BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.372 of 11.09.2018

Date of Decision: 23.02.2021

Ashok Kumar Kalia son of Sh.Charan Dass Kalia, resident of 19, Guru Nanak Nagar, Model Town, Jalandhar.

..........Complainant

Versus

National Insurance Company Limited, DAB-II, Near BMC Chowk, 20, G.T. Road, Jalandhar City, through its Branch Manager.

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before:

Sh. Kuljit Singh, President

Smt.Jyotsna, Member

COUNSEL FOR THE PARTIES:-

For complainant : Sh.K.L. Dua, Advocate

For OP : Sh.A.K. Arora, Advocate

Order

PER Kuljit Singh, President

1. The instant complaint has been filed by the complainant, wherein he alleged that he purchased joint health insurance policy No.404300/48/17/850000/180 CCN No.3784200 for Rs.2,00,000/-. Policy was valid from 18.09.2017 to 17.09.2018. The policy covered the amount spent on the medical treatment of complainant and his wife Smt.Meena Kalia during the validity of said policy. Complainant was admitted in Spine and Ortho Care Hospital, Jalandhar City; as he was not well and was suffering from back pain and remained admitted in the said hospital for treatment from 19.12.2017 to 20.12.2017. Complainant spent Rs.8531/- on his treatment in said hospital as an indoor patient. After discharge from said hospital, the complainant submitted bill for Rs.8531/- for reimbursement of said amount. His bill has not been paid. OP has contravened the terms and conditions of said policy by not making payment. Some objections were raised by OP and he submitted complete claim papers after removing objection on 10.05.2018. Complainant has written many letters to OP through email but of no effect. Lastly, prayer has been made that OP be directed to make payment of Rs.8531/- spent on his treatment alongwith interest @12% per annum from 22.12.2017 till realization. Further, he claimed Rs.10,000/- as compensation and Rs.13,000/- on account of cost of legal notice and litigation expenses.

2. Notice of the complaint was given to the OP and accordingly, OP appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that there is no deficiency in service, unfair trade practice; complainant was issued Baroda Health Policy by Ops for the period of 18.09.2017 to 17.09.2018. The said policy was subject to terms and conditions of policy. The complainant lodged a claim with claim settling agency of OP i.e. M/s Paramount Health Insurance and Insurance TPA Pvt. Ltd for the treatment taken by him for spine and ortho care for period 19.12.2017 to 20.12.2017. As per discharge summary issued by said hospital, the complainant presented with complaints of Lumbar Pain on 19.12.2017. Insured was diagnosed with Lumbar Spondylosis. The submitted documents indicate only medicine were administered. The discharge summary submitted/retrieved in the documents indicate that the patient was investigated and given treatment which could be done on OPD basis. Any hospitalization primarily for investigation is not covered under the policy of insurance. Hence the claim of the complainant was declined under clause No.4.19 of the Policy of Insurance Letter dated 10.07.2018 to this effect was written to complainant. On merits, policy of complainant and treatment taken by complainant is admitted and spent of amount by complainant is also admitted. During hospitalization of the complainant, only investigation and treatment was given which could be done on OPD basis and no hospitalization was required in the present case and as such the claim of the complainant does not fall under the terms and conditions of the policy of insurance and has been denied under clause No.4.19 of the policy of insurance. The claim has already been settled and letter dated 10.07.2018 to this effect has already been written by OP to complainant. The claim being not payable as per terms and conditions of policy of insurance has been rightly declined by OP. Making of objections by claim settling agency and removal of objections is admitted. All other averments of complaint denied and prayed for dismissal of present complaint.

3. In order to prove the case of the complainant, the counsel for the complainant has filed affidavit of complainant Ex.CW1/A alongwith some documents Ex.C-1 to Ex.C-49 and closed the evidence.

4. In order to rebut the evidence of the complainant, the counsel for OP filed affidavit of Kuldip Raj Divisional Manager and some documents Ex.O1 to Ex.O-3.

5. We have heard the argument from learned counsel for the respective parties and also gone through the case file very carefully.

6. It is an admitted fact that the complainant has purchased joint Health Insurance Policy No.404300/48/17/850000/180 for Rs.2,00,000/- from Ops for the period 18.09.2017 to 17.09.2018 by the complainant which also covered his wife Meena Kalia and the said policy is Ex. C-3. It is also an admitted fact that during the period of insurance 18.09.2017 to 17.09.2018, the complainant fell ill and was hospitalized in Spine and Ortho Care Hospital, Jalandhar City and he remained admitted there for the period 19.12.20217 to 20.12.2017 and had undergone for back pain treatment and had paid a sum of Rs.8531/- and its bill has been placed on the record. The discharge summary of Spine and Ortho Care Hospital, Jalandhar City has also been placed on the record, which shows that the complainant remained admitted with Spine and Ortho Care Hospital, Jalandhar City from 19.12.2017 to 20.12.2017 and had undergone treatment of back pain. It was argued by the counsel for the complainant that although it was the duty of the OP to reimburse the amount spent by complainant on his treatment when the bill was submitted to the Ops and declined the same on flimsy grounds that the complainant is investigated and given treatment which could not done on OPD basis. Any hospitalization primarily for investigation is not covered. But counsel for the complainant has referred to the discharge card which the complainant was admitted in hospital from 19.12.2017 to 20.12.2017. Therefore, the basis on which the claim has been repudiated is not correct. Therefore, it was argued by the counsel for the complainant that the claim of Rs.8531/- spent by the complainant be allowed.

7. OP has repudiated the claim on the basis that as per discharge summary submitted/retrieved in the documents indicate that patient was investigated and given treatment which could be done on OPD basis. Any hospitalization primarily for investigation is not covered. Therefore, in the absence of any specific evidence on the record, mere reference in the record mentioned by OP that admission in hospital is not required is not sufficient to say so. Moreover, the OP has failed to produce on record certificate or affidavit of concerned doctor regarding admission of complainant is required or not required for his treatment. The reasons for rejection of claim of the complainant are without any basis and are contrary to the documentary evidence produced by the complainant.

8. In view of the above discussion, the present complaint is partly allowed and the OP is directed to pay Rs.8531/- i.e. bill amount of treatment of complainant alongwith interest @ 5% per annum from the date of repudiation of claim till realization.  The complainant has been harassed by the OP as his claim has not been settled, hence the complainant is held entitled for compensation and litigation expenses of Rs.2000/-. The OP has no right to keep and misappropriate the public money. It must go back to the public. We, therefore, order that the OP will deposit a sum of Rs.1000/-, the estimate rough amount, with the legal aid account of this Commission. Opposite Party is directed to comply with the order within 45 days from the receipt of copy of the order

9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room after its due compliance.

ANNOUNCED IN THE OPEN COMMISSION:

23^rd Day of February 2021

(Kuljit Singh)

President

(Jyotsna)

Member