Before the Hon ble District Consumer Disputes Redressal Forum
Barnala, Punjab.
Complaint Case No : 104/2015
Date of Institution : 08.06.2015
Date of Decision : 09.10.2015
Manjit Dadu aged about 33 years s/o Sh. Basant Dayal Dadu son of Sh. Dayal Sharan Dadu C/o Dadu Kidzone, Sadar Bazar, Barnala.
...Complainant
Versus
The New India Assurance Company Limited, Kacha College Road, Barnala through its Branch Manager.
Opposite party
Complaint under Consumer Protection Act. 1986.
Present : Sh. Anuj Mohan counsel for complainant.
Sh. Vinay Kumar Jindal counsel for opposite parties.
Quorum:
1. Shri S.K. Goel : President
2. Sh. Karnail Singh : Member
3. Ms. Vandna Sidhu : Member
ORDER
(By Ms. Vandna Sidhu Member):
This complaint no. 104 of 2015 has been filed by complainant. As per complaint the complainant had purchased one Mediclaim policy namely Raksha TPA Pvt. Ltd. bearing policy no. 36130134120100000044 from Opposite party for the period from 26.10.2012 to 25.10.2013 and the complainant paid the premium of the said policy amounting to Rs. 6,478/- to the opposite party and vide said mediclaim policy the complainant, his wife Ruchi Dadu and his two infant namely Mehak Dadu and Ishan Dadu were insured by the opposite party. Complainant renewed the said policy for the period from 26.10.2013 to 25.10.2014 and paid the premium of Rs. 7585/- to the opposite party and policy no. 36130134132500000014 was issued by the opposite party. The complainant further renewed the said policy for the period from 26.10.2014 to 25.10.2015 and paid the premium of Rs. 7268/- to the opposite party and policy no. 36130134142500000039 was issued by the opposite party. On 4.2.2015 wife of complainant hospitalized in Punjab Rheumatology & Immunology Clinic, Ludhiana under the Dr. Parshant Aggarwal, MD DM (Immunology ) and she was diagnosed Sero ve Rheumatoid Arthritis and given treatment, as she been already on treatment with MTX, Leflunomide, HCQ, prednisolone, but this treatment was inadequate response to the patient so she was admitted in the hospital and administered Rituximab infusion and kept under observation as per recommended protocol. The complainant purchased Rituximab infusion from Aggarwal Pharmacy, Rajguru Nagar Ludhiana vide invoice no. A28547 dated 4.2.2015 for a sum of Rs. 37,500/- in cash when the patient was admitted in the said hospital. The said hospital charged Rs. 3550/- for admission charges, room charges, consumables and for lab tests and the patient was discharged on 5.2.2015.
2. On 19.2.2015 Ruchi Dadu again hospitalized in Punjab Rheumatology and Immunology Clinic, Ludhiana under the treatment of Dr. Parshant Aggarwal , MD DM (IMMUNOLOGY) and she was diagnosed Sero ve Rheumatoid Arthritis and given treatment and administered Rituximab Infusion and kept under observation as per recommended protocol. The complainant purchased Rituximab infusion from Aggarwal Pharmacy, Rajguru Nagar Ludhiana vide Invoice no. A30015 dated 19.2.2015 for a sum of Rs. 37,500/-. Beside this the said hospital charged Rs. 3550 /- for admission charges, room charges, consumables and for lab testes and the patient was discharged on 20.2.2015.
3. The complainant lodged the claim with the opposite parties requesting for the payment of Rs. 82,100/- the Expenses incurred by the complainant as hospitalization in the claim form, but the opposite parties illegally and arbitrarily repudiated the claim of the claimant 16.3.2015 on the ground, “the patient is diagnosed with RHEMATOID ARTHRITIS managed with injunction Rituximab which is non payable since it is an OPD procedure which is totally against law and facts, arbitrary and against the terms and conditions of the policy, as it is a hard fact that the patient was admitted in the hospital and treatment was given to the patient was admitted in the hospital and treatment was given the to the patient as indoor patient. The opposite parties repudiated the claim on flimsy ground against the advice of the doctor and presumes that it is an OPD procedure, where as the expert doctors and as per MCI protocol the patient should be admitted in the hospital and kept under observation. It is further submitted that the patient is taking regular medicines as per the instructions of the doctor but the complainant has not claimed the expenses of those medicines as she is taking the medicines being OPD.
4. That the amount of the complainant has been withheld without assigning any reason and only to create harassment and unnecessary litigation for the complainant. Opposite party is a oriented company and in case of any loss and damage they are supposed to provide services and settle the claim within two-three months from the date of loss to their customers, rather the opposite party has repudiated the claim of the complainant illegally and arbitrarily without assigning any proper reason. Thus the complainant is the consumer of the opposite party and as such the present complaint is maintainable under CP Act. The complainant has suffered a great loss and mental agony due to the negligence and deficiency of services and complainant had suffered a loss of Rs. 10,000/- as mental pain for which the opposite party is responsible. Relief claimed.-
(i) Directions may be issued to the opposite party to pay the entire claim i.e. Rs. 82,100/- alongwith interest @18% per annum. Rs. 5500/- as litigation expenses and Rs. 10,000/- as mental agony, pain and harassment. Complainant prayed for acceptance the complaint and for relief.
5. Upon notice opposite party made its appearance and gave reply of the complaint and took objections interalia that the complaint is not maintainable. Complainant has no cause of action and locus standi to file the present complaint. The complaint should be filed by wife of complainant. Complainant has not come to this Forum with clean hands and concealed the material and relevant facts from the Forum. The complainant has dragged the answering opposite party into unnecessary litigation by filing a false and frivolous complaint with an ulterior motive of extracting money from the opposite party. The complaint is bad for non joinder of necessary party. The disputes and issues raised in compliant involves intricate question of law and facts and matter involves is complicated one, which requires extensive evidence. Complainant is not consumer as per the Consumer Protection Act. Hon'ble forum has got no jurisdiction to try and entertain the present complaint. Complainant has violated the terms and conditions of the policy. The complaint is not maintainable in the present form, as per terms and conditions of the policy. The compliant is not maintainable in the present form, as per terms of policy the matter should be referred to Arbitrator. As per merits of the reply Ruchi Dadu wife of complainant was diagnosed as Rheumatoid Arthritis by Dr. Parshant Aggarwal in Punjab Rheumatology and Immunology Clinic Ludhiana and wife of complainant Ruchi Dadu administered by the complainant Rs.37500/-. The complainant has also claimed Rs. 3550/-. He also claimed Rs. 3550/- as admission charges and room charges and for lab tests. The complainant also alleged that Ruchi Dadu wife of complainant was admitted on 4.2.2015 in the above said Hospital to take the said treatment and discharged on 5.2.2015, wife of complainant Ruchi Dadu diagnosed as Rheumatoid Arthritis by Dr. Parshant Aggarwal in Punjab Rheumatology and Immunology Clinic Ludhiana Hospital and wife of complainant Ruchi Dadu again administered inj. Rituximab infusion which was purchased by the complainant Rs. 37,500/- in cash . The complainant has also claimed Rs. 37500/- as admission charges and for lab tests. The wife of complainant has discharged on 20.2.2015. The complainant lodged the claim with answering opposite party with request for the payment of Rs. 82100/-. The answering opposite party sent all the claim documents alongwith claim form submitted by the complainant to Raksha TPA Pvt. Ltd. for the approval of claim. The answering opposite party send every claim arises from Medi Claims policy to Raksha TPA pvt. Ltd. who approved and decide every claim after securitization of claim very carefully. In the present case, Raksha TPA Pvt. Ltd. repudiated the claim of the complainant after securitization of the document and after taking opinion of their experts and other competent person. Raksha TPA Pvt. Ltd. sent repudiated the claim of complainant vide letter dated 16.3.2015 on the basis of opinion of Raksha TPA Pt. Ltd. on the ground that “the patient is diagnosed with RHEMATOID ARTHIRITES after managed with inj. Rituaximab which is non payable since it is an OPD procedure. The answering opposite party has rightly repudiated the claim of complainant because as per medical norms, the treatment taken by the wife of complainant is an OPD procedure as per terms and conditions of policy hospitalization means admission in hospital for a minimum period of 24 hours in patient care consecutive hours. The claim of the complainant does not fall in this clause of policy. As per terms and conditions of policy hospitalization mean admission in hospital for a minimum of 24 hours in patient care consecutive hours except for specified procedure/treatment where such admission could be for a minimum period of 24 hours in patient care. The claim of complainant does not fall in this clause of policy. As per terms and conditions of policy, the patient has to stay in hospital for more than 24 hours for covered event. The complainant fails to prove from the documents submitted by him that his wife was admitted for 24 hours. From the documents produced by the complainant, it is very much proved that the wife of the complainant was wrongly admitted with malafide intention in the hospital just to get the claim from the answering opposite party. The wife of the complainant was admitted in hospital first time on 4.2.2015 and discharged on 5.2.2015. Second time the wife of complainant admitted on 19.2.2015. and discharged on 20.2.2015 on the next day. It clearly proves that the wife of the complainant was got admitted by the complainant just to get the compliant from the answering opposite party with malafide intention . Rather there was no need to admit wife of complainant in the hospital both times for above said OPD treatment. Moreover the complainant failed to give notice in proper time to the Raksha TPA Pvt. Ltd. and New India Assurance Co. with regard to his treatment. Punjab Rheumatology and Immunology Clinic Ludhiana Hospital is not in the list of network hospitals of Raksha TPA Pvt. Ltd. mentioned in the policy. The complainant has tried to get claim with misrepresentation, misdescription or non disclosure of material facts and by fraudulent means and device. So, claim of the complainant is liable to be repudiate on this ground. The charges claimed by the complainant for room rent admission charges consumable for lab tests does not fall under the policy. The insurance is contract between the parties and complainant and his wife is bound by the terms and conditions of the policy. The complainant is not entitled for any relief. Opposite party made request for dismiss the complaint.
6. The claim of complainant does not fall in this clause of policy. As per terms and conditions of policy, the patient has to stay in hospital for more than 24 hours for a covered event. If the patient has continuous coverage in access of 24 months with us expenses of the treatment of the complainant does not fall under the terms and conditions of policy. The complainant fails to prove from the documents submitted by him that his wife was admitted for 24 hours. From the documents produced by the complainant, it is very much proved that the wife of complainant, it is very much proved that the wife of complainant was wrongly admitted with the malafide intention in the hospital just to get the claim from the answering opposite party. The complainant tried to convert OPD treatment into the indoor/hospitalized treatment by got admitting his wife in the hospital. The wife of complainant was admitted in hospital first time on 4.2.2015 and discharged on 5.2.2015 Second time the wife if complainant admitted on 19.2.2015.and discharged on 20.2.2015 on the next day. It is clearly proves that wife of complainant was got admitted by the complainant just to get the claim from the answering opposite party with malafide intention. Rather there was no need to admit wife of complainant in the hospital both time for above said OPD treatment. So the claim of the complainant is rightly repudiated by the answering opposite party. The complainant failed to prove the at the local authorities under the clinical establishment (Registration and Regulation ) Act 2010 or under the enactment specified under the schedule of Section 56 (1) of the said act or complies with all minimum criteria mentioned in the Act. The complainant failed to give notice in proper time to the Raksha TPA Pvt. Ltd. and New India Assurance Co. with regard to his treatment, Punjab Rheumatology and Immunology Clinic Ludhiana Hospital is not in the list of network Hospital of Raksha TPA pvt. Ltd. mentioned in th policy. The complaint has tried to get claim with misrepresentation, misdescription or non disclosure of material facts and by fraudulent means and device. So this is a violation of terms and conditions and claim of the complainant is liable to be repudiate on this ground. The charges claimed by the complainant for room rent and admission charges consumables and for lab test does not fall under the policy. It is wrong and admitted that as per MCI protocol the patient should be admitted in hospital for the above said treatment. It is also wrong and denied that the answering opposite party illegally and arbitrarily repudiated the claim of the parties and complainant. The insurance is contract between the parties and complainant and his wife is bound by the rems and conditions of the policy. The complainant has filed false compliant against the answering opposite party. The opposite party has repudiated the claim of complainant as per terms and conditions conditions of policy and as per law. Opposite party made request for dismiss the complaint .
7. In support of his complaint, complainant tendered into evidence Ex.C-1 affidavit of Manjit Dadu, Ex.C-2 copy of policy schedule for the period 26.10.12 to 25.10.13, Ex.C-3 copy of policy schedule for the period 26.10.13 to 25.10.14, Ex.C-4 copy of policy schedule for the period 26.10.2014 to 25.10.2015, Ex.C-5 copy of bill dated 4.2.2015, Ex.C-6 copy of bill dated 5.2.2015, Ex.C-7 copy of discharge summary, Ex.C-8 copy of diagnosis prescribed by Dr. Prashant Aggarwal, Ex.C-9 copy of bill dated 19.2.2015, Ex.C-10 copy of bill dated 20.2.2015, Ex.C-11 copy of discharge summary, Ex. C-12 copy of diagnosis by Dr. Parshant Aggarwal, Ex.C-13 copy of letter dated 16.3.2015 and closed the evidence.
8. To rebut the evidence of the complainant opposite party tendered into evidence Ex.OP-1 Affidavit of M. Dhawal, Ex.OP-2, copy of insurance policy from dated 26.10.12 to 25.10.2013, Ex.OP-3 copy of insurance policy from 26.10.2013 to 25.10.2014, Ex.OP-4 copy of insurance policy from 26.10.2014 to 25.10.2015, Ex.OP-5 copy of terms and condition of Mediclaim policy, Ex.OP-6 copy of repudiation letter dated 16.3.2015, Ex.OP-7 copy of opinion report from Raksha TPA Pvt. Ltd., Ex.OP-8 copy of appointment information, Ex.OP-9 copy of salt information of medicine and closed the evidence.
9. After perusing the entire record minutely and hearing the arguments of both the parties this Forum considers that Ex.C-2 and Ex.OP-4 are important part of this complaint. This is a Medi-Claim policy name of the policy holder is Manjit Dadu and no. of policy is 36130134120100000044 and period of insurance is 26.10.2012 to 25.10.2013 and premium is paid Rs. 5765/- and as per Ex OP-2 and 3 this policy not insured the insurer but also covered other family members named Ruchi Dadu wife of complainant, Mehak Dadu d/o complainant, Ishan Dadu s/o complainant and renewed from 26.10.2014 to 25.10.2015.
10. We prefer to keen this judgment of Uttarakhand State Commission, Dehradun titled as United India Insurance Company Ltd. Versus Indu Joshi reported in 2009 (1) CLT-53 in which it is held as under.-
“Section 15 Insurance-Mediclaim policies reimbursement claim repudiated-contention that insured did not remain hospitalized for treatment for minimum period of 24 hours on each occasion-Not acceptable-Insured required to be hospitalized on 6 occasions starting from 18.4.2001 to 19.2.2002- Insured admitted for CAPD (Dialysis), time of minimum period of 24 hours would not apply as stipulated in clause 2.3 of Insurance Policy-Admission and discharge on 6 occasions indicates that insured used to be hospitalized also for minimum period of 24 hours- Insurance liable to pay claim under the policy along with interest.”
11. So, in this complaint a wife of complainant also admitted twice in the same hospital. Firstly, she hospitalized in Ludhiana on 4.2.2015 and on 19.2.2015. As per Ex.C-7 wife of complainant is patient of Sero ve Rheumatoid Arthritis and she admitted on 4.2.2015 and discharged on 5.2.2015. Summary of hospital course indicates on this point that she was administered Rituximab infusion and kept under observation as per recommended protocol. As per Ex.C-10 again on 19.2.2015 she was diagnosed and discharged on 20.2.2015. So, she was admitted and discharged twice. It indicates that insured used to be hospitalized for minimum period of 24 hours. Moreover, wife of complainant is also covered under the above stated policy as per Ex. C-2 and OP-4, so by this way she is also insured as well as complainant. And when complainant took this policy and in lieu of it he regularly deposit premium, it means insured and insurer came under the terms of contract as per the Indian Contract Act. So legal objection and Ex.OP-1 i.e. affidavit of M. Dhawal is useless which took objection that wife of complainant is not consumer.
12. We find that claim if the complainant is genuine one. Accordingly, the complaint of the complainant is allowed and opposite party is directed to pay Rs 82,100/- to the complainant with interest at the rate of 9% per annum from the date of filing this compliant till realization. The opposite party is also directed to pay Rs. 2,000/- to the complainant on account of litigation expenses. This order shall be complied with within 30 days from the date of the receipt of this order. Copy of this order be supplied to the parties free of costs. The file be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
9th Day of October 2015
(S.K. Goel)
President
(Karnail Singh)
Member
(Vandna Sidhu)
Member
