DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 54 of 10.2.2016
Decided on: 16.02.2017
Jaspal Passy S/o Sh.Ram Nath R/o House No.307, Bharat Nagar, Nabha Road, Patiala.
…………...Complainant
Versus
- National Insurance Company Ltd., Divisional Office, Leela Bhawan Market ComplexPatiala-147001, through its Divisional Manager.
- M/s Raksha TPA P vt. Ltd., SCO 359-360, 1st Floor, Sector 44-D, Chandigarh.
- Dr.Bhupinder Singh, Amar Hospital, Bank Colony, Patiala.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.M.L.Sharma,Advocate,counsel for complainant.
Sh.Alok Mathur,Advocate, counsel for
Opposite Parties No.1&2.
Sh.Ranjan Gupta, Advocate, counsel for
Opposite Party No.3.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Sh. Jaspal Passy has filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.) praying for the following reliefs:-
- To pay claim amount of Rs.36,105/- alongwith interest from the due date;
- To pay Rs.50,000/- as compensation on account of mental agony and harassment
- To pay counsel fee to tune of Rs.5500/-
- To grant any other relief , which this Forum may deem fit.
2. In brief, the case of the complainant is that he is the holder of staff group Mediclaim Policy (cashless) bearing No.ID M5840140632427 of O.P. No.1 and Rs.405.08 as premiums were being deducted from his salary. Through this mediclaim policy, he and his family members were insured for the medical claim. Under this policy, the medical claims are passed through O.P. No.2. His son namely Ashish Kuamr, admitted in Amar Hospital, vide admission No.2015007199 dated 15.11.2015 for the treatment of Acute Pancreatitus with Sinus Bradycardia, as diagnosed by the concerned doctors of Amar Hospital, Patiala. Rs.35,368/- were incurred on his treatment. After getting treatment he was discharged from the said hospital on 18.11.2015. The information regarding admission of his son in the hospital was given to Raksha TPA Pvt. Ltd. But inspite of cashless policy, it asked him to pay the bill amount and assured the payment of the bill within few days. On the assurance given by Raksha TPA Pvt. Ltd, he paid the bill amount of Rs.35,368/- to the hospital authorities including Rs.374/- for medicine bill.To his surprise, OP No.1 rejected his claim vide Ref.No.401400/Staff Med./2016 dated 27.1.2016 on the ground “ that patient is diagnosed with acute pancreatitis with sinus bradycardia with history cannabis and alcohol inhalation (both are the cause of pancreatitis and sinus bradycardia) and the hospitalization is also for the pancreatitis and bradycardia <Hence the claims is non-payable”. That the claim has been rejected without considering the opinion dated 17.11.2015, of the concerned doctor , who has conducted the treatment that “patient Ashish Kumar do take alcohol occasionally but the present problem is not associated with alcohol intake” It s also stated that after some time the cashless facility was availed by him for the same treatment of his son vide admission No.2016000354 dated 12.1.2016. Thus the repudiation of the claim by the OPs is unjustified and the complainant is entitled to get the claim amount alongwith compensation for causing harassment and put him to in unnecessary litigation .
3. On being put to notice, the OPs appeared and filed their separate written versions. In the written version filed by O.P. No.1, it is stated that vide Member ID No.M5840140632427, the complainant was the holder of mediclaim policy bearing No.111100/NIC/Dummy, for a period from 1.4.2015 to 31.3.2016. OP No.2 is the 3rd party administrator and provides health services. As per the terms and conditions of the insurance policy, the claim is to be processed by M/s Raksha TPA Pvt.Ltd.. It is further submitted that the patient Ashish Kumar, was admitted in the hospital with complaints of pain epigastric region of one day duration. He was investigated and diagnosed as case of Acute Pancreatitis with Sinus Bradycardia. .On going through the indoor case sheet and admission notes of the patient, it was observed that the patient had history of Cannabis inhalation and alcohol intake. Both of them being the cause of pancreatitis and sinus bradycardia, hence the claim falls out of the scope of the policy, as per clause 4.8, which reads as under:
“ Clause 4.8 Exclusion: Convalescence, general debility, “run down” condition or rest cure, sterility, any fertility, subfertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all phychiatric and psychosomatic disorders and diseases/accident due to and/ or use of intoxicating substances or such abuse or addiction etc.”
Vide detailed letter dated 16.12.2015, it was intimated to the complainant that his claim is not payable. Vide letter dated 27.1.2016, addressed by OP No.1 to OP No.2, it agreed with the observations/opinion of OP No.2. It is denied that the treating doctor of Amar Hospital, Patiala has sent any opinion dated 17.11.2015 to TPA through e-mail. It is stated that the team of medical advisors of OP No.2 after thoroughly going through the submitted documents had opined that the claim falls outside the scope of coverage as per clause 4.8 of the policy. The claim of the complainant has been rightly rejected. There is no deficiency of service on its party . After denouncing all other averments made in the complaint, it is prayed to dismiss the complaint.
4. In the written version filed by Op No.2 , it is stated that vide Member ID No.M5840140632427, the complainant was the holder of mediclaim policy bearing No.111100/NIC/Dummy, for a period from 1.4.2015 to 31.3.2016, and it is the 3rd party administrator for providing health services having nominated by virtue of the memorandum of the understanding, signed with OP No.1. It is further stated that the patient Ashish Kumar, was admitted in the hospital with complaints of pain epigastric region of one day duration. He was investigated and diagnosed as case of Acute Pancreatitis with Sinus Bradycardia. .On going through the indoor case sheet and admission notes of the patient, it was observed that the patient had history of Canabis inhalation and alcohol intake, both being the cause of pancreatitis and sinus bradycardia, hence the claim falls out of the scope of the policy, as per clause 4.8, and was rightly rejected vide detailed letter dated 16.12.2015. It is denied that it assured the complainant for the reimbursement of the amount paid by him to the hospital authorities. After denouncing all other allegations made in the complaint, it is prayed to dismiss the complaint.
5. In the written version filed by OP No.3, it is admitted that Ashish Kumar was admitted in the hospital where he was treated and discharged. It is denied that during the treatment the complainant was never told about the reasons of the disease. It is stated that problem of acute pancreatitis with sinus bradycardia can be the cause of various reasons. After denouncing all other averments made in the complaint, it is prayed to dismiss the complaint.
6. In order to prove the case of the complainant, his counsel tendered in evidence Ex.CA, sworn affidavit of the complainant alongwith documents Exs.C1 to C12 and closed the evidence.
On the contrary, the counsel for OPs No.1&2 tendered in evidence Ex.OPA, sworn affidavit of Sh.Gulzar Singh, Sr.Branch Manager of OP No.1 Ex.OPB, sworn affidavit of Vinay Batra, GM Raksha TPA, alongwith documents Exs.OP1 to OP11 and closed the evidence, while the ld. counsel for OP No.3 without tendering any document closed the evidence.
7. We have heard the ld. counsel for the parties, gone through the written arguments filed by the parties and also gone through the record of the case, carefully.
8. In the certificate, Ex.C10, it is mentioned that patient was having kidney stone problem and it has no concern with alcohol. On comparison of signature affixed on the said document with the signatures affixed on Power of attorney and the written version, by Dr.Bhupinder Singh, it is found that the signature put on certificate Ex.C10, does not match with the signatures affixed on Power of Attorney and Written version by Dr. Bhupinder Singh. The person who has issued the said certificate, has not been disclosed by the complainant. Thus no reliance can be made on the said document to arrive at a conclusion as to whether the son of the complainant was drug/ alcohol addict or not. Even the discharge summary, Ex.C12, is regarding the treatment of stone in the kidney and not for the treatment of Pancreatitis and sinus bradycardia. From bare perusal of the medical literature, Ex.OP 11, it is apparent that use of cannabis & alcohol are the cause of acute Pancreatitis and sinus bradycardia.From the in-patient history and physical record, Ex.OP5, it is apparent that the son of the complainant was admitted in Amar Hospital, Patiala on 15.11.2015 with complaint of epigastric pain . In the said document, it is clearly mentioned that the son of the complainant had a history of Cannabis inhalation and alcohol intake. This document has not been rebutted either by the complainant or by Op No.3. As per clause 4.8, which reads as under:
“Clause 4.8 EXCLUSION: Convalescence, general debility, “run down” condition or rest cure, sterility, any fertility, subfertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases/accident due to and/ or use, or misuse or abuse of drugs/ alcohol or use of intoxicating substances or such abuse or addiction etc.”
the complainant is not entitled to get the claim and the O.Ps. have rightly rejected the claim of the complainant.
9. In view of the aforesaid discussion, we do not find any merit in the complaint and the same is dismissed accordingly. The parties are left to bear their own costs. Certified copies of the order be sent to the parties free of cost under the rules. Thereafter, file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:16.02.2017
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
.
