Punjab

Ludhiana

CC/23/253

Harmohinder Singh Sachdeva - Complainant(s)

Versus

National Insurance Co. - Opp.Party(s)

complaint in person

02 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  253 dated 21.06.2023.                                       Date of decision: 02.12.2024. 

 

Harmohinder Singh Sachdeva, 112, Partap Colony, Model Gram, Ludhiana-141002.                                                                                                                                                                                           ..…Complainant

                                                Versus

1. National Ins. Co. Ltd., 4^th Floor, Grand Walk, Ferozepur Road, Ludhiana-141012.
2. MDIndia Health Insurance TPA Pvt. Ltd., Office No.12, First Floor, Madhok Complex, Ferozepur Road, Lludhiana-141001.                                                                                                 …..Opposite parties 

Complaint Under Section 35 of the Consumer Protect Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Harmohinder Singh Sachdeva in person For                                         OP1   

For OPs                          :         Sh. M.S. Jassal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant is above 75 years of age and retired as Senior Manager from Punjab and Sind Bank. He had mediclaim insurance with the OP National Insurance Company Limited under Retired Bank Employee Policy on yearly premium of Rs.57,808/- The complainant stated that the OPs assured to reimburse the medical expenses incurred by him on his illness. He was having knee problem for which he firstly sought opinion of Dr. Amandeep Singh, Orthopedic at Guru Teg Bahadur Sahib Hospital, Ludhiana who advised him to take knee injection in first stage to cure his knee pain having cost of approximately Rs.20,000/- along with other minor expenses.

                   The complainant further stated that he sought second opinion from Orthopedic doctor of Dayanand Medical Hospital, Ludhiana who also advised him to take knee injection and in case the injection would not work, then knee replacement would be done. On the asking of the complainant, the doctor asked his junior to take the complainant to TPA staff for preparing his cashless treatment estimate, which was worked out to be Rs.1,05,000/- i.e. Rs.50,000/- as operation theatre charges as well as some other test and injections. The doctor recommended admission of the complainant for giving Inj. Halonix One. According to the complainant, while taking first opinion, the doctor told him that there is no need of admission for taking these injections. As such, the complainant refused for admission just to reduce the hefty mediclaim amount. Thereafter, the complainant took third medical opinion from Orthopedic Doctor Balwant Singh Hunjan of Hunjan Hospital, Ludhiana who also advised the complainant for taking knee injection and told that if it does not work then knee replacement would be done.

                   The complainant further stated that as the three medical opinions were sufficient so he got himself injected from Hunjan Hospital, Ludhiana and he submitted all the original hospital documents, receipts, bills to OP2 on 12.04.2023 along with claim form. However, Mr. Rakesh of OP2 office at Ludhiana told the complainant that his case is in process of rejecting as he was not hospitalized and sent the rejection Email on 24.05.2023. According to the complainant, he took physiotherapy for three weeks and paid Rs.350/- per week and in all he spent Rs.1050/- for which he had not sought reimbursement in claim form. Even after post knee injection, the complainant was advised medicines for Rs.2140/- of Hunjan Hospital which he had not sought reimbursement in claim form. Further the medical techniques and processes have been improved over the time and it does not require hospitalization. The complainant further stated that he cannot insist doctor to hospitalize him to admit him in the evening and give his knee injection in the next morning to fulfill this outdated self made rule by insurance company. In the end, the complainant has prayed for issuing direction to the OPs to make the payment of Rs.20,800/- along with compensation of Rs.10,000/- for mental harassment and litigation expenses of Rs.5000/-.

2.                Upon notice, the OPs appeared and filed joint written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; the complaint being barred under Section 26 of the Consumer Protection Act; the complainant being estopped by his own act and conduct; concealment of material facts etc. The OPs stated that the complainant had taken the Group mediclaim forming part of IBA Retirees with Domiciliary policy for the year 2022-2023 bearing No.251100502210000224 for the period from 01.11.2022 to 31.10.2023 from OP1 in which OP2 was appointed as TPA.  The complainant sought opinion of three doctors for his knee problem i.e. firstly from Dr. Amandeep Singh, Orthopedic of Guru Teg Bahadur Sahib Hospital, Ludhiana explaining total medical treatment charges as Rs.20,000/-, second opinion was taken from Orthopedic doctor of Dayanand Medical Hospital, Ludhiana who also advised him to take knee injection otherwise to replace his knees but the complainant refused to get the injection done. Thereafter, third opinion was sought from Dr. Balwant Singh Hunjan of Hunjan Hospital, Ludhiana who advised him to take knee injection otherwise to replace the knees if the injection would not work. After getting the injection done, the complainant lodged his medical claim with OP2 along with the medical bills etc. OP2 TPA observed that the patient Harmohinder Singh Sachdeva was treated on OPD basis and as per policy terms OPD based treatment is not payable as insured has opted for Retirees without Domiciliary policy. As such, the claim was repudiated by OP2 as per exclusion clause 4.24 and condition No.2.34. The complainant was intimated vide Email dated 24.05.2023. The OPs further stated that in the repudiation letter dated 24.05.2023, the exclusion clause was written as 4.25 in place of exclusion clause 4.24 due to clerical mistake. The said clause 4.24 is reproduced as under:-

“Clause 4.24 Domiciliary treatment: Any expenses incurred on Domiciliary treatment are not covered.

Further the Condition No.2.34 OPD is reproduced as under:-

“OPD (Out Patient) Treatment means the one in which the insured visits a clinic/hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The insured is not admitted as a day care or in-patient.”

According to the OPs, the complainant is not entitled for any compensation from them as per the exclusion clause 4.24 and as per condition No.2.34 of the insurance policy. Further they have repudiated the claim as per exclusion clause and as per terms and conditions of the insurance policy.

                   On merits, the OPs reiterated the crux of averments made in column brief facts of the case. The OPs have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                The complainant filed rejoinder to the written statement of the OPs reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement of the OPs.

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents i.e. Ex. C1 is the copy of news paper cutting and closed the evidence.

5.                On the other hand, the counsel for the OPs tendered affidavit Ex. RA of Sh. Mohit Chawla, Deputy Manager, Legal Department, Regional Office, National Insurance Company Ltd., 4^th Floor, Grand Walk Mall, Ferozepur Road, Ludhiana along with documents Ex. R1 to Ex. R10 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, replication, affidavit and annexed documents as well as written statement, affidavit and documents produced on record by both parties.

7.                The complainant, a septuagenarian, being retired from Punjab & Sind Bank was medically insured vide Group Mediclaim – Tailor Made with Floater policy meant for Punjab and Sind Bank Retirees vide policy Ex. R1. The complainant got treatment for his knee problem from Hunjan Hospital, Ludhiana by way of taking injection Halonix One upon which he incurred a sum of Rs.20,800/-. The complainant submitted claim with the OPs vide claim form Ex. R4 and Ex. R5. However, the OPs repudiated the claim and intimation to the complainant was sent vide Email dated 24.05.2023 Ex. R10. The operative part of Ex. R10 is reproduced as under:-

“We have received the claim for Harmohinder Singh Sachdeva for Rs.20800/-. The claim has been repudiated as per insurer guideline under clause 4.25 as below:

As per claim documents it is observed that the patient was treated on OPD basis & as per policy terms OPD based treatment is not payable.”

 

8.                The complainant being aggrieved of rejection of his medical claim has challenged the said repudiation letter Ex. R10. In this regard, the relevant clauses of terms and conditions of the policy Ex. R3 are reproduced as under:-

“2.9 Day Care Centre means any institution established for day care treatment of illness and/or injuries or a medical set-up within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under:-

1. Has qualified nursing staff under its employment.
2. Has qualified Medical Practitioner(s) in charge.
3. Has a fully equipped operation theatre of its own where surgical procedures are carried out.
4. Maintains daily records of patients and will make these accessible to the insurance Company’s authorized personnel.

2.10. Day Care Treatment - Day Care Treatment means the medical treatment and/or surgical procedure which is-

i) Undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hours because of technological advancement and

ii) Which would have otherwise required a hospitalization of more than 24 hours. Treatment normally taken on an outpatient basis is not included in the scope of this definition.

3.1 Domiciliary hospitalization means medical treatment for a period exceeding 3 days for such an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:-

A) The condition of the patient is such that he/she is not in a condition to he removed to a hospital or

B) The patient takes treatment at home on account of non-availability of room in hospital.”

 

9.                The complainant, who was suffering from knee problem, visited three orthopedic specialists, firstly from Dr. Amandeep Singh, Orthopedic of Guru Teg Bahadur Sahib Hospital, Ludhiana vide OPD Card Ex. R8, secondly from Dayanand Medical Hospital, Ludhiana vide OPD Card Ex. R9 and third opinion was sought from Dr. Balwant Singh Hunjan of Hunjan Hospital, Ludhiana for alleviating the knee problem and the doctors were unanimous in administration of Injection Halonix One, but they were at variance at the manner of administration of said injection and charging of amount. According to the complainant, the doctors of Dayanand Medical College and Hospital, Ludhiana prepared estimate expenses to be more than Rs.1,00,000/-. However, the complainant, opted for his treatment with Hunjan Hospital, Ludhiana A Super Specialty Hospital and this fact can be revealed from receipt as well as certificate Ex. R6 and Ex. R7. As such, the Hunjan Hospital, Ludhiana qualifies to be a ‘Day Care Centre’ within the meaning of clause 2.10 of the policy and is  equipped to provide ‘Day Care Treatment’ as stipulated in clause 2.9 of the terms and conditions of policy. Further Dr. Balwant Singh Hunjan, of Hunjan Hospital, Ludhiana issued a certificate dated 25.03.2023 Ex. R7 certifying as under:-

“This is certified that Sh. Harmohinder singh Sachdeva is suffering from Knee B/L. He was given I/A Injections Halonix One on both knees and he was sent home after few hours the same day.”

 

The TPA OP2 while deciding the claim of the complainant, has not given any weightage to this certificate Ex. C7 and has totally ignored the same. The complainant got treatment from Hunjan Hospital, Ludhiana and was able to save about Rs.80,000/- of the OPs when compared to estimated treatment expenses of more than Rs.1,00,000/- of  Dayanand Medical Hospital, Ludhiana but instead of appreciating the act and conduct of the complainant, the OPs became too technical and harsh in dealing with the reimbursement claim of the complainant. Moreover, except the affidavit Ex. RA of one Mohit Chawla, Deputy Manager, Legal Department of the OPs, no other medical evidence has been adduced by the OPs to rebut the specific opinion Dr. Balwant Singh Hunjan. The affidavit Ex. RA is also verbatim reproduction of the averments of written reply. In the given facts and circumstances, it cannot be said that the repudiation of the claim is justified and as such, it would be just and appropriate if the OPs are directed to pay the medical expenses of Rs.20,800/- as claimed through claim form Ex. R4 along with interest @8% per annum from the date of taking treatment i.e. 25.03.2023 till date of actual payment along with composite costs of Rs.5,000/-.

10.              As a result of above discussion, the complaint is partly allowed with an order that the OPs are directed to pay the medical expenses of Rs.20,800/- as claimed through claim form Ex. R4 along with interest @8% per annum from the date of taking treatment i.e. 25.03.2023 within 30 days from the date of receipt of copy of order. The OPs shall further pay a composite cost of Rs.5,000/- (Rupees Five Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:02.12.2024.

Gobind Ram.