Punjab

Nawanshahr

CC/9/2015

Dr.Narinder Pal Sharma - Complainant(s)

Versus

National Insurance Company - Opp.Party(s)

PK Sharma

18 May 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

SHAHEED BHAGAT SINGH NAGAR

Consumer Complaint No.         :     9 of 23.01.2015

Date of Decision:                    :     18.05.2015

Dr.Narinder Pal Sharma resident of House No.B-5/302, Street No.1, Kulam Road, Nawanshahr District Shaheed Bhagat Singh Nagar.

                                                                             …Complainant

Versus

National Insurance Company Limited, Nawanshahr Branch Chandigarh Road, SBS Nagar, through its Branch Manager.

          …Opposite Party

                             Complaint under the Provisions of Consumer Protection Act, 1986

QUORUM:

SH.GOPAL KRISHAN, PRESIDENT

MS.SUDHA SHARMA, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :         Sh.P.K. Sharma, advocate

For OP                                     :         Sh.D.B. Bhalla, advocate

 

ORDER

PER SH.GOPAL KRISHAN, PRESIDENT

 

1.                Complainant - Dr.Narinder Pal Sharma filed complaint under Section 12 of Consumer Protection Act, 1986 by alleging that he is holding mediclaim policy bearing No.401803/48/11/8500000384 of National Insurance Company Ltd. Nawanshahr for the last about 10 years and paying due premium.  The above numbered policy was valid till 04.03.2013.  Complainant after having severe pain in the shoulder joint was admitted in the Life Line Hospital on 29.10.2012 at about 7:00/8:00 AM as per instructions of the doctor.  An injection based on CR Technique was administered in operation theatre followed by physiotherapy and follow-up treatment.  Complainant was discharged at about 10:00 AM on 30.10.2012.  Rs.9,700/- were spent on this treatment. Payment was made on raising of the bills.  On representation dated 26.12.2012, being made by the complainant, the Insurance Company repudiated the claim on frivolous grounds by holding that the Intra Articular Injection could have been given in OPD, due to which Hospitalization was not required.  However, decision regarding admission depends on the wisdom of the attending doctor.  Complainant filed a complaint with Ombudsmen of Insurance Company, who too dismissed the claim on the same grounds.  Act of the OP in not making payment of Rs.9,700/- tantamounts to deficiency in consumer service and that is why the above amount alongwith compensation for harassment of amount of Rs.50,000/- sought with interest @9.75 per annum.

2.                On notice being issued to OP, the same appeared and filed written statement, where through claiming that complaint is not maintainable, being hit by principles of res-judicata because Ombudsmen of Insurance Company had already dismissed the claim.  Moreover, it is claimed that complaint filed in violation of the terms and conditions of the policy.  Complaint also alleged to be bad for non-joinder of necessary parties because the TPA, the agents, who looks after mediclaim cases of Insurance Company have not been impleaded as party.  Admittedly, complainant holds mediclaim policy for the last 10 years i.e. since March, 2007.  Admittedly, complainant made representation on 26.12.2012 for reimbursement of Rs.9,700/-, but the same was declined on the ground that hospitalization was not required and claim not payable as per condition No.2.6 of the policy.  Contract of insurance is governed by the terms and conditions of the policy.  After refusal of the claim of complainant by Insurance Company, he filed the complaint with Insurance Ombudsmen, Chandigarh, which too was dismissed. Decision was given by Insurance Ombudsmen, Chandigarh after getting consent of both the parties.  No deficiency in consumer services is attributable to OP.  However, other allegations refuted and prayer for dismissal of the complaint made.

3.       Affidavit Ex.CW1 of complainant alongwith copies of Insurance policy cover note Ex.C-2, repudiation letter Ex.C-3, order dated 05.03.2014 Ex.C-4 were tendered in evidence.  Even affidavit Ex.C-14 of Jagdish Singh record keeper working in Life Line Hospital alongwith copy of the register entry of indoor patient Ex.C-15 and other documents were tendered and thereafter complainant closed the evidence.

4.                Sh.Parampal Singh Sr. Branch Manager tendered his affidavit Ex.OP1/A on behalf of OP.  Photostat copies of claim form is Ex.OP-1, mediclaim record Ex.OP-2, letter dated 29.01.2013 Ex.OP-3      and terms and conditions of the policy Ex.OP-4 were tendered by the OP and thereafter OP also closed the evidence.

5.                Arguments of counsel for the parties were heard.  File also carefully perused.

6.                Admitted facts are that complainant holds mediclaim policy qua which cover note is Ex.C-2.  Further, the admitted facts are that complainant filed claim petition for getting insurance amount of Rs.9,700/- for getting treatment, but the same was repudiated by Insurance Company  and thereafter on matter being referred to Insurance Ombudsmen, the claim of complainant was again rejected. 

7.                Complainant through his own affidavit Ex.CW1 and through affidavit Ex.C-14 of Sh.Jagdeep Singh record keeper working with Life Line Hospital, Barnala Road, Near Satluj Cinema Nawanshahr has proved that he after experiencing severe pain in the shoulder joint was treated by Life Line Hospital, Nawanshahr, due to which he remained admitted in that hospital from 8 AM of 29.10.2012 to 10 AM of 30.10.2012.  For treatment injection based on CR Technique was administered in operation theatre followed by physiotherapy and follow-up treatment.  Copy of entry of indoor patient register Ex.C-15 in this respect also produced in evidence.  Contents of Ex.C-15 lends due corroboration to affidavit Ex.CW1 and Ex.C-14 referred above.  These positive assertions of complainant have remained un-rebutted and as such there is no escape from the conclusion that the complainant remained admitted in Life Line Hospital for 26 hours for treatment of severe pain in shoulder joint.  The documentary and oral evidence produced by complainant fully proves his case qua his admission for more than 24 hours in hospital.

8.                After taking us through discharge slip Ex.C-11, it is vehemently contended by Sh.D.B. Bhalla, advocate assisted by Sh.Nipun Bhalla advocate that kind of treatment provided for the ailment was not requiring admission of the patient.  In Ex.C-11, it is mentioned as if the patient, Dr.Narinder Pal Sharma was an old case of left shoulder arthritis.  In Ex.C-11 it is also mentioned that admission of complainant was on account of severe pain in left shoulder joint.  As and when a patient happens to have severe pain in shoulder joint, he sometimes has to be kept under observation, particularly when he has history of arthritis.  So if complainant kept under observation for more than 24 hours in Life Line Hospital, then the same cannot be said to be without any basis.  In Ex.C-11, Ex.C-12, Ex.C-13 i.e. discharge sheet, discharge summary and invoice bill, specific mention has been made regarding date of admission of complainant as 29.10.2012, but of discharge as 30.10.2012.  Timing of admission of complainant was 8 AM of 29.10.2012 and discharge was 10 AM of 30.10.2012 as per entry in register of indoor patient of Life Line Hospital and as such due material has been produced to prove that complainant actually remained admitted in hospital for more than 24 hours.

9.                In Ex.C-11, ailment of complainant mentioned as “PERIARTHRITIS OF LEFT SHOULDER” .  That periarthritis means frozen shoulder. Acute pain in shoulder joint with tenderness and a stiffness is felt by patient of Periarthritis.  Periarthritis is described as frozen shoulder.  In view of acute pain in frozen shoulder, sometimes the patient has to be kept under observation for finding the extent of tenderness or stiffness and also for reducing acuteness of pain.  So even if Intra Articular Halonix injection alone was given for such treatment to complainant as reflected through Ex.C-11 and Ex.C-12, but despite that the patient bound to confide in the doctor treating him.  So if the doctor of Life Line Hospital kept complainant under observation for more than 24 hours, then he cannot be said to have acted in malafide manner.  Further, complainant by confiding in the doctor treating him, had to get himself admitted and as such it cannot be held that the treatment provided to the complainant could have been provided in OPD only.  Experienced doctors can usually inject Intra Articular Injections in less than 30 seconds as per general medical practice, but in case of acute pain of shoulder joint, the doctor can keep the patient under observation.  Therefore, submission advanced by counsel for OP has no force that actually complainant was not required to be admitted for treatment of the kind in question.

10.              Ex.C-4 is the copy of the order of office of Insurance Ombudsmen, Chandigarh through which claim of complainant for reimbursement of the medical expenses in question was rejected on ground that Intra Articular Halonix Injection could have been administered through OPD procedure.  This rejection through Ex.C-4 is ordered on the explanation of representative of Insurance Company.  What was the representation made by the representative of Insurance Company qua that the details are not give in Ex.C-4.  So order Ex.C-4 of Insurance Ombudsmen is not based on sound reasoning.  Even if in discharge sheet Ex.C-11, the time of admission and discharge not specified, but despite that the same is specifically mentioned in Ex.C-15 as well as in affidavit Ex.CW1.  Therefore, rejection of the claim on this basis through para No.5 of Ex.C-4 or through Ex.C-3 is not justified.  Orders Ex.C-3 and Ex.C-4 as are not based on proper reasoning and as such they are liable to be ignored.  These orders therefore cannot denude complainant from getting due claim amount alongwith compensation.

11.              Ex.Op-4 is the mediclaim insurance policy.  Clause 2.6 of Ex.OP-4 provides that expenses of hospitalization for minimum period of 24 hours are admissible.  Exception to this rule is with respect to specific treatments of dialysis etc. as mentioned in Clause 2.6 itself.  Case of complainant does not fall within the exception enumerated in clause 2.6 of Ex.Op-4.  Being so the complainant entitled to the amount of medical expenses of Rs.5,050/- borne by him on treatment during period from 29.10.2012 (7/8 AM) to 30.10.2012 (until 10 AM) only.  In Ex.C-6, complainant mentioned that the pain suffered by him was of severe bouts and muscle wasting of his left shoulder, due to which the movements of the left joint were very restrictive.  On X-ray examination, joint space was markedly reduced and that is why complainant was kept under observation are contents of Ex.C-6.  Even in Ex.C-12, the discharge summary card of hospital, it is mentioned that it is an F.U. case of shoulder arthritis.  So keeping of complainant under observation was necessitated due to the acute pain suffered by him.  Therefore, submission of OP has no force that admission for 26 hours of complainant was for claiming the amount of mediclaim policy only.  Note appended to clause 2.6 of Ex.Op-4 provides that for procedures/treatments usually done in OPD, amounts are not payable under the policy, even if converted to day care surgery procedure or as in patient in hospital for more than 24 hours.  The present is not case of OPD treatment of complainant because he was admitted in Life Line Hospital on 29.10.2012 and discharged there from on 30.10.2012, as discussed above.  Reference to Ex.C-11 to Ex.C-13 in this respect can specifically be made.  If at all the complainant was to get himself admitted in hospital for getting mediclaim policy amount only, then he too would have again got admitted on 10.11.2012, 24.11.2012 and 19.12.2012, when he got the same injection administered by spending Rs.1550/- each time as reflected through Ex.C-7 to Ex.C-9.  That is not the position.  So submission advanced by complainant has force that admission during period from 29.10.2012 to 30.10.2012 was essential for getting due treatment.  As claim for OPD usually not admissible as per clause 2.6 of Ex.OP-4 and as such complainant not entitled to the amount of Rs.1550/- each spent by him as OPD patient on 24.11.2012, 10.11.2012 and 19.12.2012 as reflected through Ex.C-7 to Ex.C-9.  As the amount spent by complainant as indoor patient of Rs.5,050/- (i.e. Rs.1550/- spent through bill Ex.C-10 for purchase of Halonix Injection and Rs.3500/- spent as Room Rent, Visiting fee of the doctor and procedure charges as paid through invoice Ex.C-13) not disbursed to complainant as per clause 2.6 of Ex.OP-4 and as such there is deficiency in service by Op to this extent only.    

12.              It is contended by counsel for OP that complaint is bad for non-joinder of TPA, the agent of the insurance company looking after medical claim cases, as a party.  That submission has no force because as per clause 5.1 of mediclaim policy Ex.OP-4, every notice of communication to be given or made under the policy shall be delivered in writing at the address shown in the schedule.  After going through cover note Ex.C-2, it is made out that stamp of National Insurance Company Ltd. affixed in the Column of policy schedule.  As column of policy schedule specifies name of National Insurance Company, Nawanshahr Branch in Ex.C-2 and as such in view of clause 5.1 of Ex.OP-4, notice to be communicated to OP i.e. National Insurance Company, Nawanshahr Branch only.  Therefore, even if detail of TPA given at foot of Ex.C-2, despite that impleadment of TPA is not essential, particularly when clause 1.0 of Ex.OP-4 provides that in the event of claim becoming admissible under the scheme, the company will pay the insured person, the amount of such expenses as due under the policy.  In view of this clause 1.0 of Ex.Op-4, as Insurance Company undertook to pay the admissible amount as per scheme and as such complaint against insurance Company duly filed.   

13.              Complainant is entitled to reimbursement of amount of Rs.5050/- alongwith compensation for his harassment and litigation expenses.  Complainant has to write letter Ex.C-6 to grievance cell of National Insurance Company and thereafter even he has to appear before Ombudsmen of office of Insurance as revealed by Ex.C-4 and as such certainly he suffered physical as well as mental harassment.  So complainant entitled to compensation of Rs.5000/- on account of physical and mental harassment and also to litigation expenses of Rs.5000/-.  Payment of amount of Rs.15,050/- in all be made within one month from today, failing which complainant will be entitled to interest @9% per annum from today onwards.

14               As sequel of above observations and findings, the complaint filed by Dr.Narinder Pal Sharma is allowed in terms that he is entitled to amount of Rs.5050/- spent on treatment during period of 29.10.2012 & 30.10.2012 alongwith compensation amount of Rs.5,000/- and litigation expenses of Rs.5,000/-.  Insurance Company/OP is directed to make payment within one month from today of total amount of Rs.15,050/-, failing which complainant will be entitled to interest @9% per annum on this amount from today onwards. 

15.              The arguments in the present complaint were heard on 15.05.2015 and the order was reserved.  16.05.2015 and 17.05.2015 were holidays.  Now the order be communicated to the parties as per rules.

Dated:  18.05.2015

 

  

(Sudha Sharma)                                                           (Gopal Krishan)

Member                                                                         President