Punjab

Faridkot

CC/15/100

Rohit Mittal - Complainant(s)

Versus

N.I.I.A co. Ltd - Opp.Party(s)

R.K Single

15 Sep 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     100

Date of Institution:  5.08.2015

Date of Decision :   15.09.2015

 

Rohit Mittal s/o Brij Mohan c/o M/s Neki Ram Roshal Lal, Cloth Merchants, Gurudwara Bazar, Kotkapura, Tehsil and District Faridkot.

                                                                    ...Complainant

Versus

1. The New India Assurance Company Ltd through Branch Manager, Mall Godown Road, Kotkapura. 151204.

2. Raksha TPA Pvt Ltd through its Managing Director, Chandigarh, Now, its Office at : c/o Escorts Corporate Centre, 15/5 Mathura Road, Faridabad.(Haryana) 1211003.

 ....OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Parampal Kaur, Member,

               Sh P L Singla, Member.

 

Present: Sh Ravinder Singla, Ld Counsel for complainant,

              Sh Atul Gupta, Ld Counsel for OPs

 

(Ajit Aggarwal, President)

1                                              Present complaint with earlier no. cc- 4 of 2013 was dismissed by this Forum vide order dt 1.08.2013 and being aggrieved by this order, complainant filed appeal before Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh and vide order dt 6.07.2015 on FA No. 1177 of 2013, Hon’ble State Commission Punjab, Chandigarh accepted the appeal filed by complainant and set aside the order dt 1.08.2015 passed by this Forum, remanded back the present complaint to this Forum for deciding it afresh.                             

2                                      Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of Rs 31,000/-for medical treatment and for further directing OPs to pay Rs 31,000/- as compensation for harassment and mental agony besides Rs 10,000/- as litigation expenses.

 3                                         Briefly stated, the case of the complainant is that father of complainant purchased hospitalization/medical policy bearing no. 36070134110100000089, valid from 9.11.2011 to 8.11.2012 from OP-1 and under said policy, complainant being son, his father and mother were insured for Rs 1 lac each for medical treatment expenses. It is contended that on 2.04.2012, complainant got severe pain in shoulder and neck and due to this he rushed to Dr Yashpal Sharma, M S Ortho, Ghaziabad and on his advice, complainant got conducted his X Ray and some treatment and spent about Rs 1700/-on it, but could not get much relief and thereafter, on 27.04.2012, complainant went to Dr P S Brar, Ortho at Pavitar Nursing Home, Kotkapura, where concerned doctor admitted the complainant as indoor patient for treatment on 27.04.2012 at about 9.00 am and after examination of complainant by said doctor, it was diagnosed that complainant was suffering from Cervical Spondylitis and he gave further treatment and advised him MRI C Spine and other tests and complainant was discharged from there on 28.04.2012 at 5.00 pm and was advised further treatment for two weeks and then, complainant paid Rs 668/- and said doctor advised physiotherapy to complainant. Thereafter, as per advice of doctor, complainant got done his MRI of spine on 29.04.2012 from Focus Diagnosis, Faridabad and charged Rs 7000/-from complainant and after consulting the MRI report, Dr P S Brar, advised complainant to take rest for two weeks and gave him medicine. On 16.05.2012, complainant again visited Dr Brar, who advised him to join duty and recommended light work and also advised him to take exercises. Total expenses incurred by complainant for medical treatment at Kotkapura were Rs 2,154/-. On advise of Dr P S Brar, complainant again went to Faridabad for further treatment from Dr Shivam Tyagi at Tyagi Physiotherapy Clinic, Faridabad, who treated complainant from 20.05.2012 to 8.06.2012 and complainant incurred Rs 6000/-on this. On 22.06.2012, complainant again felt acute cervical pain and he went to Pushpanjali Crosslay Hospital, Ghaziabad for treatment and spent Rs 500/-on tests, Rs 871/-for medicine and got conducted some tests on 23.06.2012 for Rs 5,330/-. Complainant again visited Dr P S Brar at Kotkapura on 1.07.2012, who gave treatment and advised some medicines, which complainant purchased from Firozepur Cantt and spent Rs 5,696/- and complainant also spent Rs 660/-on medicines on 30.07.2012. It is submitted that complainant spent overall Rs 31000/- on his treatment of Cervical Spondylitis. Complainant submitted claim alongwith original documents, bills, medical reports and prescription slips etc to OP-1, who further sent the same to OP-2 for verification. Complainant was shocked to know that OPs rejected his claim illegally and unlawfully and all this amounts to deficiency in service and trade mal practice and has caused harassment and mental tension to him for which he has prayed for directing the OPs to pay Rs 31,000/- as compensation and Rs 10,000/- as litigation expenses incurred by him besides the main relief of Rs 31,000/-on account of expenses incurred on treatment. Hence, the complaint.

4                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 15.01.2013, complaint was admitted and notice was ordered to be issued to the opposite parties.

5                                 On receipt of the notice, the OPs filed written statement taking legal objections that complaint is liable to be dismissed as complainant is not the consumer of OPs. Complaint involves complicated questions of law and facts requiring detailed evidence, which is not permissible in the Consumer Protection Act and bare perusal of the complaint clears that  entire treatment was given as outdoor patient and complainant never underwent any active management during the course of treatment and there was no need for hospitalization and  same problem can be managed on OPD basis as only physiotherapy and investigation done to complainant did not require hospitalization and therefore, claim falls out of scope of policy. However, on merits, OP has denied all the allegations levelled by complainant being wrong, incorrect and false and reiterated that there is no deficiency in service or unfair trade practice on the part of opposite parties. It is totally denied if complainant ever got severe pain in shoulder or neck as alleged and he rushed to Dr Yashpal Sharma, Ghaziabad and also denied that said doctor advised medicine. It is also denied that complainant came to Kotkapura at Pavitar Nursing Home for treatment and remained there as indoor patient on 27.04.2012 and was discharged at 28.04.2012. It is also denied that complainant spent the amount of Rs 31,000/-on treatment. It is further reiterated that there is no deficiency in service on the part of answering OPs. The allegations with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

6                            Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1, and documents Ex C-2 to C-31 and then, closed his evidence.

7                              In order to rebut the evidence of the complainant, the opposite party tendered in evidence, affidavit of Ashwani Kakkar, Divisional Manager as Ex OP-1 and documents Ex OP-2 to OP-4 and then, closed the evidence.

8                        We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

9                                      Ld Counsel for complainant vehemently contended that father of complainant Brij Mohan purchased a medical policy from OP-1 covering himself, his wife and complainant as his son for Rs 1 lac, each for medical treatment expenses which were valid from 9.11.2011 to 8.11.2012. He was purchasing this Insurance Policy regularly for many years, the copies of insurance policies valid from 10.11.2008 to 9.11.2012 are Ex C-6 to Ex C-9. On 2.04.2012, complainant got severe pain in shoulder and neck and for treatment he visited Dr Yashpal Sharma at Ghaziabad, who advised some medicines, treatment and got conducted the x-ray. For it, complainant spent Rs 1,700/- but complainant could not get much relief from this treatment. On 27.04.2012, complainant went to Dr P S Brar at Kotkapura for treatment, who admitted the complainant as indoor patient for treatment on 27.04.2012 at 9.00 am and took investigation of complainant and diagnosed acute Cervical Spondylitis. The said doctor further gave treatment and also advised for MRI and other tests and discharged him on next day i.e on 28.04.2012 at 5.00 pm and further advised rest for two weeks with medical treatment to follow up by the complainant and also advised  for physiotherapy. The discharge slip dt 28.04.2012 issued by Dr P S Brar of Pavitar Nursing Home, Kotkapura is Ex C-11 and Ex C-12. The complainant got done MRI of spine on 29.04.2012 from Focus Diagnosis, Faridabad, who charged Rs 7,000/- for it. MRI Report is Ex C-13 and bill of the same is Ex C-16. Dr P S Brar gave some medicines after consulting the MRI Report and advised complete bed rest for two weeks and asked to consult physiotherapist for active exercises. Complainant went to Faridabad and got treatment from Physiotherapist Dr Shivam Tyagi as per advise of Dr P S Brar at Tyagi Physiotheray Clinic, Faridabad from 20.05.2012 to 9.06.2012 and expenses for the same came to Rs 6,000/-. The report of the Physiotherapist is ExC-19 and receipt regarding payment is Ex C-20. On 22.06.2012, complainant again suffered pain in cervical and went to Pushpanjali Crosslay Hospital, Ghaziabad and got treatment in the said hospital, where doctor advised some tests and medicines. The complainant got conducted said tests on 23.06.2012 and spent money for it. Reports of the diagnose are Ex C-22 and 23 and bills of the same are Ex C-24 and Ex C-25. On 1.07.2012, complainant consulted Dr P S Brar at Pavitar Nursing Home, Kotkapura who gave treatment and medicines. Complainant purchased these medicines from Ferozepur and the bills of the same are Ex C-15, C-17, C-18, C-26, C-28 to C-30 and also took further  medicines etc from time to time as advised by the doctor and all he spent Rs 31,000/- for his treatment. The complainant submitted the claim alongwith requisite documents, bills, medical reports and prescription slips to OP-1 for payment. OP-1 sent the same to OP-2 for verification. The claim form is Ex C-2. OP-2 repudiated the claim of complainant on false grounds. The claim status report is Ex C-3 stating that the treatment is OPD basis and no active management is done during hospitalization and rejected the claim. The OPs have illegally and wrongly rejected the genuine claim of the complainant. This is clear cut deficiency in service and unfair trade practice on the part of OPs. The  Opposite  Parties  are  bound  to  pay the expenses incurred by complainant on his treatment      under the Medical Policy. Counsel for complainant has prayed for accepting the present  complaint.

10                                 In rebuttal, ld counsel for OPs argued that the complainant is not the consumer of the OPs and he cannot file this complaint under Consumer Protection Act. The bare perusal of the complaint alongwith documents make it clear that the entire treatment which was allegedly administered to complainant as outdoor patient and complainant never underwent any active management during the course of treatment and there was no need of hospitalization as problem of Cervical Spondylitis can be managed on OPD basis as only Physiotherapy and investigation done to complainant did not require hospitalization. The claim of the complainant falls out of the scope of Policy. There is deficiency in service on the part of OPs. Before rejecting the claim of complainant, the OPs took Expert Opinion. The complainant never got pain in his shoulder and in neck and he never visited any doctor and nothing was spent by him on his treatment either at Ghaziabad or in Kotkapura. The complainant was never admitted as indoor patient at Pavitar Nursing Home, Kotkapura on 27.04.2012 and was never discharged on 28.04.2012. He was never advised for MRI and bed rest. The complainant never took services of Physiotherapist. He never got conducted test as alleged by him. Moreover, the tests are not covered under the Medical Policy. All the bills and reports producd by the complainant are fake. The OPD charges, tests, physiotherapy and medicines are not covered under the Policy. The complainant is not entitled to seek refund of claim amount as it is not covered under the Policy. The OPs have rightly repudiated the claim of complainant. The complainant is not entitled for any amount as refund of his medical claim. There is no deficiency in service or unfair trade practice on the part of OPs and prayed for the dismissal of present complaint.

11                                                    The case of the complainant is that he  suffered from acute Cervical Spondylitis and for his treatment he visited doctors at Ghaziabad, Kotkapura and Faridabad and got his treatment and tests and also paid for medicines and in all he spent Rs 31,000/-. He was also admitted in Pavitar Nursing Home, Kotkapura for his treatment as an indoor patient but OPs illegally and unlawfully rejected his claim on the ground that he has got no active management done during the course of hospitalization and there is no need for hospitalization in Cervical Spondylitis and it can be managed on OPD basis as only Physiotherapy and investigation done which require hospitalization and claim falls out of the scope of medical policy and rejected the claim of the complainant.

12                        The OPs argued that complainant was suffering from Cervical Spondylitis for which he needs not to be admitted in hospital and it can be cured on OPD basis which is not covered under the policy and his claim is rightly rejected vide letter Ex OP-2 and OP-3. The OPs produced on file the terms and conditions of the policy as Ex OP-4. According to it, as clause no. 3.4 hospitalization means admission in any Hospital / Nursing Home in India upon the written advice of a Medical Practitioner for a minimum period of 24 consecutive hours. As per clause no. 2.5, an insured can claim pre-hospitalization charges up to 30 days period immediately before the insured’s admission to hospital and as per clause 2.6, he can claim post hospitalization medical charges up to 60 days period  immediately after the insured’s discharge from the hospital. As per clause 2.3, he can claim Surgeon, Anaesthetist, Medical Practitioner, Consultants Specialist fees. As per clause 2.4, he can claim medicines and drugs, laboratory, Diagnostic test, x-ray and other medical expenses related to the treatment. As per Ex C-11 and C-12, complainant was admitted as indoor patient at Pavitar Nursing Home, Kotkapura on 27.04.2012 at 9.00 am and was discharged on 28.04.2012 at 5.00 pm, which comes to more than 24 consecutive hours admission in the hospital. As such, he is entitled to claim the expenses for his treatment as per clause 3.4 of terms and conditions of the Medical Insurance Policy. Further as per clause 2.5, he is entitled to claim pre-hospitalization medical charges and as per clause 2.6, he is entitled to claim post hospitalization medical charges.

13.                       From the bare perusal of the record and in the light of the above discussion, we are of considered opinion that the complainant is entitled to get re-imbursement of medical expenses under the Mediclaim policy issued by the OPs and there is no deficiency in service on the part of OPs. So, OPs are ordered to pay Rs 28,879/- i.e the claim amount to complainant, which was claimed by complainant from OPs vide claim form Ex C-2 alongwith interest at the rate of 9 % per anum from the date of repudiation of claim till realization. OPs are further directed to pay Rs 5,000/-as compensation for harassment and mental tension suffered by complainant and Rs 3,000/-as litigation expenses. Ops are directed to comply with the order jointly and severally within one month from the date of receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 15.09.2015

                            

  Member            Member                   President

                                (P Singla)         (Parampal Kaur)      (Ajit Aggarwal)