| ORDER | BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR. Consumer Complaint No. 683 of 2014 Date of Institution: 30-12-2014 Date of Decision: 02-09-2015 Mr.Surinder Singh son of Sh.Hardial Singh, resident of 901-A, Street No.3, Kot Atma Singh, Ram Bagh, Amritsar. Complainant Versus National Insurance Company Limited, through its Chairman/ Managing Director/ Principle Officer service through its Branch Office at SF14, Nehru Shopping Complex, Lawrence Road, Amritsar through its Branch Manager. Opposite Party Complaint under section 12 & 13 of the Consumer Protection Act, 1986 as amended upto date. Present: For the Complainant: Sh.Deepinder Singh, Advocate. For the Opposite Party: Ms.Neena Kapoor, Advocate. Quorum: Sh.Bhupinder Singh, President Ms.Kulwant Kaur Bajwa, Member Mr.Anoop Sharma, Member Order dictated by: Sh.Bhupinder Singh, President. - Present complaint has been filed by Sh.Surinder Singh under the provisions of the Consumer Protection Act alleging therein that he has been taking the mediclaim policy for himself and his family from the Opposite Party and lastly taken the cover covering risk period from 16.8.2013 to 15.8.2014 having policy No. 401209/48/13/8500000555 from the Opposite Party. Complainant alleges that unfortunately, son of the complainant fell ill and was admitted in Sahibzada Jujhar Singh Child Care Centre, Amritsar and remained hospitalized there for the period from 4.8.2014 to 10.8.2014. The hospitalization amount and treatment cost is for Rs.11,647/- and the son of the complainant was insured for the amount of Rs.1.5 lacs. The claim was lodged with the Opposite Party being the cashless policy, but the Opposite Party did not pay any amount to the treating hospital and the payment of Rs.11,647/- was paid by the complainant, inspite of the fact that the Opposite Party issued the cashless mediclaim policy to the complainant. Thereafter, the complainant made so many visits to the Opposite Party, but the Opposite Party repudiated the genuine claim of the complainant vide letter dated 19.11.2014 on the ground that the hospital doesn’t have the fully equipped operation theatre. It is further alleged that the hospitalization doesn’t require any operative procedure, moreover, the said hospital has the arrangement of the operation theatre in case to meet any eventuality. Moreover, said policy condition has never been supplied or made aware to the complainant by the Opposite Party. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to pay Rs.11,647/- alongwith interest @ 12% per annum from the date of payment till realization. Compensation and litigation expenses were also demanded.
- On notice, Opposite Party appeared and filed written version in which it was submitted that TPA Health Services Park Medi Claim investigated the claim thoroughly and demanded the insured to submit the documents after discharge from the hospital to consider the reimbursement on merit, Third Party Administrator (TPA) constituted under the Insurance Regulatory and Development Authority expert reviewed the case and it has been perused that Master Yuvraj Singh was hospitalized in Sahibzada Jujhar Singh Child Care Centre, Amritsar with diagnosis acute Bronchitis and he was treated conservatively. On verification of inpatient records, it has been observed that the hospital does not have fully equipped Operative Theatre. As such, the claim of the complainant does not fulfill Minimum Criteria of Hospital/ Nursing Home definition vide condition 1.2 (b) of Sam Arogya Bima Policy, hence the claim is not admissible which was duly conveyed to the complainant vide letter dated 19.11.2014. While denying and controverting other allegations, dismissal of complaint was prayed.
- Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C4 and closed the evidence on behalf of the complainant.
- Opposite Party tendered into evidence affidavit of Sh.M.S.Bhatia, Ex.OP1 alongwith documents Ex.OP2 to Ex.OP6 and closed the evidence on behalf of the Opposite Party.
- 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.
- From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got medical claim policy from Opposite Party i.e. policy No. 401209/48/ 13/8500000555 from 16.8.2013 to 15.8.2014 Ex.C4 vide which the complainant himself and his family were insured with sum assured of Rs.150000/-. Son of the complainant fell ill and was hospitalized in Sahibzada Jujhar Singh Child Care Centre, Amritsar for the period from 4.8.2014 to 10.8.2014. As per discharge summary Ex.C2, the complainant spent a sum of Rs.11,647/- on the treatment of his son Harkirat Singh alias Yuvraj Singh. The matter was reported to Opposite Party. The policy was cashless, but the Opposite Party did not pay this amount to said hospital. The claim was lodged with Opposite Party, but the Opposite Party repudiated the claim of the complainant vide letter dated 19.11.2014 Ex.C3 on the ground that TPA of the Opposite Party observed that the hospital in which the son of the complainant was medically treated, doesn’t have the fully equipped operation theatre. As such, this claim is not admissible. The complainant submitted that son of the complainant did not require any operative procedure nor undergone any operation. 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.
- Whereas the case of the Opposite Party is that the son of the complainant namely Harkirat Singh alias Yuvraj Singh was hospitalized in Sahibzada Jujhar Singh Child Care Centre, Amritsar with disease ‘acute Bronchitis’ and was managed conservatively. On verification of inpatient record, it was observed that the hospital does not have fully equipped Operative Theatre. As such, the claim of the complainant does not fulfill Minimum Criteria of Hospital/ Nursing Home definition vide condition 1.2 (b) of Sam Arogya Bima Policy, so, the claim is not admissible and the Opposite Party has rightly repudiated the claim of the complainant vide letter dated 19.11.2014 Ex.C3. As such, there is no deficiency of service on the part of the Opposite Party qua the complainant.
- From the entire above discussion, we have come to the conclusion that the complainant got insurance policy No. 401209/48/ 13/8500000555 Ex.C4 for the period from 16.8.2013 to 15.8.2014 covering the complainant and his family. Son of the complainant namely Harkirat Singh alias Yuvraj Singh became ill and was admitted in Sahibzada Jujhar Singh Child Care Centre, Amritsar on 4.8.2014 and was discharged on 10.8.2014 where he was treated conservatively for disease ‘acute Bronchitis’ and the complainant spent a sum of Rs.11,647/- on the medical treatment of his son. The policy was cashless and the matter was reported to the Opposite Party, but the Opposite Party did not pay this amount to the hospital authorities, rather the Opposite Party repudiated the claim of the complainant vide letter dated 19.11.2014 Ex.C3 on the ground that during the verification, it was observed that hospital where the son of the complainant Harkirat Singh alias Yuvraj Singh undergone medical treatment for the period from 4.8.2010 to 10.8.2014 doesn’t have the fully equipped operation theatre. As per the terms and conditions of the policy i.e. condition No.1.2(b), the claim is not admissible. The complainant has categorically stated that he was 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 1.2(b) is not applicable to the complainant. Further the son of the complainant has undergone treatment at the aforesaid hospital for the disease ‘acute Bronchitis’ and the son of the complainant had not undergone any operation nor operation theatre was used for the treatment of son of the complainant. The Opposite Party was not justified in repudiating the claim of the complainant on this ground that hospital where the son of the complainant had undergone treatment, does not have fully equipped operation theatre. Consequently, we hold that the Opposite Party has wrongly repudiated the claim of the complainant regarding the treatment of his son.
- Resultantly, we allow the complaint with cost and the Opposite Party is directed to pay Rs.11,647/- to the complainant 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.
Dated: 02-09-2015. (Bhupinder Singh) President hrg (Anoop Sharma) (Kulwant Kaur Bajwa) Member Member | |
