Order dictated by:

Sh.Anoop Sharma, Presiding Member

1.  Present complaint has been filed by Sh. Sandeep Kumar Mannan & Mrs. Reetika Batra wife of Sandeep Kumar Mannan under section 11 & 12 of the  Consumer Protection Act, 1986  on the allegations that complainants obtained mediclaim Insurance policy bearing No. 401209/48/13/85000401009 for the period from 4.12.2013 to the midnight of 3.12.2014  by making premium of Rs. 10,798/- from the opposite party covering mediclaim risks of the complainant and his family members  i.e. Rs. 2 lacs for Sandeep Kumar Mannan, complainant No.1, Rs. 2 lacs for Mrs. Reetika Batra complainant No.2, Rs. 1 lac for Parth (son) and Rs. 1 lac for Mansi (daughter) . Mrs. Reetika Batra, complainant No.2 is an employee of the Punjab State Power Corporation Limited . On 29.4.2014 during the subsistence of the insurance policy, complainant No.2 Mrs. Reetika Batra, while she was working on office computer  suddenly fell down from the chair due to the leg of the chair was broken. Due to the sudden fall from the chair, complainant No.2 developed a pain in the spine which could not be treated after having pain killers  and bed rest. Her spinal cord pain got aggravated on 31.5.2014 and she started treatment from Dr.  Rohit Sharma, 355-A, New Amritsar, who advised medicine for 15 days,  but she did not get any relief. Complainant No.2 then consulted Dr. Jayant Chawla, Neuro Surgeon, K.D. Hospital and remained under his treatment till 6.7.2014. On 8.7.2014, she consulted Dr. Raj Kumar Aggarwal, Orthopaedic Surgeon of Shri Guru Ram Dass Hospital and remained under his treatment  but her condition deteriorated and ultimately she was admitted in Guru Ram Dass Hospital on 12.8.2014 as per advise of Dr. Raj Kumar Aggarwal. She was discharged from the hospital after treatment  of the Epidural by Dr. Gurmeet Singh Dhingra, MD Anaesthesia. The complainant informed the opposite party about her admission in the hospital  and also submitted the claim  to the tune of Rs. 14,539/- on 10.9.2014.  After the treatment of Epidural , complainant No.2 did not get any relief from pain of spinal cord and left leg and suffered PDPH (Post Dural Puncture Headache) a side effect of Epidural. Due to severe PDPH, complainant No.2 contacted Dr. Gurmeet Singh,who gave Epidural treatment to complainant No.2 in Sri Guru Ram Dass Hospital, who advised complainant No.2 for admission in the hospital. Accordingly on 22.8.2014 complainant No.2 was admitted in Dhingra General Hospital, Amritsar and was discharged on 23.8.2014 after the treatment. Opposite party was informed in time and subsequently lodged claim to the tune of Rs. 4175/- on 23.9.2014 and Rs. 4337/- as charges of MRI done on 9.9.2014 alongwith medicines bills dated 5.9.2014. In the month of September 2014, health of complainant No.2 started deteriorating day by day, so complainant No.1 got admitted complainant No.2 in  Fortis Hospital,Ludhiana  on 14.9.2014. A surgery was performed on complainant No.2 on 15.9.2014 and she was discharged from the hospital on 18.9.2014. The opposite party was informed well in time and subsequently claim to the tune of Rs. 1,41,686/- was lodged with the opposite party alongwith necessary documents and bills. The complainant submitted the total claim of Rs. 14,539/-+4175/-+4337/-+1,41,686/-= Rs. 1,64,737/- alongwith requisite documents for settlement and payment under the Insurance policy. However, opposite party rejected the claim vide letters dated  24.1.2015 and 28.1.2015 which the complainant took under RTI Act. It is pertinent to mention that  neither such alleged terms and conditions were ever supplied  to the complainant nor were ever explained to the complainant  and even the alleged exclusion clause mentioned in the repudiation letter, is not applicable in the present claim case . The complainant has sought for the following reliefs vide instant complaint:-

1. Opposite party be directed to pay a sum of Rs. 1,64,737/- alongwith interest @ 12% p.a.
2. Compensation to the tune of Rs. 1,00,000/-  may also be awarded to the complainant  alongwith adequate litigation expenses.

Hence, this complaint.

2. Upon notice, opposite party appeared and filed written version taking certain preliminary objections therein inter alia that complainant has not come to the court with clean hands and has tried to conceal the material facts from this Forum, therefore, the complaint is not maintainable ; that complainant is stopped by his own act and conduct from filing the present complaint. It was submitted that the third party Administrator constituted under the Insurance Regulatory and Development Authority expert reviewed the case and it has been perused that the insured was covered under the policy since 4.12.2013 only  and the current policy is in the first year. However, the patient underwent Epidural Block on 14.8.2014 and current hospitalization is for management for post dural Headache which is because of complication of Epidural Injection. Mediclaim policy does not cover the expenses incurred for surgery for prolapsed interventreal disc and related complications for first two years of inception vide exclusion clause 4.3. Hence, this claim is not admissible and so no payable. The Insurance schedule is binding on the complainant that is why the claim has not been reimbursed so far as per terms and conditions of the policy. On merits facts narrated in the complaint have specifically been denied and a prayer for dismissal of complaint was made.
3. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C42 and closed the evidence on behalf of the complainants.
4. On the other hand, Opposite Party tendered into evidence affidavit of Sh.Dheeraj Seth, Ex.OP1 alongwith documents Ex.OP2 to Ex.OP7 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainants obtained mediclaim Insurance policy bearing No. 401209/48/13/85000401009 for the period from 4.12.2013 to the midnight of 3.12.2014  by making premium of Rs. 10,798/- from the opposite party covering mediclaim risks of the complainant and his family members  i.e. Rs. 2 lacs for Sandeep Kumar Mannan, complainant No.1, Rs. 2 lacs for Mrs. Reetika Batra complainant No.2, Rs. 1 lac for Parth (son) and Rs. 1 lac for Mansi (daughter). It is the case of the complainant that  Mrs. Reetika Batra, complainant No.2 is an employee of the Punjab State Power Corporation Limited. On 29.4.2014 during the subsistence of the insurance policy, complainant No.2 Mrs. Reetika Batra, while she was working on office computer  suddenly fell down from the chair due to the leg of the chair was broken. Due to the sudden fall from the chair, complainant No.2 developed a pain in the spine which could not be treated after having pain killers  and bed rest. Her spinal cord pain got aggravated on 31.5.2014 and she started treatment from Dr.  Rohit Sharma, 355-A, New Amritsar, who advised medicine for 15 days,  but she did not get any relief. Complainant No.2 then consulted Dr. Jayant Chawla, Neuro Surgeon, K.D. Hospital and remained under his treatment till 6.7.2014. On 8.7.2014, she consulted Dr. Raj Kumar Aggarwal, Orthopaedic Surgeon of Shri Guru Ram Dass Hospital and remained under his treatment  but her condition deteriorated and ultimately she was admitted in Guru Ram Dass Hospital on 12.8.2014 as per advise of Dr. Raj Kumar Aggarwal. She was discharged from the hospital after treatment  of the Epidural by Dr. Gurmeet Singh Dhingra, MD Anaesthesia. The complainant informed the opposite party about her admission in the hospital  and also submitted the claim  to the tune of Rs. 14,539/- on 10.9.2014.  After the treatment of Epidural , complainant No.2 did not get any relief from pain of spinal cord and left leg and suffered PDPH (Post Dural Puncture Headache) a side effect of Epidural. Due to severe PDPH, complainant No.2 contacted Dr. Gurmeet Singh,who gave Epidural treatment to complainant No.2 in Sri Guru Ram Dass Hospital, who advised complainant No.2 for admission in the hospital. Accordingly on 22.8.2014 complainant No.2 was admitted in Dhingra General Hospital, Amritsar and was discharged on 23.8.2014 after the treatment. Opposite party was informed in time and subsequently lodged claim to the tune of Rs. 4175/- on 23.9.2014 and Rs. 4337/- as charges of MRI done on 9.9.2014 alongwith medicines bills dated 5.9.2014. In the month of September 2014, health of complainant No.2 started deteriorating day by day, so complainant No.1 got admitted complainant No.2 in  Fortis Hospital,Ludhiana  on 14.9.2014. A surgery was performed on complainant No.2 on 15.9.2014 and she was discharged from the hospital on 18.9.2014. The opposite party was informed well in time and subsequently claim to the tune of Rs. 1,41,686/- was lodged with the opposite party alongwith necessary documents and bills. The complainant submitted the total claim of Rs. 14,539/-+4175/-+4337/-+1,41,686/-= Rs. 1,64,737/- alongwith requisite documents for settlement and payment under the Insurance policy. However, opposite party rejected the claim vide letters dated  24.1.2015 and 28.1.2015 which the complainant took under RTI Act. It is pertinent to mention that  neither such alleged terms and conditions were ever supplied  to the complainant nor were ever explained to the complainant  and even the alleged exclusion clause mentioned in the repudiation letter, is not applicable in the present claim case. Moreover,  policy terms and condition were never supplied to the complainant. Ld.counsel for the complainant submitted that the Opposite Party has wrongly repudiated the claim of the complainant and all this amounts to deficiency of service on the part of the Opposite Party.
7. Whereas the case of the Opposite Party is that the third party Administrator constituted under the Insurance Regulatory and Development Authority expert reviewed the case and it has been perused that the insured was covered under the policy since 4.12.2013 only  and the current policy is in the first year. However, the patient underwent Epidural Block on 14.8.2014 and current hospitalization is for management for post dural Headache which is because of complication of Epidural Injection. Mediclaim policy does not cover the expenses incurred for surgery for prolapsed interventreal disc and related complications for first two years of inception vide exclusion clause 4.3. Hence, this claim is not admissible and so no payable. The Insurance schedule is binding on the complainant that is why the claim has not been reimbursed so far as per terms and conditions of the policy. As such, there is no deficiency of service on the part of the Opposite Party  qua the complainant.
8.   From the entire above discussion, we have come to the conclusion that the complainants obtained mediclaim Insurance policy bearing No. 401209/48/13/85000401009 for the period from 4.12.2013 to the midnight of 3.12.2014  by making premium of Rs. 10,798/- from the opposite party covering mediclaim risks of the complainant and his family members  i.e. Rs. 2 lacs for Sandeep Kumar Mannan, complainant No.1, Rs. 2 lacs for Mrs. Reetika Batra complainant No.2, Rs. 1 lac for Parth (son) and Rs. 1 lac for Mansi (daughter). On 29.4.2014 during the subsistence of the insurance policy, complainant No.2 Mrs. Reetika Batra, while she was working on office computer  suddenly fell down from the chair due to the leg of the chair was broken. Her spinal cord pain got aggravated on 31.5.2014 and got treatment from the hospitals. The opposite party was informed well in time and subsequently claim to the tune of Rs. 1,41,686/- was lodged with the opposite party alongwith necessary documents and bills. The complainant submitted the total claim of Rs. 14,539/-+4175/-+4337/-+1,41,686/-= Rs. 1,64,737/- alongwith requisite documents for settlement and payment under the Insurance policy. However, opposite party rejected the claim vide letters dated  24.1.2015 on the ground that Mediclaim policy in question does not cover the expenses incurred for surgery for prolapsed interventreal disc and related complications for first two years of inception vide exclusion clause 4.3. Hence, this claim is not admissible and so no payable. The complainants have categorically stated that they were never supplied terms and conditions of the policy. The Opposite Party could not produce any evidence to prove that terms and conditions of the policy were supplied to the complainant. It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insruance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus of prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company.  In the present case opposite party could not produce any document that they furnished the terms and conditions of the policy including the exclusion clause, to the complainant. It has been held by the Hon'ble Supreme Court of India in case M/s. Modern Insulators Ltd Vs. Oriental Insurance Co.Ltd 1(2000) CPJ 1 (SC) that if the terms and conditions were not supplied to the complainant, the exclusion clause is not binding upon the complainant. Opposite party could not prove the supply of terms and conditions of the policy, as such this exclusion clause 4.3 is not applicable to the complainant. Consequently, we hold that the Opposite Party has wrongly repudiated the claim of the complainant regarding the treatment of his son.
9. Resultantly, we allow the complaint with cost and the Opposite Party is directed to pay Rs.1,64,737/- to the complainants within one month from the date of receipt of copy of this order, failing which the Opposite Party shall be liable to pay interest @ 9% per annum on the aforesaid amount from the date of filing the complaint till the payment is made to the complainant. Opposite Party is also directed to pay costs of litigation the tune of Rs.2,000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum

Dated: 15.02.2017.