| ORDER | BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR. Consumer Complaint No. 422 of 2015 Date of Institution: 03.07.2015 Date of Decision: 28.10.2015 Bir Inder Singh Bhalla C/O Hari Transport Co.(P) Limited, Shaheed Bhagat Singh Road, I/S Sheran Wala Gate, Amritsar, Mobile-9855505330 Complainant Versus - M/s.National Insurance Company Limited, Queen’s Road Branch, Amritsar.
- M/s.Dedicated Healthcare Services TPA (India) Private Limited, Cambata Building (Eros Theatre Building), East Wing, 3rd Floor, 42, Maharishi Karve Road, Churchgate, Mumbai-4000020.
Opposite Parties Complaint under Consumer Protection Act. Present: For the Complainant: In person. For the Opposite Party No.1: Sh.S.K.Davesar, Advocate For the Opposite Party No. 2 : Exparte. Quorum: Sh.Bhupinder Singh, President Ms.Kulwant Kaur Bajwa, Member Mr.Anoop Sharma, Member Order dictated by: Sh.Bhupinder Singh, President. - Present complaint has been filed by Sh.Bir Inder Singh Bhalla under the provisions of the Consumer Protection Act alleging therein that he got medi claim insurance policy from Opposite Party No.1 for himself and his wife Prabhjot Kaur. Complainant alleges that Smt.Prabhjot Kaur insured felt high blood pressure and she was admitted in Beri Hospital, Ganga Building, Putlighar, Amritsar on 27.3.2015. Prabhjot Kaur insured was pregnant and she was hospitalized to control the high blood pressure so that it may not harm pregnancy which was expected on 9.4.2015. However, the doctor advised to take emergency steps to get the delivery by caesarean operation, which was done on 27.3.2015. Prabhjot Kaur insured was discharged on 30.3.2015. The complainant spent Rs.42393/- on the treatment of his wife Prabhjot Kaur insured. The claim was lodged with the Opposite Parties alongwith entire medical record, but the Opposite Parties repudiated the claim of the complainant by stating that the insurance was not covered under clause 4.12 of the policy. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to pay Rs.42,393/- i.e. the hospital charges+ medical bills. Compensation and litigation expenses were also demanded.
- On notice, none appeared on behalf of Opposite Party No.1, despite service, so Opposite Party No.1 was proceeded against exparte vide order 12.8.2015 of this Forum. However, later on at the stage of evidence, Sh.S.K.Davesar, Advocate appeared on behalf of Opposite Party No.1.
- None appeared on behalf of Opposite Party No. 2 despite service, so Opposite Party No. 2 was proceeded against exparte vide order dated 12.8.2015 of this Forum.
- Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C25 and closed the evidence on behalf of the complainant.
- Opposite Party No.1 tendered into evidence affidavit of Sh.Suresh Sharma, Divisional Manager Ex.OP1/1 alongwith documents Ex.OP1/2 to Ex.OP1/4 and closed the evidence on behalf of the Opposite Party No.1.
- We have carefully gone through the pleadings of the parties; arguments advanced by the complainant and ld.counsel for Opposite Party No.1 and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for Opposite Party No.1
- From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got medi claim insurance policy from Opposite Party No.1 for himself and his wife Prabhjot Kaur. Wife of the complainant namely Prabhjot Kaur insured felt high blood pressure and she was admitted in Beri Hospital, Ganga Building, Putlighar, Amritsar on 27.3.2015. Prabhjot Kaur insured was pregnant and she was hospitalized to control the high blood pressure so that it may not harm pregnancy which was expected on 9.4.2015. However, the doctor advised to take emergency steps to get the delivery by caesarean operation, which was done on 27.3.2015 i.e. on the same day when she was admitted in the aforesaid hospital and she was discharged on 30.3.2015. The complainant spent Rs.42,393/- on the treatment of his wife Prabhjot Kaur insured. The claim was lodged with the Opposite Parties alongwith entire medical record of the patient, but the Opposite Parties repudiated the claim of the complainant vide letter dated 8.6.2015 Ex.OP1/2 on the ground that as per clause 4.12 the expenses incurred on the hospitalization due to maternity is not covered as per the policy in question. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite parties qua the complainant.
- Whereas the case of the Opposite Party No.1 as per the affidavit filed by Suresh Kumar, Divisional Manager of the Opposite Party No.1 Ex.OP1/1 is that on receipt of the claim from the complainant, the matter was examined by Opposite Party No.2-Dedicated Healthcare Services TPA (India) Private Limited, and vide its letter dated 27.3.2015 Ex.OP1/3 the said TPA submitted that maternity is not covered as per policy terms and conditions, so the claim of the complainant has rightly been repudiated by the Opposite Parties vide letter dated 8.6.2015 Ex.OP1/2 and the same was conveyed to the complainant. Ld.counsel for the opposite party No.1 submitted that there is no deficiency of service on the part of the Opposite Party No.1 qua the complainant.
- From the entire above discussion, we have come to the conclusion that the complainant obtained policy bearing No.404400/48/14/ 8500000831 Ex.C4 from Opposite Party No.1 for himself and his wife Prabhjot Kaur for a sum insured Rs.3 lacs each, which was valid for the period from 9.12.2014 to midnight of 8.12.2015. Complainant submitted that he had been taking the policy for himself and his wife Prabhjot Kaur since 2013. Wife of the complainant Prabhjot Kaur insured was admitted in Beri Hospital, Ganga Building, Putlighar, Amritsar on 27.3.2015 and she gave birth to a baby on the same day through caesarean operation. Opposite Party No.1 submitted that as per the terms and conditions of the policy i.e. Exclusion clause 4.7 any treatment arising from or traceable to pregnancy/ childbirth including caesarean section, miscarriage, surrogate or vicarious pregnancy, abortion or complications thereof including changes in chronic conditions arising out of pregnancy other than ectopic pregnancy which may be established by medical reports, is not payable under the policy. Plea of the complainant that Prabhjot Kaur insured was admitted in the hospital as a result of high blood pressure due to which caesarean operation of the lady was to be conducted in advance, so the claim of the complainant is payable, is not tenable because Prabhjot Kaur insured was admitted in Beri Hospital, Ganga Building, Putlighar, Amritsar due to complications arising as a result of pregnancy/ child birth and she gave birth to a child on the same day through cesarean operation. As per clause 4.7 of the terms and conditions of the policy Ex.OP1/4, any amount spent on the treatment of pregnancy or any treatment arising from or traceable to pregnancy/ childbirth including caesarean section, is not payable under this policy. Opposite Parties were, therefore, justified in repudiating the claim of the complainant vide letter dated 8.6.2015 Ex.OP1/2 as per terms and conditions of the policy. So, there is no deficiency of service on the part of the Opposite Parties qua the complainant.
- Resultantly, we hold that the complaint is without merit and the same is hereby dismissed with no order as to cost. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Dated: 28-10-2015. (Bhupinder Singh) President hrg (Anoop Sharma) (Kulwant Kaur Bajwa) Member Member | |
