BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.109 of 2015

Date of Instt. 17.03.2015

Date of Decision :20.07.2015

Manu Aggarwal wife of Ramesh Aggarwal R/o H.No.174, Grover Colony, Dilbagh Nagar Extn., Jalandhar.

..........Complainant Versus

1. National Insurance Company Limited, Regd.Office-3, Middleton Street, Post Box No.9229, Kolkata-700071.

2. National Insurance Company Ltd, GT Road, BMC Chowk, Jalandhar through its Branch Manager.

3. Aman Aggarwal, agent of National Insurance Company Ltd, 17, Guru Ram Dass Enclave, Sher Singh Colony, Jalandhar.

4. TPA of National Insurance Company Ltd, i.e M/s Raksha TPA Pvt Ltd, 5/5, Mathura Road, Fandabad, Faridabad.

.........Opposite parties

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.Vishal Sodhi Adv., counsel for complainant.

Sh.AK Arora Adv., counsel for OPs No.1 and 2.

Sh.Dinesh Kumar Asstt.Manager of Opposite party No.4.

Opposite party No.3 exparte.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that the complainant got a hospitalization benefit policy individual mediclaim from opposite parties No.1 & 2 through their agent i.e opposite party No.2 on 1.5.2012 vide receipt No.401100/81/12/0000000877 for herself and for her children namely Amit Aggarwal and Sumit Aggarwal for a sum of Rs.4621/-. In continuation of the said policy the complainant had again purchased hospitalization benefit policy individual mediclaim from opposite parties No.1 & 2 through their agent i.e opposite party No.3 on 30.4.2013 vide receipt No.401100/81/13/0000000735 for herself and for her children namely Amit Aggarwal and Sumit Aggarwal for sum of Rs.4621 for the period of 1.5.2013 to 30.4.2014. In the month of February, 2014, the complainant had visited to Mumbai to meet her Massie(mother's sister) Parveen Aggarwal for a week, in order to attend a family function and do the journey through train and she was well at that time and during her stay in her aunt's house, she felt severe pain in her stomach and her relatives got her checked up through Dr.P.S.Shah, Shah Piles Hospital, Shop No.1, Mrkaz View CHS, Near 24 Karat Talkies, Opposite Excel Industries, S.V.Road, Jogeshwari (W) Mumbai. After check-up of the complainant, Dr.P.S.Shah found that the complainant/patient was suffering with internal external hemorrhoids and chronicsures in ano. And in such, complainant was advised for H.A.I. Doctor had opined that the treatment was necessary for the patient due to severe pain. Regarding the same medical certificate issued by the Dr.P.S.Shah of Shah Piles Hospital is attached. The complainant had paid a sum of Rs.23,625/- upon her medical treatment vide consultancy and medical prescription bill and further she had paid a sum of Rs.2502/- for medicines. The complainant had submitted application to the opposite parties for reimbursement of payment made for medical bills and medical treatment i.e sum of Rs.26,127/- and the said application was duly processed through opposite party No.3, who further forwarded the same to opposite parties. But contrary to the hopes of the complainant, the claim of the complainant was repudiated vide letter dated 5.6.2014 by the opposite parties. On such like averments the complainant has prayed for directing the opposite parties to pay her a sum of Rs.26,127/- on account of medical expenses. She has also claimed compensation of Rs.70,000/-.

2. Upon notice, opposite parties No.1,2 and 4 appeared and filed their written replies. In its written reply, opposite parties No.1 & 2, inter-alia, pleaded that in the present case, the claim of the complainant has been made non payable by opposite party No.4 with the following observations:-

"Patient admitted and diagnosed with internal external hemorrhoids fissures in ANO manage surgically. As per policy conditions this treatment comes under two year exclusion clause. The policy being in the 2nd year of inception. Thus the claim non payable as per clause 4.3 internal external hemorrhoids, fissures in ANO".

3. They further pleaded that the complainant was admitted at Shah Piles Hospital on 16.2.2014 and was discharged on 18.2.2014. She was diagnosed with Internal External Hemorrhoids, Fissures in ANO and had undergone the treatment for the same. As per the policy terms and conditions, the expenses on treatment of this disease is not payable for the first two years of the operation of policy. The complainant's policy was in the second year of its inception. Thus the claim of the complainant has rightly been repudiated under exclusion clause 4.3 of the policy of insurance by M/s Raksha TPA Pvt Ltd, which is a claim settling agency of the opposite parties. They denied other material averments of the complainant.

4. In its separate written reply, opposite party No.4 pleaded that the insurance contract is between the insured and the insurer i.e The National Insurance Co.Ltd (opposite parties No.1 & 2). As per the privity of the contract, the insurance company by itself or its TPA (opposite party No.4) is obliged to process the claim as per the terms and conditions of the policy laid down by opposite parties No.1 & 2. It further pleaded that the claim was recommended for repudiation as per terms and conditions of the policy laid down by the insurance company.

5. In support of her complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CW1/A alongwith copies of documents Ex.CW1/1 to Ex.CW1/15 and closed evidence.

6. On the other hand, learned counsel for the opposite parties No.1 and 2 has tendered affidavit Ex.OPA alongwith copies of documents Ex.OP-1 to Ex.OP-6 and closed evidence. Further Assistance Manager of opposite party No.4 has tendered affidavit Ex.OP4/A and closed evidence.

7. We have carefully gone through the record and also heard the learned counsels for the parties and further gone through the written arguments submitted on behalf of complainant.

8. The facts involved in the present complaint are not much disputed. In the written arguments, the complainant has taken a plea that opposite party No.4 has filed written reply but has not come to the witness box to prove the contents of its written reply. We have carefully considered this contention raised on behalf of complainant. In-fact the opposite party No.4 is not necessary party in the present proceedings. It is claim settling agency. The complainant has no privity of contract with opposite party no.4. The privity of contract is only between the complainant and insurance company. Next objection of the complainant is that opposite parties No.1,2 & 4 have failed to produce single document alongwith their written reply dated 8.5.2015. So the documents exhibited by opposite parties No.1 & 2 should be excluded. We have carefully considered this objection raised on behalf of complainant. No objection was raised by complainant or her counsel when the documents were exhibited. In case, the complainant wanted any document for the purpose of leading her evidence, she could have moved an application in this regard but no such application was moved by the complainant or on her behalf by his counsel. The present proceedings are summary in nature. The strict rules of pleadings and evidence are not applicable to the present proceedings. Learned counsel for the complainant contended that the exclusion clause under which the claim of the complainant has been repudiated, was never supplied to the complainant and as such can not for the part of the contract of insurance. Learned counsel for the complainant has also mentioned certain authorities in the written arguments and further attached certain authorities alongwith it but same are on its own facts. The complainant has not taken the policy for the first time. The policy in question was taken for the second year. In the complaint, the complainant has no where alleged that terms and conditions of the policy were not supplied to her at the time of taking the policy. So this version of the complainant, in the circumstances of the present case, can not be accepted. From the bill Ex.CW1/4 produced by the complainant herself, it is evident that she was operated upon for Internal External Hemorrhoids-C Fissures in ANO. Ex.OP/1 is policy and terms and conditions are attached with it. Exclusion clause 4.3 provides that company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any person in connection with or in respect of - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

"4.3 During the first one year of the operation of the policy the expenses on treatment of Benign ENT disorders and surgeries like Tonsilectomy Adeniodectomy/Mastiodectomy/ Tympanoplasty.

Treatment of disease such a Cataract, Begin Prostatic, Hyperthropathy, Hysterectomy, Hernia, Hydrocele, Congenital Internal Disease, Fissures/Fistula in anus. Piles, Sinusitis and related disorders, Polycstic ovarian diseases, Non-infective arthritis. Undescended testis, Surgery of gall bladder and bile duct excluding Gout & Rheumatism. Hypertension, Diabetes, Calculus diseases, surgery for prolapsed intervertebral disc unless arising from accident, surgery of varicose veins are not payable for first two years of operation of the policy".

9. So from the exclusion clause 4.3, it is evident that the expenses incurred upon the treatment of Fissures/Fistula, Piles in anus are not payable for first two years of operation of the policy. Hemorrhoids are also knows as piles. So as per exclusion clause 4.3 of the policy, the claim in this case was not payable and has rightly been rejected by the insurance company.

10. In view of above discussion, we hold that there is no merit in the present complaint and same is hereby dismissed with no order as to cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated

20.07.2015 Member Member President