Punjab

Ludhiana

CC/14/524

Daljit Singh - Complainant(s)

Versus

National Ins.Co.Ltd - Opp.Party(s)

31 Mar 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

                                                 C.C. No.524 of 28.07.2014

                                                          Date of decision:31.03.2015 

1.Daljit Singh aged about 53 years s/o Late Sh.Labh Singh.

2.Charanjit Kaur aged about 46 years w/o Sh.Daljit Singh

  Both r/o H.No.273, Phase-I, Urban Estate, Dugri, Ludhiana.

                                                          ….Complainants.

                                       Versus       

1.National Insurance Company Ltd.,Branch Office No.6, G.T.Road, Miller Ganj, Ludhiana through its Branch Manager/Office Incharge.

2.Park Mediclaim TPA Pvt. Ltd., 702, Vikrant Tower, Rajindra Palace, New Delhi through its Manager/Branch Manager/Office Incharge.

                                                                             …Opposite parties

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:    Sh. R.L.Ahuja, President.

                   Sh.Sat Paul Garg, Member.

                   Ms. Babita, Member.

                  

Present:       Sh.C.S.Channa, Adv. for complainants.

Sh.Mohinder Singh Jassal, Adv. for Ops.

 

                                                ORDER

 

SAT PAUL GARG, MEMBER

 

1.                Present complaint under Section 12 of the Consumer Protection Act, 1986 has been filed by Sh.Daljit Singh and Mrs.Charanjit Kaur(hereinafter in short to be described as ‘Complainants’) against National Insurance Company Limited and others (hereinafter in short to be described ‘Ops’), directing them to pay Rs.15,267.87P and Rs.74,080/- to the complainants on account of incurring expenses on medical treatment of complainant no.2 at Satguru Partap Singh Apollo Hospital and to pay Rs.50,000/- as compensation alongwith interest @18% p.a. till the final payment and litigation expenses and other benefits to the complainants.

2.                In brief, the case of the complainants is that the complainants alongwith their children namely Jasmeet Singh and Manpreet Kaur had availed a Parivar Mediclaim Policy of OP1 bearing No.404500/48/10/8500000072, thereafter the policy was being renewed to different policy numbers and lastly in the year 2013, the complainant obtained the policy bearing No.401603/48/13/8500000053 from the period valid for 28.4.2013 to 27.4.2014 in the account of complainant no.1 which covers all the four members of the complainants and also covers different types of diseases as per policy terms and conditions. The main benefit of the policy was hospitalization upto Rs.3 lakh to any policy holder and i.e.why the complainants had availed the abovesaid policy. In the month of June 2013, the complainant no.2 felt some uneasiness due to her menstrual discharge, so being educated lady, the complainant visited the Satguru Partap Singh Apollo Hospital on 10.6.2013 and she consulted Dr.Zeenie Sarda Girn, who checked the complainant no.2 and advised some medicines for three months as per her prescription dated 10.6.2013. However, despite started taking the medicine as advised by the said doctor, there was no improvement in the health of complainant no.2, so the complainant no.2 again visited the said doctor on 16.8.2013, 19,8,2013 and 25.9.2013. Thereafter, the said doctor advised to the complainant to admit in the hospital for operation. On 23.10.2013, the complainant no.2 admitted in the hospital for operation but was discharged on the next day i.e. 24.10.2013 with the instruction to arrange the blood for the operation. Thereafter, the complainant no.1 arranged the blood and again on 26.10.2013, the complainant no.2 was admitted in the hospital for the operation and after the successful operation, the complainant no.2 was discharged on 28.10.2013 with the advised medicines. The complainant no.1 lodged his claim with the Ops by submitting requisite documents for claim of Rs.15,267.87P and Rs.74,080/- as per the policy terms and conditions. Original file alongwith original bills and other relevant documents had been submitted with the Ops while lodging the claim. However, the claim of the complainants had been declined/refused by the Ops on the basis of discharge summary dated 28.10.2013 by alleging that the disease of the complainant no.2 was pre-existing disease and the complainant no.2 was suffering from the abovesaid disease for the last 3-4 years, therefore, the claim of the complainant is not admissible as per exclusion clause 4.1. However, the complainant no.2 first time admitted in the hospital on 23.10.2013 and discharged on 24.10.2014 and there is also discharge summary dated 24.10.2013 and according to this discharge summary, there is no mention of pre-existing disease for the last 3-4 years and this discharge summary is also required to be taken into consideration by settling the claim of the complainants by the Ops but they flatly ignored the same. If there was any malafide intention in the mind of the complainant with regard to the history mentioned by the hospital, they could have changed the same while lodging the claim, the complainant only came to know regarding typographical error on the part of the hospital staff when his claim was refused and after receiving the refusal order, the complainant astonished to see the order based on the discharge summary dated 28.10.2013. Thereafter, the complainant went to the hospital and contacted the concerned doctor regarding the typographical error who had given letter by mentioning that the word mentioned last 3-4 years is typing error, infact, the patient had complaints of the disease since 3-4 months, so in the discharge summary, it typed as 3-4 years by mistake, so it is changed accordingly. The Ops had blindly declined/refused the claim of the complainants only on the basis of discharge summary dated 28.10.2013 and have ignored the discharge summary dated 24.10.2013. Hence, this complaint.

3.                Upon notice of the complaint, OPs were duly served and appeared through their counsel Sh.Mohinder Singh Jassal, Advocate and filed their written reply, in which, it has been submitted in the preliminary objections that the present complaint filed by the complainants against the answering Ops is not maintainable and is liable to be dismissed. It is submitted that the complainant alongwith his family had taken the Parivar Mediclaim for Family Policy bearing No.401603/48/13/8500000053 for the period from 28.4.2013 to 27.4.2014 in the account of complainant no.1 Daljit Singh from the answering OP1 for a sum of Rs.3 lakh and answering OP2 was appointed as TPA in the policy. It is submitted that the complainant no.2 Smt.Charanjit Kaur had remained admitted in Satguru Partap Singh Apollo Hospital, Ludhiana from 26.10.2013 to 28.10.2013 for her treatment. After the receipt of the claim form and the hospital records and the discharge summary of complainant no.2 and letter dated 24.10.2013 of Satguru Partap Singh Apollo Hospital, Ludhiana by the TPA Park Mediclaim TP Pvt. Ltd. The Satguru Partap Singh Apollo Hospital, Ludhiana had also issued letter dated 24.10.2013. As per this letter dated 24.10.2013, the complainant no.2 was having the pre-existing disease i.e. with history of Increased Menstrual Losses for 3-4 years, for which, she underwent Laparoscopic Assisted Vaginal Hysterectomy with Adhesiolysis. So, the claim of the complainants was not payable under the exclusion clause 4.1 of the Parivar Mediclaim for Family Policy. The exclusion clause 4.1 reads as under:-

“4.1 Pre-Existing Disease:-

All pre-existing diseases when the cover incepts for the first time until 48 months of continuous coverage has elapsed. Any complication arising from pre-existing disease ailment/disease/injuries will be considered as a part of the pre-existing health condition or disease. Diabetes and Hypertension, if pre-existing disease, will be covered from the inception of the policy on payment of additional premium by the insured person.”

On merits, it is submitted that the complainant no.2 was having the pre-existing disease, so the complainants are not entitled for the medi-claim under exclusion clause 4.1 of the policy and the claim of the complainants had rightly repudiated by the answering Ops. Otherwise, similar pleas were taken as mentioned  in the preliminary objections and at the end, denying any deficiency in service and all other allegations of the complainants levelled against the answering OPs being wrong and incorrect, answering OPs made prayer for dismissal of the complaint with costs.

4.               In order to prove the case of the complainants, learned counsel for the complainants tendered into evidence affidavit of complainant no.1 as Ex.CA and affidavit of complainant no.2 as Ex.CB, in which, they have reiterated all the contents of the complaint. Further, learned counsel for the complainants has proved on record documents Ex.C1 to Ex.C27. Further, learned counsel for the complainants has examined witnesses Sh.Ashok Sharma, Record Keeper DO-II, National Insurance Company Bansal Complex, Dholewal Chowk, Ludhiana as Ex.CW3, who has proved documents Ex.CW3/1 to Ex.CW3/100 and Dr.Zeenie Sarda Girn as CW4, who proved the certificate Ex.CW3/20.

5.                On the other hand, learned counsel for the Ops adduced evidence by placing on record affidavits Ex.RA of Sh.R.K.Wadhawan, Sr.Branch Manager of OP1, in which, he has reiterated all the contents of the written reply filed by the OPs and rebutted the case of the complainant. Further, learned counsel for the Ops has proved on record documents Ex.R1 and Ex.R16.

6.                During the course of arguments, learned counsel for the complainants has filed the written arguments, in which, it has been submitted that when the complainant lodged her claim with the insurance company at that point of time, the complainants had already paid about Rs.38,548/- to the Ops and thereafter, the complainants had again deposited Rs.12,915/- with the Ops and total an amount of Rs.51,463/- had been paid to the Ops and the claim of the complainants is about Rs.89,347/- only. In this case, the complainant no.2 Charanjit Kaur was having menstrual discharge for 2-3 times in a month and it is not a possible for the complainant to wait for a long time to get any claim. As per statement of CW4 Dr.Zeenie Sarda, who had performed the surgery/treatment of the complainant, had deposed in her chief examination that she had issued the certificate Ex.CW3/20 and also identifying her signatures. She had also submitted that by this certificate, she had certified that there was error in the discharge summaries. The patient had complaints of having bleedings from 3-4 months, but in the discharge summary, it was typed as 3-4 years, so it was changed accordingly. The Ops have not produced such medical record or evidence to prove their case that such type of problem virtually takes 3-4 years to develop and thereafter, the operation is conducted. Therefore, the Ops have failed to prove its case that the patient was having pre-existing disease. Moreover, as per insurance policy and guidelines, the insurance companies have their own paneled doctors to conduct any medical of the insurer, but in this case, no such medical examination was conducted before proving insurance policy. Otherwise, similar pleadings were taken as mentioned in the complaint and at the end, made prayer for the relief as claimed for.

7.                On the other hand, learned counsel for the Ops has filed the written arguments, in which, he has reiterated all the contents of the written reply filed by the Ops and further, it is averred that after receiving the claim form and other documents from the complainants, it was found at the time of processing the claim by the TPA Park Mediclaim Pvt. Ltd. that the complainant no.2 was medically examined by Doctor of Satguru Partap Singh Apollo Hospital, Ludhiana in O.P.D. The attending doctor had prescribed the medicines to Smt.Charanjit Kaur by prescription slip dated 10.6.2013 to be taken by Smt. Charanjit Kaur for the period mentioned in the prescription slip dated 10.6.2013. The treating doctor had not mentioned the history of the patient. The concerned doctor of the aforesaid hospital had also prepared the Inpatient History and physical record of the patient with history of Increased Menstrual Losses for 3-4 years. The complainants have made over writing over the 3-4 years in the patient history and physical record prepared by the doctor of the said hospital. As per the discharge summary dated 24.10.2013 issued by the Satguru Partap Singh Apollo Hospital, Ludhiana, the complainant no.2 Smt.Charanjit Kaur was having pre-existing disease i.e. with history of Increased Menstrual Losses for 3-4 years. Moreover, as per the patient history and physical record prepared by the doctor of Satguru Partap Singh Apollo Hospital, Ludhiana as well as the discharge summaries dated 24.10.2013 and 28.10.2013 issued by Satguru Partap Singh Apollo Hospital, Ludhiana, the complainant no.2 Smt.Charanjit Kaur was having pre-existing disease i.e. with history of Increased Menstrual Looses for 3-4 years, for which, she underwent Laparoscopies Assisted Vaginal Hysterectomy with Adhesiolysis. So, the claim of the complainants was not payable under the exclusion clause 4.1 of the policy in question and the same was repudiated by the Ops on 6.12.2013 and the same was intimated to the complainants. Further, the complainants with malafide intention got the certificate dated nil issued from Satguru Partap Singh Apollo Hospital, Ludhiana. This certificate was again provided by the complainants to the National Insurance Company Limited. The National Insurance Company Limited again sent the claim file alongwith this certificate to the Park Mediclaim TPA Pvt. Ltd. for processing the claim of the complainants on the basis of this letter issued by the doctor. The Park Mediclaim TPA Pvt. Ltd. again denied the claim of the complainants vide letter dated 26.3.2014. On verification of inpatient record of Smt.Charanjit Kaur at Apollo Hospital and it was observed that the patient was hospitalized with complaints of Menorrhagia for 3-4 years which was over written and changed to 3-4 months without any counter signatures. In this certificate issued by the abovesaid hospital stating that the patient had complaints of Mennorrhagia for 3-4 months and it was typed as 3-4 years by mistake in discharge summary seems to be an afterthought for their recommendation for denial of claim since it was handwritten inpatient papers not typed. Hence, their earlier decision dated 6.12.2013 should remain unchanged. The repudiation of the mediclaim of the complainants was based on the terms and conditions of the policy and claimed to be legal, valid and enforceable in the eyes of law. 

8.                We have gone through the written arguments filed by learned counsel for the parties and have also perused the record on file very carefully.

9.                It is evident that the complainant no.1 Sh.Daljit Singh had availed the insurance policy in question from the OP1 which covered all the four members of the family of the complainant and also covered the different diseases as per the policy terms and conditions. The main benefit of the policy was hospitalization upto Rs.3 lakh to any policy holder and i.e.why the complainants had availed the abovesaid policy by paying the requisite premium to the OP1. Further, it is evident that the complainant no.2 Smt.Charanjit Kaur was admitted in the Satguru Partap Singh Apollo Hospital, Ludhiana due to her menstrual discharge on 23.10.2013 to 24.10.2013 and 26.10.2013 to 28.10.2013 and thereafter, the claim was lodged with the Ops. However, the same was repudiated by the Ops on the ground that the complainant no.2 was suffering from pre-existing disease i.e. with history of Increased Menstrual Losses for 3-4 years, for which, she had undergone Laparoscopic Assisted Vaginal Hysterectomy with Adhesiolysis. So, the claim of the complainants was not payable under the exclusion clause 4.1 of the Parivar Mediclaim for Family Policy. The exclusion clause 4.1 which provides as under:-

“4.1 Pre-Existing Disease:-

All pre-existing diseases when the cover incepts for the first time until 48 months of continuous coverage has elapsed. Any complication arising from pre-existing disease ailment/disease/injuries will be considered as a part of the pre-existing health condition or disease. Diabetes and Hypertension, if pre-existing disease, will be covered from the inception of the policy on payment of additional premium by the insured person.”

10.              As such, the complainant no.2 was suffering from aforesaid disease for the last 3-4 years as per the medical record of the Satguru Partap Singh Apollo Hospital, Ludhiana. But thereafter got 3-4 months changed 3-4 months. Perusal of the document Ex.C26 reveals that complainant no.2 Smt.Charanjit Kaur was hospitalized from 23.10.2013 to 24.10.2013 and 26.10.2013 to 28.10.2013 with diagnosis of Menorrhagia for 3-4 years. She underwent Total Abdominal Hysterectomy with Adhesiolysis on 26.10.2013. Whether the medical professionals are authorized to changing their own stand especially when earlier deposition of the patient was clarified in the medical claim by change their own version regarding the pre-existing disease? Those stands taken by the medical professional or hospital doctor regarding the patient are not tenable which apparently appear to be case of accommodating the patient for getting their medical claim from the insurance company.

11.              In view of the above discussion, we hereby dismiss the complaint of the complainants being devoid of any merits with no order as to costs. Copies of the order be sent to the parties free of cost and thereafter, file be consigned to the record room.

 

                 (Babita)             (Sat Paul Garg)         (R.L.Ahuja)

              Member                 Member                President 

Announced in Open Forum.

Dated:31.03.2015

Gurpreet Sharma