BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.273 of 2020
Date of Instt. 04.09.2020
Date of Decision: 24.05.2023
Sanjeev Chopra age 47 years s/o Prem Sagar Chopra R/o H. No.8/298A, Doaba College Road, Ward No.10, Jalandhar.
..........Complainant
Versus
1. M/s United India Insurance Co. Ltd through its Managing Director/Chairman, Regd. & Head Office:24, Whites Road, Chennai-600014, Branch Office No.2, Syal House, Lajpat Nagar Market, Jalandhar.
2. Raksha TPA Pvt. Ltd., through its Managing Director/Chairman, DO 3, Ludhiana, 2nd Floor, Batra Plaza Building Opposite ARC Mall, Ferozepur Road, Ludhiana.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Deven Sharma, Adv. Counsel for the Complainant.
Sh. A. K. Arora, Adv. & Sh. Nitish Arora, Adv. Counsels for OP No.1.
OP No.2 exparte.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the OPs are engaged in the business of providing insurance coverage with regards to the person and property to general Public for consideration throughout India and more particularly at Jalandhar. The complainant is in the habit of purchasing Medical claim insurance policy from the OP No.1 through agent of OP No.1. Details of previous policies purchased earlier by the complainant from OP No.1 which are as follows: -
i. Individual Health Insurance Policy, Policy No:2009002817P111270814 and the period of Insurance policy was from 8.11.17 to Midnight on 7.11.2018.
ii Individual Health Insurance policy, policy No:- 2009002816P110511077 attached as Annexure-2 and the period of insurance was from 8.11.2016 to midnight of 7.11.2017.
The OP issued a health insurance policy bearing policy number:-2009002818P110159440 for the period of 8.11.2018 to 7.11.2019 after paying the premium of Rs.15,903/- and Rs.2863/- for CGST and SGST etc. which is also mentioned in the insurance policy. The complainant only received the 3 pages of the policy issued by the OP No.1 and there is no terms and conditions mentioned in the said policy no.2009002818P110159440 for the period of 8.11.2018 to 7.11.2019. The complainant never received any terms and conditions of the above mentioned policy at any time till now. Unfortunately, complainant fell ill on 18.6.2019 and was admitted in Dayanand Medical College & Hospital, Ludhiana and was discharged on 19.6.2019 after treatment and the complainant has paid the total amount of Rs.23,100.46. In the discharge summary issued by the Hospital to the complainant clearly mentioned that the complainant was diagnosed with Hypertension and in clinical examination the complainant was found Pallor Positive, Jaundice positive and Edema positive. In the second last para of discharge summary doctor advised the complainant to follow up the same after 5 days of discharge from the Hospital and also advised to repeat the Thyroid profile after 1 month and in the last para of the discharge summary doctor has advised the complainant three Medicines tab pan 40 mg od, tab cobadex- cz od, tab telma- am 40 mg od and advised the complainant low salt advise. The wife of the complainant on 18.6.19 moved an intimation letter to Senior Divisional Manager of United India Insurance Company Limited D.O-iii, Ludhiana, regarding admission and the treatment of complainant Dayanand Medical College and Hospital Ludhiana. The said intimation letter and claim papers in original were forwarded to Raksha TPA on 2.7.19. Thereafter the wife of the complainant again moved an. application to Senior Divisional Manager of United India Insurance Company Limited along with all the original documents, bills and etc., which was received by the Raksha TPA PVT LTD, Ludhiana on 15.07.2019. The United India Insurance Company Limited repudiated the claim of the complainant on the false ground by giving the opinion the patient admitted in Hospital K/C/O HTN, Obesity. There is no Active management done during hospitalization, Patient admitted only for investigation and evaluation purpose hence claim recommended for repudiation as per Clause 4.8. The said clause 4.8 finds no mention in the insurance policy issued by the OP as such, is an afterthought and malafide and tantamount to deficiency in service and unfair trade practice. Due to the above said facts complainant suffered mental tension, mental agony, financial loss and harassment etc. and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.2,00,000/- to the complainant as compensation in all for mental tension, harassment, inconvenience etc.
2. Notice of the complaint was given to the OPs, but despite service OP No.2 did not appear and ultimately, OP No.2 was proceeded against exparte, whereas OP No.1 appeared through its counsel and filed written reply and contested the complaint by taking preliminary objections that there is absolutely no cause of action in favour of the complainant to file the present complaint against the answering OP. It is further averred that there is no deficiency of service or unfair trade practices on the part of OP and that being so, the present complaint is not maintainable, thus is liable to be dismissed with costs. It is further averred that immediately on the receipt of Claim documents for the reimbursement of medical expenses qua the treatment of the complainant for the period 18.06.2019 to 19.06.2019, claim was registered by the OP. Complainant was called upon to provide the Treating Doctor's Certificate justifying indication for hospitalization in this case and so also original Discharge Summary for the hospitalization dated 18.06.2019 of the complainant vide letter dated 22.07.2019. In response to letter dated 22.07.2019, the complainant produced original Discharge Summary, the copy of which already placed on the record by the complainant and Certificate dated 31.07.2019 of the Treating Doctor. As per the said certificate issued by the treating doctor, the complainant was admitted for monitoring Blood Pressure and Evaluation for the symptoms detailed in the said certificate and the complainant was discharged on 19.06.2019 in stable condition. Discharge summary and certificate issued by the Treating Doctor was considered by OP No. 2 i.e. the Claim settling agency of the answering OP, the observation and opinion of OP No.2 is as under:-
‘Patient Admitted in hospital K/C/O HTN. Obesity, there is no active management done during hospitalization. Patient admitted only for investigation and evaluation purpose, hence claim recommended for repudiation as per clause 4.8’. Accordingly OP No.2 Raksha Health Insurance TPA Pvt. Ltd. wrote letter dated 26.08.2019 to the answering OP for repudiation of claim being Non-Tenable. Thus, the claim of the complainant was repudiated by the answering OP as per clause 4.8 of the policy of insurance. The policy of insurance along with its clauses is on record. On merits, the factum with regard to purchase of insurance policies by the complainant is admitted and it is also admitted that the claim was filed by the complainant, which was repudiated, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder not filed by the complainant.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the complainant and counsel for the OP No.1 very minutely.
6. The complainant has alleged that he had purchased a medi-claim insurance policy from the OP No.1 in the year 2016 and the same was effective from 08.11.2016 to midnight of 07.11.2017. The copy of the insurance policy has been proved by the complainant Ex.C-2. This policy was again extended and he purchased new policy for the year 2017-18, which was effective from 08.11.2017 to mid night on 07.11.2018, which has been proved as Ex.C-1. He again purchased the policy, which was effective from 08.11.2018 to 07.11.2019 and the same has been proved as Ex.C-3. The complainant has alleged that he fell ill on 18.06.2019 and was taken to DMC, Hospital, where he was treated and medicines were prescribed. Claim was filed, but the same was repudiated on the ground of exclusion clause 4.8. He has alleged that he was never provided and supplied the terms and conditions allegedly mentioned in the insurance policy. He has been supplied only 3 pages of the insurance policy, in which the terms and conditions were not attached. The complainant has alleged the unfair trade practice and deficiency in service on the part of the OPs for repudiating the claim under exclusion clause, which was never brought to the notice of the complainant.
7. The OPs on the other hand has not denied the insurance policies purchased by the complainant. It has also not been denied by the OPs that the claim was filed by the complainant, which was repudiated. It has been alleged by the OP that in the certificate of the doctor Ex.OP1/2, the complainant was admitted for monitoring blood pressure and evaluation for the symptoms mentioned in detail in the certificate and the claim was declared as non-tenable by the OP No.2 as per clause 4.8 of the policy. The OP has referred the policy Ex.C-3, wherein it has been mentioned that the terms and conditions are attached. They have alleged the repudiation letter as legal.
8. The complainant has proved on record the bills and the documents showing that he was admitted in the DMC Hospital. He has proved the bills for the medicines Ex.C-4 to Ex.C-15. Ex.C-16 is the discharge summary. Perusal of Ex.C-16 shows that the complainant was admitted in the hospital on 18.06.2019 and he was discharged on 19.06.2019. He was admitted in emergency as per Ex.C-7, wherein it has been mentioned as Emergency OPD Consultation DMCH i.e. emergency doctor. Rs.500/- were paid by the complainant for emergency consultation. The complainant was diagnosed with hypertension and obesity. He was having history of Pinpricking Sensation, Restlessness and Heaviness of Head. He was found suggestive of Mild Hepa Tomegaly with Grade 2 Fatty Infiltration. The OPs were intimated about the admission of the complainant. Ex.C-18 is the letter written by the complainant to the OP for reimbursement. The OP’s observation has been proved as Ex.C-19, where the claim was recommended for non-pay as per clause 4.8.
9. The OPs have relied upon the letters written to the complainant for providing doctor certificate Ex.OP1/1 and as per the OPs, the original doctor certificate was provided. Ex.OP1/2 is the certificate of the doctor. The patient as per the doctor was diagnosed with hypertension and obesity and he was admitted for monitoring blood pressure and evaluation for the symptoms and he was discharged on 19, June. The clause 4.8 relied upon by the OPs provides that ‘Charges incurred at Hospital or Nursing Home primarily for diagnosis, x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home’.
It is not disputed that the complainant had been paying premium since 2016. Clause 4.8 shows that the claim is not payable if the expenses are incurred at hospital for diagnoses, x-ray or laboratory examinations or other investigations, but in the present case, perusal of the discharge summary Ex.C-16 shows that the complainant was admitted in emergency and was diagnosed with hypertension and obesity and having the problem of Pinpricking Sensation, Restlessness and Heaviness of Head. USG Abdomen and Pelvis was suggestive of Mild Hepa Tomegaly with Grade 2 Fatty Infiltration. Grade 2 Fatty Liver, as per Medical Jurisprudence, is a dangerous disease, if not treated promptly, it will lead to hepatitis, cirrhosis or liver cancer. Grade 2 Fatty Liver is a transitional stage between severe and mild. So, in the case of the present complainant, the medicine was prescribed to the complainant of hypertension and other diseases found by the doctor. It cannot be inferred from the documents produced on record that he was diagnosed or merely for investigation. The complainant was admitted and remained in the hospital for one day under observation. He paid the fee and purchased the medicines. The bills have been proved by the complainant. So, it is the duty of the OP to reimburse the claim as they are taking the premium. Perusal of Ex.C3, the insurance policy, shows that it has been highlighted that the terms and conditions and clauses attached as per the respective individual plans. This is set standard clause of the OPs and as per individual plans, the terms and conditions are attached, but it has nowhere been mentioned in the case of the complainant or in this policy Ex.C-3, which of the terms and conditions have been attached with the policy. The complainant has alleged that the terms and conditions were never supplied to him. It has been held in a case titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Rajwant Kaur and Other”, 2021 (3) CLT 540 (CHD) that ‘the onus is on the appellant insurance company to prove that it provided the terms and conditions of the policy to the complainant and the same were in her knowledge’. It has been held in a case titled as “National Insurance Co. Ltd. & Ors Vs. M/s Saraya Industries Ltd”, 2020 (1) CLT 278 (NC) that ‘it is the duty of the insurance company to supply all the terms and conditions of an insurance policy to the policy holder-there cannot be any presumption under law on the terms and conditions.
10. The law referred by the counsel for the OP of Hon’ble Supreme Court, in a case titled as ‘United India Insurance Co. Ltd. Vs. M/s Harchand Rai Chandan Lal’ that ‘Insurance Policy Contract of insurance Terms and conditions of Insurance policy Definition of It is only the terms and conditions specifically prescribed in the insurance policy which will govern the contract between the parties Terms of insurance policy have to be given the same definitions as provided in the policy and will be interpreted with reference to the same not any other laws.’, but the same is not applicable as the OPs have failed to prove that the terms and conditions were supplied to the complainant. Similarly, the law referred by the OP is not applicable to the facts of the present case as the complainant has alleged that he has never received the policy schedule and terms and conditions, so when he had not received the policy schedule, how can he reject the policy immediately after it was received as observed by the Hon'ble National Commission. It has been held by the Hon’ble Punjab & Haryana High Court, in a case titled as ‘The Oriental Insurance Co. ltd. Vs. Naresh Sharma and others’ that ‘Insurance Medical Insurance - Applicant had suffered headache, giddiness and hypertension - As per exclusion clause certain usual diseases like arthritis, cataract, Piles, diabetes, gout and rheumatism, surgery of gallbladder etc. have been excluded for first two years - Heart disease does not find mention in exclusion clause Normally it is not necessary to admit a patient suffering from hypertension is not required to be admitted in a hospital Investigation shows that the symptoms could lead to a heart - disease X-ray of the chest and Echo test of the patient was conducted Prolonged treatment of four days could not be the result of simple hypertension - It could be the symptoms of heart disease or heart attack Hence, the claim of respondent for reimbursement of medical bills could not be rejected. So, as per the law laid down by the Hon’ble Punjab & Haryana High Court since he was suffering from other diseases also, therefore, the hypertension and the obesity can be a symptom of any serious disease. So, it cannot be considered hypertension only and accordingly, we are of the opinion that the claim of the complainant has been wrongly and illegally repudiated by the OPs and the same is hereby set-aside and further, find that the complainant is entitled for the relief as claimed.
11. In view of the above detailed discussion, the complaint of the complainant is partly allowed and the OPs are directed to pay hospital expenses, medicine expenses and other charges etc. as per bills submitted in the Court by the complainant. Further, OPs are directed to pay a compensation including litigation expenses of Rs.20,000/- for causing mental tension and harassment to the complainant. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
24.05.2023 Member Member President
