BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.134 of 2017

Date of Instt. 08.05.2017

Date of Decision: 18.07.2018

Arvinder Kaur W/o Satinder Pal Singh R/o H. No.686, G.T.B. Nagar, Jalandhar.

..........Complainant

Versus

1. National Insurance Co. Ltd., 89, Mahavir Marg, BMC Chowk, Jalandhar, Through its Branch Manager.

2. Raksha TPA, SCO 122 (Basement), Cabin No.5, Feroze Gandhi Market, Ludhiana-Punjab.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Harvimal Dogra (Member)

Present: Sh. H. S. Sachdev, Adv Counsel for the Complainant.

Sh. Darshan Singh, Adv Counsel for the OP No.1 and 2.

Order

Karnail Singh (President)

1. This complaint is filed by the complainant, wherein alleged that the OPs after acceptance of the insurance premium, issued the insurance policy for a period from 01.11.2015 to 31.10.2015, vide policy No.404305/48/15/8500000215, but all of sudden on 05.07.2016, the complainant started suffering Losse Motion and Vomiting and due to which, complainant visited M. K. Hospital situated at 28, Vijay Nagar, Jalandhar, Dr. M.K. Arora Consultant Physician, Gastroenterologist and accordingly, doctor prescribed the test and admitted the complainant at 10:30 PM on 05.07.2016 and got discharged on 06.07.2016 at 12:00 midnight and at the time of discharge, the complainant got paid all the hospital bill of Rs.6913/-, which is duly covered in the insurance policy. Thereafter, after paying the above said amount, the complainant applied to the OP No.1 for the claim of the above said amount of Rs.6913/- and with regard to the same, had submitted all the documents to the OP No.1. Thereafter, complainant got an intimation from OP No.1 that their claim has been recommended as Non Payable as reason mentioned “due to Non Continuous Hours Hospitalization in this case” by the OP No.2. It is pertinent to mention here that doctor of the M. K. Hospital have particularly mentioned on his letter head that complainant got admitted on 06.07.2016 at 10:30 PM and discharged on 06.07.2016 at 12 Mid Night, which means the complainant continuously remained admitted for 25.30 hours and the OP No.2 pointed out the wrong clause, which is totally vague and unfair trade practice. The complainant asked to pay the claim time and again to OP No.1 and OP No.2, but they gave no response with regard to the same and declined the request, which is clear cut deficiency in service as well as unfair trade practice. The complainant has also suffered a financial loss as well as suffered mental tension, harassment and agony due to non payment of the medical claim of the complainant and thus, 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 the amount of Rs.6913/- along with interest @ 18% per annum for medical claim and further be directed to pay Rs.50,000/- as damages and amount of compensation on account of mental tension, and harassment and be also directed to pay litigation expenses of Rs.30,000/-.

2. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through their counsel and filed written reply and contested the complaint by taking preliminary objections that the complainant has suppressed the material facts from this Forum and even the present complaint has not been filed by the complainant in proper form and therefore, the same is not maintainable and is liable to be dismissed. It is further averred that the complainant is estopped by his own act, conduct, admission and omissions from filing the present compliant. It is further alleged that no specific and justifiable allegation regarding the negligence or deficiency in providing the services has been made out, only layman conjectures have been averred and hence, the present complaint is liable to be dismissed out rightly on this ground alone. It would be very worthwhile to mention here that the complainant, who is claiming insurance policy for the period 01.11.2015 to 31.10.2015 is not in the record of the OP. The averments in the complaint are not only incorrect, but also misleading. The complainant is abusing the process of law and even the complaint of the complainant is bad for non-joinder of necessary party as admitted by the complainant that he had availed the medical assistance from following institutions/hospitals i.e. Dr. M. K. Arora, but the said doctor is not impleaded in the present complaint and therefore, the complaint is liable to be dismissed. On merits, the allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

3. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit Ex.CA along with some documents Ex.C-1 to Ex.C-11 and then closed the evidence.

4. Similarly, counsel for the OP No.1 and 2 tendered into evidence affidavit Ex.OP-A along with some documents Ex.OP-1 to Ex.OP-7 and then closed the evidence.

5. We have heard the learned counsel for the complainant and also gone through the written arguments submitted on the file by the OPs.

6. Out-rightly, we can say without any hesitation that the purchase of the insurance policy by the complainant is not denied by the OPs rather the OPs took a plea that the insurance policy claimed by the complainant for a period 01.11.2015 to 31.10.2015, is not in the record of the OPs. We carefully scanned this point and find that the copy of insurance policy Ex.C-1, which is placed on the file by the complainant, itself showing the covering period of the insurance policy 01.11.2015 to mid night 31.10.2016, but in-evidently the complainant mentioned the date 01.11.2015 to 31.10.2015, instead of 31.10.2016, the policy number is the same, which is mentioned by the complainant in complaint as envisaged in the insurance policy, so whenever any clerical mistake and typographical mistake, the same can be ignored, but we cannot deny that the complainant has not obtained the insurance policy from the OP rather this factum has been established by the complainant by bringing on the file a photostat copy of the insurance policy along with all documents.

7. Now, question hings in the air is only whether the claim of the complainant is rightly repudiated by the OP simply on the ground, which is mentioned in the repudiation letter dated 19.09.2016 Ex.OP-5 that “there is no continuous 24 hours hospitalization in this case because the patient admitted on 05.07.2016 at 10:30 PM and discharged on 06.07.2016 at 12:00 Mid-afternoon. The above observation as made in the repudiation letter is based upon the report of the Investigator i.e. Raksha TPA Pvt. Ltd. and copy of the Investigator is available on the file Ex.OP-7, wherein the bottom, the discharge time is mentioned on 06.07.2016 at 12:00 Mid-afternoon, if we calculate the hours from 05.07.2016 at 10:30 PM to 06.07.2016 at 12:00 Midnight, then it comes more than 24 hours, but while calculating the said period, the OP has mistakenly got a word Mid-afternoon instead of midnight if we calculate the time till mid-afternoon, then obviously the hours are less than 24 hours. So, with these observations, we are of the considered opinion that the claim of the complainant has been wrongly repudiated.

8. We cannot make any suspicion on the discharge of the complainant/patient at 12:00 Midnight, it depend upon the condition of the complainant or on the advice of the treating doctor, when the patient feel himself a fit for discharge and doctor also agreed with the patient, then the time is not a hurdle for discharging the complainant at a midnight. So, the version of the OP that the time for discharging at midnight create suspicion, is not acceptable and moreover, the judgments referred by the learned counsel for the OP, cited in 2013 (4) C.P.R. 9, titled as “Jindal Heart Institute and Infertility Centre Vs. Sukhdev Singh and Others” and 2006 (4) C. P. J. 239, titled as “Prema and Others Vs. Life Insurance Corporation of India Ltd.”. We have gone through the aforesaid judgments and find that the facts of the aforesaid judgments are not identical to the facts of the case in hand, therefore, these judgments are not helpful in any manner to the OP.

9. From the over all circumstances as discussed above, itself established that the complaint of the complainant is proved and accordingly, the same is partly accepted and OPs are directed to pay the amount of Rs.6913/- for medical claim of the complainant along with interest @ 12% per annum from the date of repudiation of the claim i.e. 19.09.2016, till realization and further OPs are directed to pay compensation of Rs.15,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month 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.

10. 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 Harvimal Dogra Karnail Singh

18.07.2018 Member President