Punjab

Rupnagar

CC/19/120

jagjit singh - Complainant(s)

Versus

national insurance company - Opp.Party(s)

Chetan Kumar Gupta

03 Sep 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ROPAR

 

                                Consumer Complaint No.120 of 2019

                                Date of institution: 24.10.2019

                                Date of Decision: 03.09.2020

 

Jagjit Singh aged 53 years, son of Gurucharan Singh, resident of House No.3420, Adarsh Nagar, Ropar, District Ropar 

…….Complainant

Versus

 

1. National Insurance Company, Ropar, through its Branch    Manager
2. Safeway Insurance TPA Private Limited, through its   Manager office at SCO-6&7, Ground Floor, Ranjan Plaza,   Palam Enclave, Zirakpur, District Mohali, Punjab

                                                    ……..Opposite Parties

              Complaint under Consumer Protection Act.

 

      Quorum:   Shri Sanjiv Dutt Sharma, President.

                      Capt. Yuvinder Singh Matta, Member

 

      Present: Sh. Chetan Kumar Gupta, Adv. counsel for                                complainant

                 Sh. Amit Gupta, Adv. For OP No.1

                  OP No.2 exparte

     

Order dictated by :-  Shri Sanjiv Dutt Sharma, President

Order

The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant (hereinafter referred as ‘CC’ for short) against the Opposite Parties (hereinafter referred as ‘OPs for short) on the ground that the CC had subscribed the insurance policy of the OP No.1 bearing policy No.40470150191 from branch office, Ropar, which was renewed time to time. The policy is attached as Ex.C1. It is averred that in the month of June, 2019, the CC had a severe pain in the tail bone and visited, the Civil Hospital on 04.07.2019, got his physiotherapy and X ray done but there was no relief. Lateron, the CC visited Surjit Hospital, Ropar, but there was no improvement in his health condition. It is averred that CC visited BS Hospital and Physiotherapy Centre, Ropar on 31.07.2019, but his condition remained the same. Ultimately, on 8.8.2019, the CC went to Parmar Nursing Home, where he was admitted for his treatment. It is averred that cashless policy was shown to the hospital and they sent the same for approval with the OP No.1. It is averred that OP No.2 refused for accepting the cashless policy on 12.8.2019 and as such, the CC had no  alternative except to pay all the bills and expenses. However, the CC had the option to submit the claim for reimbursement etc. The grievance of the CC is that the cashless policy was rejected by the OP No.1 on the ground that "Epidural Cortico Steroid Injection" does not required 24 hours hospitalization and is not listed under any day care procedure. The letter was submitted to the OP1 on 28.8.2019 but of no use. It is averred that CC had to suffer unnecessary hardships and even had to borrow money from his friends etc. It is averred that Epidural CorticoSteroid Injection is powerful anti-inflammatory medicine directly inserted into the space outside of the sac of fluid around spinal cord. This area is called the epidural space. The CC further has clarified the objections raised by the OP. It is specifically alleged that Epidural CorticoSteroid Injection is not intentioned in any of the exclusion clauses.

2. Thus, alleging deficiency in service on the part of the OPs, the CC has     sought the refund of Rs.32,831/- along with interest @ 24% per     annum to the CC and also a compensation to the tune of Rs.50,000/- and litigation charges, separately. Complaint of the complainant is   duly signed and verified.
3. In reply, the OP2 has chosen to remain ex-parte vide our orders dated        13.03.2020.
4. In reply, the OP1 has admitted the subscription of the policy by the         CC, which was valid from 15.7.2019 to 14.7.2020. It is also admitted          that CC has intimated one claim with regard to this treatment from        Parmar Nursing Home as alleged in the complaint w.e.f. 8.8.2019 to        12.8.2019, for acute lumber disc prolapse and an amount of   Rs.32,831/- but the said claim as advised by M/s Safeway Insurance TPA Pvt. Ltd was not payable as EPIDURAL CORTICOSTEROID        INJECTION does not required 24 hours hospitalization. It is          specifically averred that claim of the CC files under the exclusion          clause i.e. Diagnostic and evaluation purpose, where such diagnosis         and evaluation can be carried out as outpatient procedure and the          condition of the patient does not require hospitalization.
5. It is specifically alleged by the OP that as per the condition of the CC,     he never required any hospitalization and could be well treated as     outpatient procedure in the OPD. It is further averred that medical    bills prior to the hospitalization are not covered within the scope of the policy.
6. Thus, alleging that the claim was not payable as Epidural      Corticosteroid injection does not require 24 hours hospitalization and        has sought the dismissal of the complaint.
7. In support of his complaint, CC has tendered his duly sworn affidavit        Ex.CW1/A along with documents Ex.C1 to Ex.C9 and closed the   evidence. On the other hand, the learned counsel for OP No.1 has tendered duly sworn affidavit of Sh. Sanjeev Khurana, Deputy        Manager of OP1 as Ex.OP1/A along with documents Ex.OP1 to Ex.OP6 and closed the evidence.
8. We have heard the arguments advanced by the learned counsel for the        contesting parties and have perused the complaint and minutely. The       OP has mainly rejected the claim of the CC on the ground that        diagnostic and evaluation purpose where such diagnosis and           evaluation can be carried out as outpatient procedure and the        condition of the patient does not require hospitalization. It is        specifically averred by the OP that claim is not maintainable as the          same is beyond coverage provided under the policy. It is alleged by          the OP that the condition of the patient never required any       hospitalization and the epidural corticosteroid injection does not     require 24 hours hospitalization.
9. On the other hand, the complainant has specifically stated that epidural corticosteroid injection is powerful anti-inflammatory medicine directly inserted into the space outside of the sac of fluid around spinal cord. This area is called the epidural space. He has further averred that same is different from epidural anesthesia given just before childbirth or certain types of surgery epidural anesthesia may not require 24 hours hospitalization. To my mind, the OP No.1 has wrongly confronted the difference and obtained a wrong report from OP No.2.
10.  To my mind, I feel, that doctor who treated the CC was best judge to       see whether the CC required the immediate hospitalization for the      treatment or not. We feel, that the insurance companies officials       who are sitting in their respective offices cannot judge the condition   of the CC without obtaining any specific opinion from a medical     expert. The evidence of the OP is not supported by any medical       expert opinion that the line of treatment adopted by the Parmar    Nursing Home, which required the hospitalization of the CC for         certain period was not inconsonance with the medical protocol or the CC was not required any hospitalization or rather the line of       treatment by keeping the CC in hospitalization by Parmar Nursing        Home, Ropar, was wrong etc.
11.  In the absence of any cogent, reliable or trustworthy evidence from         the side of the OP, I feel that rejection of the claim of the CC was     definitely based on surmises and conjectures and on flimsy grounds. I     am also feel that, the deficiency in service on the part of the OP No.1           is a writ-large on the file. The OP1 was definitely deprived the CC    initially from cashless treatment and lateron by rejecting the genuine         claim of the CC.
12.  I have perused the entire evidence of the CC also the CC has          submitted only one bill of Parmar Nursing Home i.e. at Page 12 of Rs.21,000/- only. We do not find any other bill of Parmar Nursing   Home in the file. It is clear from the bill that CC was admitted in the     Hospital on 08.08.20219 and was discharged on 12.08.2019 and had   to pay Rs.21000/- total to Parmar Nursing Home, Ropar.
13.  In view of our above discussion, the present complaint of the CC is        allowed with the direction to the OP No.1 to pay Rs.21,000/- to the          CC along with interest @ 12% per annum from the date of admission        i.e. 8.8.2019. Further, the OP1 is burdened to pay a compensation to       the tune of Rs.10000/- to the CC. The OP No.1 is further directed to        comply with the above said order within the period of 30 days from           the date of receiving the copy of this order.  Free certified copies of    this order be sent to the parties, as per rules. The files be consigned to     record room.
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September 03, 2021

(Sanjiv Dutt Sharma)

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(Capt. Y.S. Matta)

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