Punjab

Ludhiana

CC/15/71

Neha Kapoor - Complainant(s)

Versus

M/s Star Health & allied Ins.co.Ltd - Opp.Party(s)

Munish Mittal

16 Sep 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No.71 of 05.02.2015

Date of Decision            :   16.09.2015

 

Neha Kapoor w/o Pankaj Kapoor r/o H.No.1202/99, Sardar Nagar, Rahon Road, Near Sandhu Dairy, Ludhiana. 

….. Complainant

Versus

M/s Star Health and Allied Insurance Co.Ltd., Branch Office at 2716, First Floor,

Gagan Complex, Back side Majestic Park Plaza Hotel, Gurdev Nagar, Pakhowal

Road, Ludhiana-141001, through its Branch Manager.

           

…Opposite parties

 

                   (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.SAT PAUL GARG, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :        Sh.Munish Mittal, Advocate.

For OP                           :        Sh.Rajeev Abhi, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Complainant Smt.Neha Kapoor filed complaint under Section 12 of the Consumer Protection Act, 1986(hereinafter referred to as the ‘Act’) against the Ops, by alleging that she and her husband on assurance of high return and reimbursement benefit of medical claims, got shifted their medical policy with OP vide plan namely Family Health Optima Insurance Policy vide policy No.P/161114/01/2014/0011662 valid for the period from 9.7.2013 to 8.7.2014. Complainant and her family members were covered by this policy for sum insured of Rs.3 lakhs. Neither the complainant nor her family members were suffering from any disease at the time of shifting of their policy. Earlier complainant and her family members had been getting policies for four consecutive years without any break. As complainant fell ill and that is why she was admitted in Sachdeva Nursing Home, Basti Jodhewal, Ludhiana for treatment of enteric fever on 4.2.2014. Complainant was discharged on 13.2.2014. During hospitalization, an amount of Rs.50,000/- approximately was spent on treatment of complainant. A claim was lodged with OP for reimbursement of the amount spent on treatment of complainant, but in the beginning, OP put queries for calling upon the complainant to provide documents. After the necessary documents required by Ops were submitted by the complainant, they failed to settle the claim, despite the fact that complainant proclaimed that in case, OP have any doubt, then they can approach the hospital directly or can appoint any employee for collecting information there from. Instead of settling the claim, OP repudiated the claim vide letter dated 9.6.2014 by taking false pleas. Reminders were sent to OP for reimbursing the claim, but to no effect. Thereafter, complainant served a legal notice dated 10.12.2014 on OP through her counsel, but even then, amount is not reimbursed. By pleading deficiency in service on the part of OP, complainant sought directions to OP to reimburse the amount of Rs.50,000/- and compensation for harassment of amount of Rs.50,000/- also claimed. Even legal expenses sought.

2.                          OP filed written statement by pleading interalia as if complaint is not maintainable; complainant is estopped by her act and conduct from filing the complaint and that complicated questions of law and fact requiring elaborate evidence are involved, due to which, Forum has no jurisdiction. Admittedly, husband of complainant for self alongwith complainant and dependent children’s namely Gazal Kapoor and Archit Kapoor obtained family health optima insurance policy for sum insured of Rs.3 lakhs. It is claimed that as per condition No.4 of the policy, original bills, receipts and other documents, upon which, the claim based has not been submitted. Complainant lodged the claim in the first year of insurance policy for reimbursement of medical expenses of treatment of Enteric Fever at Sachdeva Nursing Home, Ludhiana on 4.2.2014, but on scrutiny of the claim, it was observed that as per discharge summary and certificate of treating doctor, the insured patient (complainant) has a past history of celiac disease, which was diagnosed on 10.10.2013. From documents submitted by the complainant at the time of lodging of claim, it could not be ascertained as to whether previous surgery of Etiology for celiac disease was conducted on the complainant or not. For processing of the claim, OP called upon the complainant vide letters dated 4.3.2014, 27.3.2014 and 28.4.2014 to supply the following documents:-

• Letter from the treating doctor stating the treatment and consultation details of celiac disease.
• UGI scopy, colonoscopy, blood investigations done during diagnosis of celiac disease.
• Hospitalization details for diagnosis of celiac disease including prior discharge summary, if the patient was admitted earlier for celiac disease.

 However, these documents have not been submitted by the complainant despite wait for sufficient time and that is why, claim was rightly repudiated vide letter dated 9.6.2014. It is claimed that there is no deficiency in service on the part of OP. Each and every other averment of the complaint denied.

3.                Complainant to prove her case tendered her affidavit Ex.CA alongwith documents Ex.C1 to Ex.C31 and thereafter, her counsel closed the evidence.

4.                On the other hand, afidavit Ex.RA of Sh.Rajnish Kohli, Assistant Vice President(Claims)  of OP tendered in evidence alongwith documents Ex.R1 to Ex.R25 and thereafter, counsel for OP also closed the evidence.

5.                          Written arguments by both the parties submitted and even oral arguments addressed and were heard. Records gone through minutely. 

6.                Certainly, contract of insurance is binding on the parties and nothing can be added or subtracted thereto by assigning different meaning to the words. This contention of counsel for OP supported by ratio of cases Swift Limited vs. New India Assurance Co.Ltd. and others-IV(2012)CPJ-148(N.C.); Usha Sharma vs. New India Assurance Co.Ltd.-I(2012)CPJ-448(N.C.); United India Insurance Co.Ltd. vs. Harchand Rai Chandan Lal-IV(2004)CPJ-15(S.C.) and Deokar Exports Pvt. Ltd. vs. New India Assurance Co.Ltd.-I(2009)CPJ-6(S.C.). So, case of the parties certainly to be governed by terms and conditions of the insurance policy Ex.R2.

7.                There is no dispute between the parties regarding insurance policy in question which was purchased by husband of complainant for self, complainant and two minor issues. As per condition no.4 of Ex.R2 (which form part of Ex.R1), the insured person/s shall obtain and furnish the company with all the original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the said claim. This clause is binding on the complainant, so       that it is contended that documents demanded through Ex.R11 to Ex.R13 has not been submitted by complainant. It is on account of non submission of these documents that repudiation of the claim took place vide letter Ex.R10. Even if the terms of contract qua supply of documents is binding on the complainant, but despite that it has to be seen as to whether really demanded documents could have been supplied by the complainant to OP or not.

8.                Earlier complainant and her family members were having medi-claim insurance policy for their family from Oriental Insurance Company Limited is a fact born from perusal of Ex.C2 to Ex.C4. So certainly complainant and her family members shifted their policy with OP1 through Ex.C1 or Ex.R1.

9.                There is no dispute regarding the fact that complainant got treatment for Enteric Fever + O/C of Celiac Disease from Sachdeva Nursing Home, Basti Jodhewal, Ludhiana by remaining admitted there from 4.2.2014 to 13.2.2014 because discharge card Ex.C7=Ex.R5 alongwith receipt of bearing of expenses of Rs.31,200/- Ex.C20 are produced on record. In the medical certificate to be filled in by treating doctor Ex.R8, it is mentioned that complainant was having past history of celiac disease, but at the same time, in column 8 of Ex.R8 itself it is mentioned that present ailment of Enteric Fever O/c of Celiac Disease has no concern with the pre-existing disease. Claim Form Ex.R9 was submitted by the complainant. Ex.R7 is certificate issued by doctors of Sachdeva Nursing Home, Basti Jodhewal, Ludhiana to show that Celiac Disease is not related with Enteric Fever. So, even if complainant may be having a past record to Celiac disease, but despite that same has no concern with Enteric Fever, for which, treatment was got by the complainant from Sachdeva Nursing Home, Basti Jodhewal, Ludhiana during the period from 4.2.2014 to 13.2.2014. Despite this, a letter from treating doctor was sought qua exact onset and duration of celiac disease. Record of past consultation papers/past investigation report for celiac disease was sought through Ex.R12 and Ex.R13. In Ex.R17 the certificate dated 20.3.2014 of Sachdeva Nursing Home, Basti Jodhewal, Ludhiana, it is mentioned that patient is a follow up case of Celiac Disease, which was diagnosed on 10.10.2013. However, no treatment was given for Celiac Disease because medical treatment in that respect is not required as per Ex.C17. Through Ex.C18 dated 9.4.2014, it is mentioned that endoscopy of the complainant was done and even blood test and ultra sound conducted and thereafter, reports in that respect handed over to the complainant. In Ex.C18, it has also been mentioned that complainant was not treated for Celiac Disease and medication for the same was not given to the complainant because medication for Celiac Disease is not required. Same are the contents of certificate Ex.C19 of date 20.2.2014. As medication for celiac disease not required and that is why treatment for the same was not given as per record produced by the complainant. If such medical treatment was not required, then how the complainant could have produced the record of medical treatment of Celiac Disease. Question of producing past consultation papers, past investigation report for Celiac Disease by the complainant with OP would have arisen only, if she would have got treatment for the same. Such treatment for Celiac Disease not got and as such, if record for celiac disease not produced by the complainant, then on account of that fault to complainant cannot be attributed.

10.     Celiac Disease is a digestive disorder that occurs in reaction to gluten, a protein found in rye, barley, wheat and hundreds of foods made with these grains. The body’s immune system reacts to the gluten and causes damage to the intestine. This disease is fairly common and it may cause anemia, fatigue, osteoporosis, infertility, miscarriage, mouth ulcer, tingling, numbness in the hands and feet. So virtually celiac disease is a disease caused by allergies of food intakes. In view of that reports of doctors referred above fully believable that Celiac Disease has no concern with Enteric Fever, for which, complainant remained admitted in hospital. So, repudiation of claim on account of non submission of record of disease of Celiac is not proper. In repudiation letter Ex.R10, it is mentioned that record of admission of complainant for earlier treatment for Celiac Disease has not been produced and that is why the claim is repudiated. As treatment by complainant for Celiac Disease by way of admission in the hospital never obtained and as such, question of production of discharge summary by complainant with OP does not arise. So, repudiation of claim is not justified on this ground. However, complainant was handed over the record of past consultation papers/past investigation as per Ex.R6 or Ex.C17 and Ex.C18 and as such, complainant must have produced that record with OP. It is contended by counsel for the complainant that whatever documents available with the complainant, same had been submitted along with the claim form, but said contention controverted by claiming that record of ultrasound, colonoscopy and endoscopy has not been produced. Such record after lapse of time may not be available with the complainant, but complainant has not candidly admitted so. Some fault on the part of complainant also remains. In view of that fault, deficiency in service on the part of OP exclusively not proved. However, repudiation of claim on ground of non submission of record pertaining to Celiac Disease is not justified because Celiac Disease has no concern with Enteric Fever, for which, the complainant remained admitted in Sachdeva Nursing Home, Basti Jodhewal, Ludhiana. So order of repudiation of claim deserves to be set-aside and same is hereby set-aside.

11.              Therefore, as a sequel of the above discussion, the present complaint stands disposed of in terms that complainant will submit the available original documents with OP within 15 days from the receipt of copy of this order and after receipt of those documents, OP will reconsider the claim of complainant within 30 days there from. Order passed with no order as to costs. Copy of this order be made available to the parties free of costs as per rules.

12.                        File be indexed and consigned to record room.

 

 

(Sat Paul Garg)                                                 (G.K.Dhir)

   Member                                                            President

Announced in Open Forum

Dated:16.09.2015

Gurpreet Sharma.