BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.140 of  2014

Date of Institution: 14-03-2014

Date of Decision: 14-05-2015

Swaran Singh Jaswal son of Shri Jagir Singh Jaswal, resident of  488, Green Avenue, Amritsar.

Complainant

Versus

1. New India Assurance Company Limited, Regional Manager, Regional Office, 117, The Mall, Mall Road, Amritsar.
2. New India Assurance Company Limited, Branch Office: G.T.Road, Kamadeep Mansions Phagwara through is Branch Manager.
3. M/s.Raksha TPA (P) Limited, SCF 181, IInd Floor, Sector 7-C, Opposite Sports Stadium Chandigarh.

 Opposite Parties

Complaint under section 12 and 14 of the Consumer Protection Act.

Present: For the Complainant: Sh.Rajiv Sharma, Advocate.

              For the Opposite Parties  No.1 & 2: Sh.P.N.Khanna, Advocate

             For the Opposite Party No.3: Exparte.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Swaran Singh Jaswal  under the provisions of the Consumer Protection Act alleging therein that  he alongwith his wife Rupinder Kaur jointly got medical insurance from Opposite Party No.1 vide policy No.36100334110100000314 with I.D.No.9012664390 for a period from 31.12.2011 to 30.12.2012 for Rs.5 lacs. Complainant alleges that in the month of May, 2012 Smt.Rupinder Kaur insured, wife of the complainant suddenly fell ill seriously and was admitted in Madaan Hospital, Majitha Road, Amritsar due to her serious condition, where she remained for hospitalization from 6.6.2012 to 8.6.2012 for disease of HCV +ve Hepatitis. During her stay in the hospital and even thereafter said Rupinder Kaur insured, had gone through various medical tests besides regular treatment, which she is still continuously getting, for the said particular disease.  The complainant submitted the medical claim of his wife on the basis of  said policy with the Opposite Parties. Said medical claim policy covered all the expenses for her medical treatment regarding the said disease and as per the terms and conditions of the policy, the complainant is legally entitled to the expenses which were incurred by him for the medical treatment of his wife, for the said disease. The total expenses which were  incurred at that time, was to the extent of Rs.3,34,781/- and for which the complainant claimed the same from the Opposite Parties.  But instead of making the payment of the medical claim, the Opposite Parties  in a wrong and illegal way passed the impugned order dated 1.1.2012, vide which the claim of the complainant was declined. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to pay the medical claim of Rs.3,34,781/-. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Parties  No.1 & 2 appeared and filed written version in which it was submitted that the claim of the complainant was repudiated by Opposite Party No.3-M/s.Raksha TPA Private Limited on merits on the ground that Smt.Rupinder Kaur patient was found a case of Hepatitis (HCV+ve). Claim for treatment was taken on OPD basis from May 2012 to October, 2012 alongwith hospitalization at Madaan Hospital, Majitha Road, Amritsar from 6.6.2012 to 8.6.2012. As per  discharge summary, no active management was done during hospitalization. The treatment for HCV +ve patients is injection Pegasys. The injection is given subcutaneously and given on OPD basis and  does not require any hospitalization. As the hospitalization is not necessary/ required, the claim falls out of the scope of the policy, therefore, the claim was repudiated as per condition No.1 & 2 of the policy. While denying and controverting other allegations, dismissal of complaint was prayed.
3. None appeared on behalf of Opposite Party No.3-Raksha TPA Private Limited, so Opposite Party No.3 was proceeded against exparte vide order dated 23.5.2014 of this Forum.
4. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C15 and closed the evidence on behalf of the complainant.
5. Opposite Parties  No.1 & 2 tendered into evidence affidavit of Sh.Sunil Mahajan Ex.OP1,2/1, affidavit of Dr.Amandeep Singh on behalf of TPA Ex.OP1,2/2  alongwith  documents Ex.OP1,2/3 to OP1,2/10 and closed the evidence on behalf of the Opposite Parties  No.1 & 2.
6. 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.
7. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that complainant Swarn Singh Jaswal alongwith his wife Rupinder Kaur jointly got medical insurance vide policy No.36100334110100000314 with I.D.No.9012664390 from Opposite Party No.1 for a period from 31.12.2011 to 30.12.2012 for Rs.5 lacs (Ex.C2).  In the month of May, 2012 Rupinder Kaur insured, wife of the complainant, fell ill and she was admitted in Madaan Hospital, Majitha Road, Amritsar from 6.6.2012 to 8.6.2012  and was diagnosed disease  HCV +ve Hepatitis. Even thereafter said Rupinder Kaur insured had gone through various medical tests besides regular treatment. She is still continuously getting treatment for the said disease.  The complainant has spent  Rs.3,34,781/-  on the medical treatment of Rupinder Kaur insured. The claim was lodged with Opposite Parties  No.1 & 2, but the Opposite Parties  No.1 & 2 passed an order dated 1.11.2012 vide which they declined the claim of the complainant. The complainant submitted representation dated 5.1.2013 (Ex.C7) to reconsider the case of the complainant, but the Opposite Parties  vide letter dated 21.1.2013 Ex.C5 submitted that the case of the complainant is of Hepatitis for which injection Pegasys given is an OPD based procedure and does not require hospitalization. So, the claim is not payable. Ld.counsel for the complainant submitted that the complainant remained admitted in the hospital and she was diagnosed HCV +ve Hepatitis for which long and very expensive treatment is required. Opposite Parties  have wrongly repudiated the claim of the complainant and all this amounts to deficiency in service on the part of the Opposite Parties  qua the complainant.
8. Whereas the case of the Opposite Parties  No.1 & 2 is that Opposite Party No.3- M/s.Raksha TPA Private Limited has already  repudiated the claim of the complainant on merits on the ground that Smt.Rupinder Kaur insured was found a case of Hepatitis (HCV+ve). Treatment was taken on OPD basis from May 2012 to October, 2012 alongwith hospitalization at Madaan Hospital, Majitha Road, Amritsar from 6.6.2012 to 8.6.2012. As per  discharge summary, no active management was done during hospitalization. The treatment for HCV +ve patients is injection Pegasys. The injection is given subcutaneously and given on OPD basis and does not require any hospitalization. Hence, the claim of the complainant is not payable by Opposite Parties. So, the claim of the complainant has rightly been declined by the Opposite Parties vide letter dated 21.1.2013 Ex.C5.    Ld.counsel for the Opposite Parties No.1 and 2 submitted that there is no deficiency of service on the part of the Opposite Parties  No.1 & 2.
9. From the entire above discussion, we have come to the conclusion that the  complainant Swarn Singh Jaswal alongwith his wife Rupinder Kaur were insured with the Opposite Parties  No.1 & 2 vide mediclaim  policy bearing No.36100334110100000314 Ex.C3 for a period from 31.12.2011 to 30.12.2012 for Rs.5 lacs.  Rupinder Kaur insured wife of the complainant fell seriously ill and was admitted in Madaan Hospital, Majitha Road, Amritsar for the period from 6.6.2012 to 8.6.2012  and was diagnosed disease  HCV +ve Hepatitis. As per discharge/ follow up card Ex.C12, she was given injections Pegasys, which are very expensive. The complainant alleges that he spent a sum of Rs.334781/- on the medical treatment of Rupinder Kaur. In this regard, he has produced bills Ex.C11 running into 56 pages. The claim was lodged with Opposite Parties, but the Opposite Parties repudiated the claim of the complainant vide letter dated 21.1.2013 Ex.C5 on the ground that the case of the complainant is of  HCV +ve Hepatitis for which injections Pegasys given, which is an OPD based procedure and does not require hospitalization.
   Therefore, the claim of the complainant is not payable. We have gone through the entire record of this case. The insured Rupinder Kaur, wife of the complainant was admitted in Madaan Hospital, Majitha Road, Amritsar as per discharge/ follow up card Ex.OP1,2/7. She was diagnosed a very serious disease of HCV +ve Hepatitis for which very expensive treatment is required and that  too for a long period. The Opposite Parties can not be allowed to state that for this disease the hospitalization was not required and that it is an OPD based procedure. HCV +ve Hepatitis is very serious disease and the patient remained admitted in Madaan Hospital, Majitha Road, Amritsar for the period from 6.6.2012 to 8.6.2012. Resultantly, we hold that Opposite Parties  have wrongly repudiated the claim of the complainant on this ground. However, as condition No. 3.1 and 3.2 of the  terms and condition of the policy (produced by the Opposite Parties  themselves), the insured is entitled to reimbursement of the expenses, he/ she has incurred 30 days prior to admission and 60 days after the discharge from the hospital. As per the bills produced by the complainant, he had spent Rs. 1,70,651.50 for the period from 9.5.2012 to 8.8.2012 i.e. 30 days prior to admission and 60 days after the discharge from the hospital. The bills of which are produced on record by the complainant, total amount of which comes to Rs.1,70,651.50 and as per the terms and conditions of the policy, the complainant is entitled to get this amount spent by him on the medical treatment of his wife insured Rupinder Kaur for the period from 9.5.2012 to 8.8.2012.
10. Consequently, we partly allow this complaint with costs and the Opposite Parties  No.1 & 2 are directed to reimburse this amount of Rs.1,70,651.50 within one month to the complainant from the date of receipt of copy of this order, failing which the complainant shall be entitled to the interest @ 9% per annum on the said amount, from the date of filing of the complaint till the payment is made to the complainant. The Opposite Parties  No.1 & 2 are also directed to pay Rs.2000/- to the complainant on account of litigation expenses.   Copies of the order be furnished to the parties free of costs. 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: 14-05-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                 (Kulwant Kaur Bajwa)    (Anoop Sharma)

              Member                         Member