but the OP No.2 in its reply denied the issuance of such certificate.  Take notice of the same, vide zimni order dated 17.12.2019, the OP No.2 was directed by the Commission as under:-

“ It is argued that the OP No.1 treated the policy under surgical benefits whereas the same falls under major surgical head. Now OP No.2 is directed to clarify from the treating doctor whether it is a major surgery or not. The OP No.2 shall also verify whether signatures on the certificates issued by it are of its authorities or not. The attendance register of that period shall also be produced by OP No.2 on 21.1.2020. Final remaining arguments shall also be heard on that date.

 

9]       However, besides giving number of opportunities to clarify, none turned up on behalf of OP No.2 for the reasons best known to it.  The record reveals that the complainant again was issued a certificate by OP No.2 Hospital stating the factum of his stay in the Hospital as more than 28 hours as was stated in the earlier certificate issued.  The certificate later was issued after filing of the reply by OP No.2.  The non-appearance of OP No.2 and the reluctance shown in not clarifying the actual position and another issuance of certificate by the said Hospital raises a presumption in favour of the complainant that he remained admitted in Hospital for more than 28 hours.  Also, the presumption raised in favour of the complainant goes unrebutted in the absence of OP No.2, who till date of arguments and till the case has been reserved for orders, has not turned up to explain its position. Thus in the given scenario and factual position, it is established that the OP Insurance Company has wrongly repudiated the balance medical reimbursement claim of the complainant, which amounts to deficiency in service on its part.

10]      Taking into consideration the above discussion and findings, the deficiency in service on the part of Opposite Party No.1 stands proved. Therefore, the complaint stands allowed against OP No.1 with direction to reimburse the balance medical claim of the complainant to the tune of Rs.62,905/- with interest @6% p.a. from the date of rejection i.e. 17.12.2016 till its payment. The OP No.1 is also directed to pay compository amount of Rs.10,000/- towards compensation and  litigation expenses.

         This order shall be complied with by the Opposite Party No.1 within a period of 30 days from the date of receipt of its certified copy, failing which it shall be liable to pay additional compensation cost of Rs.5000/- apart from above relief.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

12^th January, 2022                                                                                                                                               sd/-

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

(PRITI MALHOTRA)

MEMBER

 

Sd/-

(B.M.SHARMA)

MEMBER