Punjab

Patiala

CC/16/490

Dr. Anshuman Mittal - Complainant(s)

Versus

National Insurance co. - Opp.Party(s)

Sh Mayank Malhotra

12 Oct 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

 

                                          Consumer Complaint No. 490 of 19.12.2016

                                           Decided on:         12.10.2018

 

Dr. Anshuman Mittal S/o Sh. Darshan Kumar Mittal R/o H.No.14-B, New Lal Bagh Colony, Patiala , District  Patiala.

                                                                    …………...Complainant

                                      Versus

1.       National Insurance Co. Ltd., 401406-NIC, B.O. Patiala, 25, Factory Area, Patiala through Divisional Branch Manager.

2.       Vipul Medcorp, TPA Pvt. Ltd., SC1 No.98, First Floor, Industrial Area, Phase-II, Chandigarh-160002 through its  Manager.

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

 

QUORUM

                                      Sh. M.P.Singh Pahwa, President

                                      Smt. Neelam Gupta, Member

                                      Sh. Kanwaljeet Singh, Member        

 

ARGUED BY

                                      Sh.Mayank Malhotra Advocate, counsel for complainant.

                                      Sh.Inderpal Singh Advocate, counsel for OP No.1.

                                      Opposite Party No.2 ex-parte.                                     

 ORDER

                                    SH. M.P.SINGH PAHWA,PRESIDENT

1.       Dr. Anshuman Mittal (hereinafter referred to as the complainant) has filed this complaint against National Insurance Co. Ltd. & Anr. (hereinafter referred to as the OPs).

2.       Briefly, the case of the complainant is that OP no.2 is working in association with OP no.1 Complainant bought medical insurance policy from OP no.1 by the name of Parivar Mediclaim policy under policy No.401406/48/15/8500000040 for  the period from 13.5.2015 to 12.5.2016 with an annual premium of Rs.7286/- approximately. At the time of purchase of the policy, it was conveyed to the complainant that the policy is floater policy under which his wife and  kids are also covered.

3.       On 28.1.2016, complainant suffered serious headache. He was hospitalized in Sadbhavna Medical Heart Institute, Patiala from 28.1.2016 to 29.1.2016. He was diagnosed with cluster headache .Various tests were conducted and it was declared that he had suffered with severe cluster headache and cervical spondylosis. Although the complainant has taken health medi-claim policy, the OPs were required to clear the bills but OPs did not pay the bill on time. Complainant was forced to pay the hospital bills of Rs.18000/- approximately, at the time of discharge from the hospital. It was conveyed to agent of OPs no.1&2 and he assured that complainant is fully covered under the policy. All his expenditure during hospitalization will be reimbursed to him.

4.       After getting discharge from the hospital, complainant written letter to OPs and sent claim form alongwith  all the medical bills on 14.4.2016.The OP has repudiated the claim vide letter dated 7.5.2016 on the ground that as per policy, admission for diagnostic and evaluatory purposes is not payable. The complainant sent a letter and submitted all his reports duly verified by Dr.Harminder Singh, DM, Neurology, on 24.5.2016, whereby he has specifically mentioned that the complainant was never admitted for the reasons of evaluatory purposes rather he had suffered severe cluster headache and cervical spondylosis for which hospitalization is required. The certificate was duly submitted with OPs No.1&2 as per their requirement. The OPs have repudiated the claim on flimsy grounds on 9.6.2016 and have done great injustice with the complainant.

5.       The complainant has alleged unfair trade practice and deficiency in service on the part of OPs. He has also claimed damages to the tune of Rs.50,000/-.It is further pleaded that legal notice dated 15.9.2016 was sent to the OPs for refund of Rs.18000/- and Rs.50,000/- as compensation but to no response. Hence this complaint, whereby the complainant also claimed Rs.50,000/-costs of litigation.

6.       Upon notice, none appeared on behalf of OP no.2.It was proceeded against exparte vide order dated 21.2.2017. OP No.1 appeared through counsel and contested the complaint by filing the reply.

7.       In reply the OP No.1 raised preliminary objections that the complaint is not maintainable as the complainant is not a consumer of the OP; that complainant was insured by the OP under Parivar Mediclaim Policy subject to terms and conditions of the policy only. The complaint is false, frivolous and vexatious. That as per submitted documents, the complainant was diagnosed as a case of cluster headache and cervical spondylosis. He was observed in the hospital and investigated for the same. As per policy terms and conditions, admission for diagnostic and evaluatory purposes is not payable; that the complainant has not come to this Forum with clean hands. He has tried to mislead the Forum.

8.       On merits, the OP has denied all the material averments. It is reiterated that the complainant was not admitted for treatment purposes. He had been only diagnosed as a case of cluster headache and cervical spondylosis and remained in the hospital for investigation of the same. As per policy terms and conditions, admission for diagnostic and evaluatory purposes is not payable.

          In further reply, the OP has denied all the averments of the complainant and reiterated his stand as taken in the preliminary objections.

9.       Parties were afforded opportunity to produce their evidence.

10.     Complainant tendered into evidence his affidavit, Ex.CA, copy of legal notice, Ex.C1, postal receipts, Ex.C2, certificate, Ex.C3, copy of letter dated 7.7.2016  Ex.C4, copy of letter dated 7.5.2016 Ex.C5.

11.     OP tendered into evidence affidavit of Bhupinder Singh, Ex.OPA, copy of policy,Ex.OP1, copy of terms and conditions, Ex.OP2 and copy of certificate, Ex.OP3. The OP No.1 has also submitted the written arguments.

12.     We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.

13.     The ld. counsel for the complainant has reiterated his stand as taken in the complaint. It was further submitted by the ld. counsel for the complainant that the OP has repudiated the claim vide letter, Ex.C4 by pleading that the patient was observed in hospital and was investigated .The admission was for diagnostic and evaluatory purposes and is not payable But the evidence brought on record by the complainant is to the effect that he was not admitted only for diagnostic and evaluatory purposes.

14.     The complainant has produced on record medical record, Ex.C3, whereby it was certified that complainant has suffered from severe cluster headache and cervical spondylosis and he has not been treated for any stress related disorder.

          As per the case history, ExC4 also the complainant has suffered from severe headache with vomiting and giddiness/cluster headache. Therefore, it cannot be concluded by any stretch of imagination that the complainant remained admitted only for diagnostic or evaluatory purposes.

15.     On the other hand, the ld. counsel for the OP has submitted that the claim is to be settled as per terms and conditions of the policy. OP No.1 has brought on record copy of the policy, Ex.OP2. The operative clause of this policy makes it clear that ‘the hospitalization for treatment is the pre condition for reimbursement’.

          In this case, the complainant has not obtained any treatment. He was admitted only for diagnostic and investigation purposes. OP has also relied upon certificate Ex.OP3, issued by Sadbhavna Medical Institute. It was clarified that the complainant was observed in the hospital and investigated for the problem. This certificate also shows that hospitalization was not for treatment but only for investigation purposes. Therefore, the claim was rightly repudiated.

16.     We have given careful consideration to the submissions.

17.     The admitted facts are that the complainant obtained mediclaim policy of the OPs. The complainant after taking treatment from Sadhbhavna hospital, submitted the claim, which has been repudiated vide letter dated 7.7.2016,Ex.C3.

          A perusal of this letter revealed that the repudiation is on the ground that the admission for diagnostic and evaluatory purposes is not payable.

 Therefore, the main point for determination is as to whether the admission was for diagnostic and evaluatory purposes or for some treatment. Ex.C4 also contains brief case history, which shows that the complainant was suffering from severe headache with vomiting and giddiness/cluster headache. This history shows that the complainant got admission only for taking treatment of this problem. Complainant has also placed on record certificate,Ex.C3,  issued by treating Dr.Harminder Singh , whereby it was certified that the complainant was  suffering from severe cluster headache and cervical spondylosis.

18.     The only reliance of the OP is on the certificate, Ex.OP3. Of course, in this certificate also, it is mentioned that the complainant was admitted in connection with severe headache, vomiting and giddiness. but it is further mentioned that he was observed in hospital and investigated for this problem. From this fact alone it cannot be concluded that no treatment was given to the complainant or that he was admitted only for the purpose of investigation. In these circumstances the repudiation of the claim is not justified.

19.     The complainant has claimed amount of Rs.18000/- spent for treatment. OP has not disputed this amount.

20.     For the reason recorded above, the complaint is partly accepted with costs of Rs.5000/-. The OP No.1 is directed to pay Rs.18000/- alongwith interest @ 9% per annum from the date of repudiation i.e. 7.7.2016 till payment.

          The complaint against OP no.2 stands dismissed.

21.              Compliance of the order be made by OP No.1 within a period of 45 days from the date of the receipt of the certified copies of this order. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter, file be indexed and consigned to the Record Room.

ANNOUNCED

DATED: 12.10.2018    

 

 Kanwaljeet Singh                   Neelam Gupta             M. P. Singh Pahwa

       Member                                 Member                                      President