Punjab

Sangrur

CC/543/2016

Mandeep Singh - Complainant(s)

Versus

National Insurance Company Ltd. - Opp.Party(s)

Shri L.K.Singal

02 Mar 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  543

                                                Instituted on:    06.09.2016

                                                Decided on:       02.03.2017

 

Mandeep Singh son of late Shri Amrik Singh, R/O Guru Nanak Colony, House No. B-06/0859, Block-D, Sangrur.

                                                        …Complainant

                                Versus

1.             National Insurance Co. Ltd. Branch Malerkotla Pili Kothi, Thandi Sarak, Malerkotla through its Branch Manager.

2.             National Insurance Co. Ltd. Divisional Office, Sangrur through its Divisional Manager.

3.             The Manager, Raksha TPA Pvt. Ltd. SC 359-360, 1^st Floor, Sector 44-D, Chandigarh.

4.             The New India Assurance Co. Ltd. through its G.M., CDU Commerce, Center 1^st Floor, Tardeo Road Mumbai 400 034.

5.             The New India Assurance Co. Ltd. through its Divisional Manager, College Road, Sangrur.

                                                        ..Opposite parties.

 

 

For the complainant  :       Shri L.K.Singla, Adv.

For OP No.1&2         :       Shri Ashish Kumar, Adv.

For OP No.4&5         :       Shri Amit Bhalla, Adv.

For OP No.3             :       Exparte.

 

 

 

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Mandeep Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the father of the complainant, namely, Amrik Singh was official with the OP number 1 and the OP number 1 got insurance policy as staff group mediclaim from OP number 4 vide policy number 111100/NIC/Dummy for the period from 1.4.2015 to 31.3.2016 and issued ID card to Amrik Singh with E No.34819 and member ID No.M5840420234819.  Further case of the complainant is that Shri Amrik Singh fell ill and was admitted in Bansal Hospital and Heart Centre, Sangrur on 29.4.2015 and remained there till 1.5.2015 and on 2.5.2015 and was further referred to Apollo Hospital, Ludhiana where he remained admitted from 2.5.2015 to 8.5.2015.  Further case of the complainant is that Shri Amrik Singh unfortunately died due to post cardiac arrest, but the Ops rejected the claim vide letter dated 24.8.2015 on the ground that as per the summary of patient he was alcoholic from the last 25 years and due to this reason the claim is not payable. It is stated further that the so lodged claim of Rs.2,25,322/- was repudiated by the OPs, which is said to be wrong and illegal. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Ops be directed to pay to the complainant an amount of Rs.2,25,322/- along with interest @ 18% per annum from the date of death i.e. 8.5.2015 till realisation and further claimed compensation and litigation expenses.

 

2.             In reply filed by OP number 1 and 2, it has been admitted that the complainant lodged the claim with the OP number 1 for Rs.2,25,322/- on 10.6.2015 regarding the medical expenses of Shri Amrik Singh (referred to as DLA in short) and the same was forwarded to OP number 3 vide letter dated 12.6.2015 for further action.  The OP number 3 after examining the entire record observed that the claim is not payable as per clause 4.8 of the terms and conditions of the policy, as the DLA was admitted with C/O Aute Pancreatitis/DM/HTN from 15 years.  As per the discharge summary of the DLA, he was alcoholic from 25 years and alcoholic is the main contributing fact in causing pancreatitis, diabetes, HTN and further stated that the DLA was also having pre existing disease and the same were not covered under the policy.  It is denied that the cause of death of the DLA was post cardiac arrest. On the other hand, the cause of death was alcoholic and the main contributing factor for causing acute pancreatitis, diabetes and HTN is alcohol and it is stated that the claim has rightly been repudiated.  The other allegations levelled in the complaint have been denied.

 

3.             In reply filed by Op number 4 and 5, legal objections are taken up on the grounds that the complaint is not maintainable and that the complainant has no cause of action to file the present complaint. On merits, it is denied that the complainant lodged any claim with the OP.  It has been stated that he mediclaim policy as well as identity proof issued by Raksha TPA and only Raksha TPA is liable to pay the claim. It has been stated that Raksha TPA issued letter to the complainant stating that the DLA is alcoholic for the last 25 years and due to this reason the claim is not tenable.  It is stated that the claim has rightly been repudiated.

 

4.             Record shows that the OP number 3 did not appear despite service, as such OP number 3 was proceeded exparte.

       

5.             The learned counsel for the complainant has produced Ex.C-1 copy of legal notice, Ex.C-2 copy of postal receipt, Ex.C-3 copy of summary of treatment, Ex.C-4 copy of prescription slip, Ex.C-5 copy of death summary, Ex.C-5 affidavit of Surjit Kaur, Ex.C-7 affidavit of complainant, Ex.C-8 copy of order dated 19.8.2016 and closed evidence.  The learned counsel for OP number 1 and 2 has produced Ex.OP1&2/1 affidavit, Ex.OP1&2/2 copy of insurance policy and closed evidence. The learned counsel for OP number 4 and 5 has produced Ex.OP4&5/1 affidavit, Ex.OP4&5/2 copy of medical insurance policy, Ex.OP4&5/3 copy of letter to complainant, Ex.OP4&5/4 copy of OPD slip, Ex.OP4&5/5 copy of MRI whole abdomen and closed evidence.

 

6.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

7.             It is an admitted fact that the DLA being an employee of the OP number 1 was insured under the policy taken by OP number 1 for its employees, a copy of which on record is Ex.OP1&2/1.  It is further not in dispute that the complainant vide letter dated 10.6.2015 lodged the claim with the OP number 1 and claimed an amount of Rs.2,25,322/- on account of medical expenses incurred by the DLA and accordingly the OP number 1 forwarded the claim and medical bills for Rs.2,25,322/- to OP number 3 for further action vide letter dated 12.6.2015, but the OP number 3 rejected the claim in view of clause 4.8 of the terms and conditions of the policy and further the case of the OP number 1 is that the TPA i.e. OP number 3 rightly rejected the claim as the disease were also pre existing and the same were not covered under the policy.   The OP number 1 has further contended that the cause of death of the DLA was diabetes, acute pancratitis and HTN as the DLA was an alcoholic and the alcohol is the main contributing factor for causing acute pancreatitis, diabetes and HTN.  But, we are unable to go with such a contention of the learned counsel for the OP number 1, as the OP number 1 has not produced any cogent, reliable and trustworthy evidence to support such a contention that the DLA was an alcoholic and died due to that reason.  We may mention that the OP number 3 i.e. Raksha TPA Pvt. Ltd. who had to settle the claim chose to remain exparte.  There is no explanation from the side of the Ops number 1 and 2 that why the TPA remained exparte.  It is an admitted fact in the reply that the OP number 1 forwarded the claim documents and medical bills to the OP number 3 for settlement of the claim, who repudiated the claim. 

 

8.             Now, the question which arises for determination before us is whether the OP Number 3 has rightly repudiated the claim or not on account of that the DLA had pre existing disease.  We have also perused the copy of death summary Ex.C-5 issued by Satguru Partap Singh Apollo Hospital, Ludhiana, where the DLA died and its perusal shows that the main cause of death of the DLA was that on 8.5.2015 patient suddenly had bradycardia and cardiac arrest meaning thereby the DLA died due to cardiac arrest and not of any other reason and in the final diagnosis column, it has been mentioned “Hypoxic brain injury- post cardiac arrest” and further in the column “Immediate cause of Death is mentioned as Post Cardiac arrest-hypoxic brain injury and diffuse cerebral dysfunction”.  This document is duly signed by Dr. Harpreet Singh Khetarpal, Senior Consultant of the hospital. 

 

9.             In repudiating the claim, the OPs have relied upon the discharge summary of Satguru Partap Singh Apollo Hospital Ludhiana which is document Ex.C-9 and we have perused this document Ex.C-9 and we do not find any evidence of the OP in support of its version. On the other hand, the learned counsel for the complainant has cited the judgment of the Hon’ble National Commission delivered in the Revision Petition No.2738 of 2008 in which it has been held that history recorded in hospital bed ticket is not to be treated as evidence as the doctor, recording the history has not been examined. The Hon’ble National Commission has mentioned that “To be noted that in support of which is stated in the case sheet neither the doctor who recorded their case sheet was examined nor his affidavit filed as also mentioned in its order by the State Commission.”

 

10.           Further it is the specific version of the complainant that the terms and conditions were never supplied by the OPs as the policy has been taken by OP number 1 by the employer of the DLA. In such like situation, reliance can be made on the citation of the Hon’ble Supreme Court of India delivered in Civil Appeal No.6895 of 1997 in the case of Modern Insulators Limited versus Oriental insurance Company Limited. The Hon’ble Supreme Court has held that “as the above terms and conditions of the standard policy wherein exclusion clause was included were neither a part of the contract of insurance nor disclosed to the appellant, respondent cannot claim the benefit of the said exclusion clause.” In the light of the above citation, we find that the OPs have failed to tender any reliable and cogent evidence in support of their version that the terms and conditions were supplied as no document has been placed on record to show that the terms and conditions were ever made known to the complainant.

 

11.           Now the question arises as to what amount the complainant is entitled as per the policy document. It is the own case of the OP number 1 that the complainant lodged the claim for Rs.2,25,322/- and submitted the bills for the same, which were forwarded to OP number 3 by the OP number 1 for settlement of the claim.  But, instead of settling the claim of the complainant the OP number 3 wrongly repudiated the claim without properly applying its mind.  As such, we are of the considered opinion that the complainant is entitled to get an amount of Rs.2,25,322/- as claimed by the complainant.  

 

12.           So, from the above discussion, we find that the OPs are not only deficient in service, but also had indulged in unfair trade practice and as such, we allow the complaint and direct the OPs number 1 to 3 to reimburse the complainant a sum of Rs.2,25,322/-  along with interest @ 9% per annum from the date of filing of the present complaint i.e. 06.09.2016 till realisation. We further order the OPs number 1 to 3 to pay to the complainant a sum of Rs.5,000/- being the amount of compensation for mental tension and agony and a sum of Rs.5,000/- being the litigation expenses.

 

13.           This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                March 2, 2017.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                             

                                                                (Sarita Garg)

                                                                    Member

 

 

                                                         (Vinod Kumar Gulati)

                                                                    Member