BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.01 of 2016

Date of Instt. 04.01.2016

Date of Decision : 20.10.2016

Nirmal Chand S/o Sh. Bachan Chand Resident of Village Toye, P.O. Ghogra, Tehsil Dasuya, District Hoshiarpur.

..........Complainant

Versus

M/s New India Assurance Co. Ltd., PUDA Complex, Near District Administrative Complex, Jalandhar, Through its Branch Manager.

.........Opposite party

Complaint Under Section 12 of The Consumer Protection Act.

Before: S. Bhupinder Singh (President)

Sh.Parminder Sharma (Member)

Present: Sh.Vikas Kumar Gupta Adv.,counsel for the complainant.

Sh.R.K. Sharma Adv., counsel for opposite party.

Order

Bhupinder Singh (President)

1. The complainant Nirmal Chand has filed the present complaint under 'The Consumer Protection Act' against the opposite party (hereinafter called as OP) in which the complainant has submitted that he obtained Medical Health Insurance Policy bearing No.36090434141900000001 from the OP for the period 21/10/2014 to 20/10/2015. The complainant felt weakness of L upper limbs and he approached Sacred Heart Hospital, Jalandhar for treatment. Resultantly the above said hospital admitted the complainant on 24/8/2015 where he was diagnosed suffering from DM2 with Cervical Radiculopathy with diabetic Neuropathy and he was medically treated and was discharged on 27/8/2015. The OP was informed and the TPA of OP allowed the cashless facility for the treatment of the complainant but later on refused to provide cashless facility. The complainant lodged the claim with the OP for reimbursement for the medical expenses as the complainant had spent a sum of Rs. 13,983/- on his medical treatment but the OP wrongly repudiated the claim of the complainant vide letter dated 9/9/2015 on the ground that the patient is diagnosed with D.D. Neuropathy but no active management is done during hospitalization and as per the terms and conditions of the policy, expenses during hospitalization for investigation is non payable. The complainant submitted that he was admitted and treated by the OP for the aforesaid ailments as per discharge card. The OP has wrongly repudiated the claim of the complainant. On such averments, the complainant has prayed for directing the OP to reimburse the amount of Rs. 13,983/- to the complainant. He also requested for compensation to the tune of Rs. 50,000/- and cost of litigation to the tune of Rs. 20,000/-.

2. Upon notice, OP appeared through counsel and filed a written statement in which the OP submitted that the complainant was admitted in Sacred Heart Hospital, Jalandhar with past history of Diabetes Millitus and was diagnosed Diabetes Mellitus with Cervical Radiculopathy and Diabetic Neuropathy. On scrutiny of documents by the Raksha TPA Pvt. Ltd., it was found that there was no active management done during hospitalization and only investigations were done and medical bills are of only oral tablets. Therefore, it was clear that the patient was admitted in the hospital only for investigation. Therefore, the claim is not payable as per condition/ Exclusion Clause No. 4.10 of the insurance policy which reads as under:-

“The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of charges incurred at the hospital or Nursing Home Primarily for Diagnostic, X-Ray or Laboratory examination or other diagnostic studies not consistent with incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a hospital.”

The OP submitted that they have repudiated the claim of the complainant as per terms and conditions of the policy so there is no deficiency in service on the part of the OP qua the complainant.

3. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C25 and closed his evidence.

4. On the other hand, learned counsel for the OP has tendered into evidence affidavit Ex.OA alongwith copies of documents Ex.O1 to Ex. O6 and closed evidence.

5. We have heard the Ld. counsel for the parties, minutely gone through the record and have appreciated the evidence produced on record by both the parties with the valuable assistance of Ld. counsels for the parties.

From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it stands fully proved on record that the complainant obtained medical health insurance policy bearing No. 36090434141900000001 Ex. C25/ Ex.O1 from the OP for the period from 21/10/2014 to 20/10/2015. During this period, the complainant became ill as he was feeling weakness in L upper limbs and he approached the Sacred Heart Hospital, Jalandhar for treatment. Resultantly, the aforesaid hospital authorities admitted the complainant on 24/8/2015 where he was diagnosed suffering from DM2 with Cervical Radiculopathy and Diabetic Neuropathy and he was medically treated for the aforesaid diseases and was discharged on 27/8/2015 as is evident from the discharge card of the complainant issued by Sacred Heart Hospital, Jalandhar Ex. O6. It is the admitted case of both the parties that the policy is cashless policy and the complainant informed the OP when he was admitted in the aforesaid hospital and the TPA i.e. The Raksha TPA Pvt. Ltd., allowed the cashless facility and the aforesaid hospital was informed in this regard but later on the OP refused the cashless facility. The complainant had spent a sum of Rs. 13,983/- on his medical treatment in the aforesaid hospital as per bills Ex. C2 to Ex. C20 and the final bill issued by the Sacred Heart Hospital Ex. C21. The complainant lodged claim with the OP after he was discharged from the hospital but the OP repudiated the claim of the complainant vide letter dated 9/9/2015 Ex. C1/ Ex. O5 on the ground that the patient was admitted in the hospital only for investigation and no active management was done during hospitalization and as per policy terms and conditions i.e. exclusion clause No. 4.10 of the insurance policy Ex. C25/ Ex. O1, the company shall not be liable to make any payment in respect of any expenses incurred by insured person regarding charges at hospital primarily for diagnostic purposes.

6 From the perusal of the record of the complaint at Sacred Heart Hospital particularly the discharge card of the complainant Ex. O6, the complainant was admitted in the aforesaid hospital on 24/8/2015 and was discharged on 27/8/2015 and he was diagnosed as suffering from DM2 with Cervical Radiculopathy and Diabetic Neuropathy and he was medically treated for the aforesaid disease for four days i.e. 24/8/2015 to 27/8/2015. The admission of the complainant in the hospital was done by the Sacred Heart Hospital, Jalandhar authorities being necessary for the treatment of aforesaid disease of the complainant diagnosed and was medically treated. The OP could not produce any evidence in the form of any certificate from the medical expert or medical authorities to the effect that the admission of the complainant was not required or that he was admitted only for diagnostic purposes and not for medical treatment for the aforesaid disease nor OP has examined any medical expert to prove that the complainant was admitted in the aforesaid hospital only for diagnostic purposes and not for medical treatment of the complainant for the aforesaid diseases. Resultantly we hold that the OP has wrongly repudiated the claim of the complainant vide letter dated 9/9/2015 Ex. C1/ Ex. O5. The complainant also served legal notice dated 26/9/15 Ex. C22 on the OP but even then OP did not settle the claim of the complainant and the complainant was forced to file the present complaint.

7. In view of the above discussion, we allow this complaint with cost and OP is directed to reimburse the aforesaid amount of Rs. 13,983/- spent by the complainant on his medical treatment during hospitalization at Sacred Heart Hospital, Jalandhar. The opposite party is also directed to pay cost of litigation to the tune of Rs. 3,000/- to the complainant. Compliance be made by the OP within a period of one month from the receipt of this order failing which the OP shall be liable to pay interest @9% per annum on this amount Rs. 13,983/- from the date of repudiation of the claim i.e. 9/9/2015 till the payment is made to the complainant. Copies of the order be sent to the parties free of cost, under rules. File be consigned to the record room.

Dated Parminder Sharma Bhupinder Singh

20.10.2016 Member President