BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.335 of 2014

Date of Instt. 23.09.2014

Date of Decision :19.03.2015

Ravi Kant Aggarwal son of Balwant Rai R/o 1506, Urban Estate Phase-II, Jalandhar.

..........Complainant

Versus

National Insurance Company Limited, Branch Office-II, 89, Mahavir Marg, BMC Chowk, Jalandhar through its Senior Branch Manager.

.........Opposite party

Complaint under section 1 2 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.KC Malhotra Adv., counsel for complainant.

Sh.RS Arora Adv., counsel for opposite party.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite party on the averments that law abiding citizen complainant above named obtained mediclaim insurance policy (individual) covering risk to reimburse/indemnify expenses to the insured persons expenses incurred for hospitalization and for medical/surgical treatment at any hospital/nursing home for any disease or suffer from any illness/ailments, disease or injury sustained from opposite party through its authorized agent for the period stated in the policy schedule dated 22.8.2013 by renewal effective from 30.8.2013 to 29.8.2014. The complainant has been continuously and un-interruptly insured himself and his wife Smt.Vanita Aggarwal under mediclaim insurance policy (individual) since year 2007 without any gap/break and sting by opposite party. The policy No.401104/48/13/8500000 246 was allotted. Insured persons covered by medical benefit insurance policy are complainant and his wife Vanita Aggarwal as under:-

Note:-In case of Ravi Kant Aggarwal cumulative bonus amount is Rs.5000/- and in case of Smt.Vanita Aggarwal nil subject to exclusion of previous disease mentioned Rs.20000/- and Rs.60000/- respectively.

2. The cover note and policy schedule of policy was issued in the name of complainant. Vanita Aggarwal, wife of the complainant, co-insured with opposite party consulted Dr.Harmeet Pal Singh, Modern Hospital, Model Town, Jalandhar for Para-Umblical Hernia and gastric sleeve for obesity and on examination diagnosed and clinical test was advised two surgeries for these diseases and admitted Vanita Aggarwal in Modern Hospital, Jalandhar, on 24.9.2013. Dr.Harmeet Pal Singh is surgeon who performed two surgeries in one sitting (one Gastric Sleeve for obesity and Hernia surgery Para Umbical Hernia). She remained admitted from 24.9.2013 to 30.9.2013. The complainant was charged Rs.80,000/- for obesity surgery and paid the same to the hospital. After discharge from the hospital, the complainant made a claim each for the said surgeries for Rs.80,000/- for obesity and Rs.67055/- for Hernia for medical and surgical expenses incurred for reimbursement for hospitalization and on account of medicine, incurred for medical and surgical expenses including medicine for reimbursement and treatment expenses to opposite party to settle the claim. Duly completed claim on prescribed form, bills and receipts and discharge certificate alongwith the clinical test reports etc were submitted. All the formalities and the requirements whichever asked for, were completed and complied with for settlement and reimbursement of medical claim as stated above. However, opposite party refused to entertain the claim for Rs.80,000/- for obesity surgery on the pretext that claim there under is not admissible regardless the complainant submitted payment bill for Rs.80,000/- in respect thereto to opposite party. Opposite party vide letter dated 7.5.2014 called comments of the complainant and simultaneously intimated cryptically and vaguely that the claim is not maintainable as the complainant has not disclosed material facts that the patient (wife of the complainant) underwent two surgeries. The complainant replied vide letter dated 12.5.2014. The complainant later on submitted certificate dated 20.12.2013 from treating doctor in response to query for performing two surgeries in one sitting. To utter surprise and dismay of the complainant, opposite party vide letter dated 9.6.2014 unilaterally, arbitrarily on whims and fancy repudiated mediclaim reimbursement for Rs.67055/- of Hernia surgery on the pretext the complainant has tried to get expenses incurred for obesity surgery under the alleged Hernia surgery. On such like averments, the complainant has prayed for directing the opposite party insurance company to pay mediclaim amount of Rs.67055/- and Rs.80,000/- alongwith interest. He has also claimed compensation and litigation expenses.

3. Upon notice, opposite party appeared and filed a written reply pleading that the fraud on the company is attempted by the proxy complainant in combination with the hospital. Alongwith the claim form was appended by Vanita Aggarwal the test report dated 25.9.2013 from Dr.Prem Singh Clinical Lab, which turned out to be for the operation of obesity for which she had got herself admitted in the hospital on 24.9.2013. She was confronted by this fact and the opposite party wrote letter dated 9.12.2013 whereby she did not deny having undergone surgery of obesity. The complainant planned this all in way with the hospital that she would be getting herself admitted for Hernia since she would be claiming indemnification for Hernia from the insurance company, so every material charges be shown for the operation of Hernia i.e room charges, OT, Dressing and lab charges etc be attributed to the expenses for surgery of Hernia by the hospital. What actually spilled the beans was the lab report and bill dated 25.9.2013 which were submitted alongwith the claim form by the insured i.e from Dr.Prem Singh Clinical Lab, Jalandhar and when confronted by those by letter of the opposite party, only then admitted that she had gone in for surgery of obesity, although stated that out of innocence and inadvertently had sent these documents to the company which did not relate to her claim and asked for their return. The proxy complainant has come, among other, to wrongly claim expenses incurred on the surgery of obesity when the proxy complainant and the treating hospital very well knew that surgery of obesity was not covered. The insured made no claim of surgery of obesity in the claim form either, now the proxy complainant raising a bogey of it under the false hope that by stretching his claim, something may be achieved out of the two, notwithstanding his knowing that the judicial scrutiny strongly disapproves such crafty moves in litigation. None out of the two claims is tenable, and the complaint in toto deserves to be dismissed. It denied other material averments of the complainant.

4. In support of his complaint, learned counsel for complainant has tendered into evidence affidavits Ex.CA to Ex.CC alongwith copies of documents Ex.C1 to Ex.C22 and closed evidence.

5. On the other hand, learned counsel for the opposite party has tendered into evidence affidavit Ex.OA alongwith copies of documents Ex.O1 to Ex.O4 and closed evidence.

6. We have carefully gone through the record and heard learned counsels for the parties.

7. It is not disputed that complainant obtained mediclaim insurance policy for himself and his wife Vanita Aggarwal. Ex.C9 is policy document and in it the name of the insured is mentioned as Ravi Kant Aggarwal. So complainant being insured is entitled to file the present complaint claiming the medical expenses in respect of surgery undergone by his wife i.e co-insured. The wife of the complainant underwent two surgeries i.e one for Hernia and second of Obesity in one sitting i.e at the same time. After discharge from the hospital, the complainant submitted claim with opposite party insurance company but opposite party insurance company repudiated his claim vide letter dated 9.6.2014 Ex.C1 wherein it is mentioned as under:-

"This has reference to our earlier correspondence on the captioned subject. While going through claim papers and statement of treating surgeon given to our investigator we have noted that you have concealed the material facts to insurance company, which is a violation of policy condition. Patient Mrs.Vanita Aggarwal undergone two surgeries in one sitting but only one alleged Hernia surgery was disclosed by you in the claim form to the company and the surgery of obesity (which is not covered under the policy) was not disclosed by you. So you have tried to get expenses incurred for Obesity surgery under the bill of alleged Hernia surgery. So your claim is repudiated as you have concealed the material facts".

8. Counsel for the opposite party contended that wife of the complainant had undergone two surgeries in one sitting but in the claim form only one surgery of Hernia was disclosed as such tried to get expenses incurred for obesity surgery under the claim of Hernia surgery. So the claim of the complainant was repudiated due to concealment of above fact. On the other hand, it has been contended by learned counsel for the complainant that complainant being a layman has wrongly attached the report relating to Gastric Sleeve surgery and he has clarified this fact vide letter Ex.O1 wherein it is mentioned as under:-

"With reference to your letter, I wish to inform you that my wife had undergone 2 surgeries in one sitting to avoid the risk of anesthesia twice. First of Gastric Sleeve for obesity and second for Hernia surgery for Para Umbilical Hernia. As the Hernia surgery is eligible for claim, I am claiming for the Hernia surgery only.

I am enclosing herewith a certificate from Modern Hospital, Jalandhar declaring that 2 surgeries (one claimable and other not) were undertaken simultaneously and the amount paid (receipt enclosed) for first surgery by me to modern hospital for Gastric sleeve surgery is not being claimed. I, being a non-medical man had attached wrongly the histopathology report of my first surgery (which is not claimed).

I view of above facts, I request your to return my original histopathology report of Dr.Prem Singh Clinical Lab pertaining to first surgery and kindly get my file reviewed by your medical examiner afresh for the 2nd surgery i.e Hernia surgery (without histopathology report)".

9. So the complainant has explained to the insurance company that he is not claiming anything for Gastric Sleeve surgery and his claim is only for Hernia Surgery. The claim for obesity is not payable as per condition No.4.19 of the terms and conditions of the policy Ex.O4. So complainant is only entitled to expenses incurred by him for Hernia Surgery. Counsel for the opposite party contended that as both surgeries were performed in one sitting as such medical expenses in respect of anesthesia and certain other charges can not be differentiated. We have carefully considered this contention advanced by learned counsel for the opposite party. Ex.C3 is certificate given by the hospital wherein they have mentioned that they have charged Rs.80,000/- separately for obesity surgery. So complainant is not entitled to this amount which he paid on account of obesity surgery as same is not payable under policy. The complainant has claimed Rs.67055/- on account of expenses of Hernia Surgery. Ex.C6 contains the details of expenses in this regard. As per Ex.C6, he has spent Rs.67055/- on Hernia Surgery. Out of the said amount Rs.48730/- was paid to the hospital vide bill dated 30.9.2013 Ex.C1 and the remaining amount is regarding dressing charges, lab charges, chemist bill and consultation charges in OPD. The complainant has also produced the chemist bills Ex.C10 to Ex.C19, bill of lab test for Rs.670/- Ex.C20. In our opinion, the opposite party insurance company was not justified in rejecting the claim of the complainant in respect of Hernia surgery on the ground that he has also claimed expenses of surgery for obesity while submitting the claim form without mentioning the factum of obesity surgery separately. We feel that genuine claim of the complainant should not be disallowed on the ground that it was coupled with the claim which was not payable under the terms and conditions of the policy.

10. In view of above discussion, the present complaint is partly accepted and opposite party insurance company is directed to pay Rs.67055/- to the complainant alongwith 9% interest from the date of filing of the present complaint till the date of payment. The complainant is also awarded Rs.3000/- on account of litigation expenses. Copies of the order be sent to the parties free of costs under the rules. File be consigned to the record room

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

19.03.2015 Member Member President