Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 240
Instituted on : 19.04.2022
Decided on : 18.06.2024
Ghanshyam Dass s/o Sh. Banarasi Dass resident of 1485/3, HUDA Rohtak.
………..Complainant.
Vs.
- National Insurance Company Ltd. 3 Middleton Street Prafull Chandra Sen Sarani, Kolkata-700071 Through its M.D./C.M.D./Manager.
- Safeway Insurance TPA Pvt. Ltd. 815, Vishwa Sadan, District Centre, Janakpuri, New Delhi-110058 through its CEO Sh.P.P.Singh.
…….Opposite parties.
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR.VIJENDER SINGH, MEMBER.
Present: Sh.S.S.Vij, Advocate for the complainant.
Sh.R.K.Bhardwaj, Advocate for the opposite party No.1.
Opposite party No.2 already exparte.
ORDER
NAGENDER SINGH KADIAN PRESIDENT:
1. Brief facts of the case, as per the complainant are that he is retired employee of Punjab National Bank and a member of group health Insurance policy of National Insurance Company having policy no.251100/20/21/10000295 and employee ID is 0068822. The policy is being administered by opposite party no.2. The complainant paid an amount of Rs.54850/- as insurance premium and the policy is valid for the period from 01.11.2021 to 31.10.2022. The complainant is suffering from cancer and under regular treatment of Rajiv Gandhi Cancer Institute since 2016. The complainant was admitted to Rajiv Gandhi Cancer Institute on 17.11.2021 on medical advice of doctor and was discharged on 18.11.2021 after due treatment. On discharge from the hospital, the complainant submitted the original doctor prescription and medicine bills amounting to Rs.26444/- for reimbursement. The opposite party No.2 rejected the claim of the complainant under clause 4.1. The clause 4.1 mainly deals with expenses which are excluded such as expenses related to any admission primarily for diagnostic and evaluation purpose. The complainant is an old patient of Rajiv Gandhi Cancer Hospital since 2016 and was admitted in the hospital as per the advice of doctor for treatment and not for diagnostic and evaluation purpose. Hence this clause 4.1 is not applicable on the complainant. The complainant requested the opposite parties many times to reimburse the said amount of Rs.26444/- to the complainant but the respondents are avoiding the matter on one pretext or the other. The act and conduct of the opposite parties is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to disburse the claim amount of Rs.26444/- alongwith interest, compensation of Rs.100000/- and Rs.11000/- as litigation expenses to the complainant.
2. After registration of complaint, notices were issued to the opposite parties. Opposite party No.1 in preliminary objections of its reply has submitted that the claim of the complainant is not payable because the claim is hit by policy terms and conditions specifically exclusion clause 4.1 in which (a) Expenses related to any admission primarily for diagnostics and evaluation purpose only are excluded. b) Any diagnostic expenses which are not related or not incidental to the currant diagnosis and treatment are excluded. On merits, it is submitted that complainant is suffering from cancer and is under regular treatment in Rajiv Gandhi hospital since 2016. It is wrong that the complainant was admitted in Rajiv Gandhi Cancer Institute on 17.12.2021 on the medical advice of doctors and was discharged on dated 18.12.2021 after treatment(As per our observations, dates are wrongly mentioned). The claim is hit by exclusion clause 4.1 of the policy therefore the claim of the complainant is not maintainable. All the other contents of the complaint were stated to be wrong and denied and opposite party no.1 prayed for dismissal of complaint with costs. On the other hand, opposite party No.2 did not appear despite service of notice through registered post. Hence the opposite party no.2 was proceeded against exparte vide order dated 16.08.2022 of this Commission.
4. Ld. Counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C9 and has closed his evidence on dated 26.05.2023. Ld. Counsel for complainant also tendered amended affidavit Ex.CW1/B on 30.04.2024 and closed his evidence. Ld. counsel for the opposite party no.1 has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R3 and closed his evidence on 16.01.2024.
5. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
6. We have perused the documents placed on record by both the parties. In the present case claim of the complainant has been repudiated by the opposite party no.2 vide its letter dated 18.11.2021 Ex.R3 on the ground that : “Cashless denied under exclusion 4.1 as hospitalization primarily for diagnostic and evaluation purpose is not payable as per policy T & C”. We have perused the meaning of evaluation. As per google search, medical evaluation means : “A medical evaluation involves a physical exam and perhaps some common medical tests to determine a person’s overall state of health. During the medical examination, the healthcare practitioner will look for signs of illness, injury, disease, or other physical conditions.” But in the present case the complainant was suffering from cancer and he was under treatment since 10.03.2016 at Rajiv Gandhi Cancer Research Centre. As per certificate Ex.C3 issued by Rajiv Gandhi Cancer Institute and Research Centre, complainant was diagnosed case of Carcinoma Pyrifrom Sinus and he completed his radiation treatment alongwith concurrent chemotherapy on 10.03.2016 at Rajiv Gandhi Cancer Institute and Research Centre. He came with complaints of difficulty in swallowing and hoarseness of voice for the last 5-7 days and has been advised for admission for evaluation and thereby further treatment. Meaning thereby no fresh illness was evaluated during the admission of the complainant in Rajiv Gandhi Research Centre on 18.11.2021. As the patient was already taking treatment from Rajiv Gandhi Cancer Institute and Research Centre since 10.03.2016, so as per our opinion the patient was not admitted for diagnosis and evaluation of disease. As per opposite party explanation of exclusion clause 4.1 mentioned at page no.33 of Ex.C6 and also placed on record by the opposite party as Ex.R2 is as under:-
“a) Expenses related to any admission primarily for diagnostic and evaluation purposes only are excluded.
b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded”.
But the expenses of complainant are not related to diagnostic and evaluation purpose. Hence the clause 4.1 is not applicable in this case. We have perused the documents placed on record by both the parties. As per final bill summary annexed with Ex.C4, the complainant was admitted in the hospital on 17.11.2021 and was discharged on 18.11.2021 i.e. under the policy period and he spent an amount of Rs.25400/- on his treatment. Hence the treatment of complainant covers under the policy and he is entitled for the amount of treatment i.e. Rs.25400/-.
7. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite party No.1 to pay the claim amount of Rs. 25400/-(Rupees twenty five thousand and four hundred only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e.19.04.2022 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
18.06.2024.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
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Vijender Singh, Member.
