DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/143

Date of Institution : 22.02.2018/29.11.2021

Date of Decision : 16.08.2022

Shri Surinder Kumar Mahajan son of Shri Tarlok Nath, aged about 66 years, resident of H. No. 11, Prince Avenue, Circular Road, Amritsar being died through his LRs.-

1) Kiran Mahajan widow.

2) Gaurav Mahajan Son

3) Isha Mahajan Daughter. …Complainant

Versus

National Insurance Company Limited, D-26, Court Road, Amritsar through its Manager or any other Authorized Officer.  

…Opposite Party

Complaint U/S 12 and 13 of The Consumer Protection Act, 1986

Present: Sh. Pardeep Mahajan Adv counsel for complainant.

Sh. PN Khanna Adv counsel for the opposite party. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 12 and 13 of the Consumer Protection Act against National Insurance Company Limited, Amritsar. (in short the opposite party). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant obtained National Mediclaim Insurance policy from the opposite party and remained paying the premium for the continuous period of 15 years and last premium was paid in the month of March 2016. 

3. It is further alleged that the complainant is suffering from cancer and his treatment is going on in hospital at Amritsar and Mumbai and said disease is duly covered under the said policy. The complainant spent huge amount for his treatment which was required to be recovered by the complainant from the opposite party as per the terms and conditions of the policy. After getting the treatment the complainant applied for his claims with the opposite party amounting to Rs. 1,72,950/- but they have declined and repudiated the claims of the complainant vide letters dated 28.7.2017 and 22.8.2017. All the relevant documents have already been provided to the opposite party within the stipulated time period. The act of the opposite party amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay Rs. 1,72,950/- the amount of two claims alongwith interest at the rate of 18% per annum till actual realization.   

2) To pay Rs. 1,00,000/- on account of compensation for mental agony and harassment. 

3) To pay Rs. 5,500/- as litigation expenses.

4) Any other relief to which the complainant is found entitled. 

4. Upon notice of this complaint, the opposite party filed written statement taking preliminary objections that the complaint filed by the complainant is not maintainable. It is submitted that the complainant has aggregated number of claims of different dates, different months and different years and different cause of ailment which is not allowed under the CPC except with the prior permission to be taken from the concerned court. Further, he should filed separate complaint for each cause of action. The claim of the complainant has already repudiated on the basis of documents submitted by the complainant as well as terms and conditions of the policy and recommendations made by TPA. There is no deficiency in service on the part of opposite party. Further, the complaint is bad for non joinder of necessary parties as TPAs are not impleaded as necessary parties in the present complaint.

5. On merits, it is submitted that the complainant is bound by terms and conditions of policy. The claims have been rightly repudiated by the opposite party Rest of the submissions on merits already submitted by the opposite party in the preliminary objections so there is no need to repeat the same. Lastly, the opposite party prayed for the dismissal of the present complaint with costs.

6. To prove his case the complainant tendered in evidence his  own affidavit Ex.C-1, copy of letter dated 5.8.2017 Ex.C-2, copy of letter dated 28.7.2017 Ex.C-3, documents Ex.C-3 to Ex.C-41 and closed the evidence. 

7. To rebut the case of the complainant the opposite party tendered in evidence affidavit of Puneet Kanodia Ex.OP/1, affidavit of Gurbachan Singh Ex.OP/2, copy of report of Surinder Mahajan of Sushrut Hospital dated 24.2.2017 Ex.OP-/3, copy of repudiation letter by TPA of complainant dated 18.7.2017 Ex.OP-/4, copy of policy from 12.3.2016 to 11.3.2017 Ex.OP-/5, affidavit of Kalpan Ex.OP-/6, copy of Day Care Angles/Discharge Summary dated 24.6.2017 Ex.OP/7, copy of recommendation written from Safeway Insurance TPA to opposite party Ex.OP/8, repudiation letter dated 22.8.2017 Ex.OP/9, copy of dispatch register Ex.OP/10, copy of policy with terms and conditions Ex.OP/11 and closed the evidence.   

8. We have heard the learned counsel for the parties and gone through the record on the file. Written arguments also filed by the opposite parties. 

9. In the present case there is no dispute regarding the purchase and validity of the insurance policy. It is also admitted by the opposite party that they repudiated the claims of the complainant. 

10. The opposite party repudiated the claim of the complainant vide letter dated 28.7.2017 Ex.C-3 and in this letter it is clearly mentioned that complainant was admitted in hospital for Chemotherapy on 24.10.2016 and now he is claiming for Hormonal Therapy. Ailment has been treated on OPD basis as on 24.2.2017 for Hormonal therapy and the Hormonal therapy is payable in hospitalization. Also this claim does not fall under the pre post hospitalization. Hence this claim is repudiated. It is also mentioned in this letter that OPD treatment is not payable/claim does fall under pre post hospitalization clause. Further, the opposite party also repudiated the claim of the complainant vide letter dated 22.8.2017 in which it is also mentioned that on scrutiny of documents it was observed that the patient Surinder Mahajan aged 66 years was admitted in day care Angels from 24.6.2017 in day care and was diagnosed with Neuroendovine tumour with liver metastasis. As per policy terms and conditions Hormone therapy treatment is not payable in Day Care as well as Hospitalization (If primarily for Hormonal therapy). Hence claim is repudiated according to Exclusion Clause 4.14. 

11. The above mentioned documents have been filed by the complainant and it is evident that the complainant failed to prove on the file that he took the treatment of his disease by way of hospitalization of more than 24 hours or he is entitled to the treatment expenses of day care or OPD treatment. The complainant also failed to prove on the file that he remained admitted in the hospital for his treatment so he is also not entitled for any pre hospitalization or post hospitalization expenses. Further, in our view also the insurance companies have been paying the treatment expenses only on the hospitalization. 

11. Secondly, the opposite party repudiated the claim of the complainant according to Exclusion Clause 4.14. We have perused the terms and conditions of the policy and clause 4.14. mentioned as under.-

“4.14 Cosmetic, plastic surgery, sex change, hormone replacement.-

Cosmetic or aesthetic treatment of any description, change of life or sex change operation, hormone replacement therapy, Expenses for plastic surgery other than as may be necessitated due to illness/ disease/injury. 

It is clearly mentioned in letters Ex.C-2 and Ex.C-3 that the complainant has taken treatment for Hormonal Therapy and as per Clause 4.14 of the terms and conditions the expenses of Hormonal Therapy are not payable. The complainant has failed to prove on the record by way of any evidence or document that he is entitled for the expenses of Hormonal Therapy on Day care/OPD basis. Even in repudiation letter dated 18.7.2017 Ex.OP-4 it is clearly mentioned that OPD treatment is not payable. In this way, complainant failed to prove any deficiency in service or unfair trade practice on the part of the opposite party. 

12. In view of the above discussion and evidence produced by both the parties there is no merit in the present complaint and same is accordingly dismissed. However, no order as to costs or compensation. Copy of the order will be supplied to the parties by the District Consumer Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        16th Day of August 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member