BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 541 of 2015

Date of Institution: 27.08.2015

Date of Decision: 04.03.2016

Mr.Amandeep Singh (aged 40 years) Arora son of Mr.Surjit Singh Arora, resident of House No. 2701, Ram Nagar, Gali No.2, Sultan Wind Road, Amritsar. 

Complainant

Versus

The New India Assurance Company Limited, through its Chairman/ Managing Director/ Principle Officer, service through its Branch Office at 118, Mall Road, Amritsar through its Branch Manager.   

Opposite Party

Complaint under section 12 and 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh.Deepinder Singh, Advocate

              For the Opposite Party: Sh.S.S.Randhawa, Advocate

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 Sh.Amandeep Singh Arora under the provisions of the Consumer Protection Act alleging therein that  the complainant by virtue of his job, has been assigned the Health Insurance from the Opposite Party for himself, his wife and two children vide policy No.1112700/34/14/04/00000062 covering risk period from 7.9.2014 to 6.9.2015. Complainant alleges that unfortunately the wife of the complainant fell ill and was to be hospitalized at K.D.Hospital, Amritsar for the treatment of multiple Sclerosis, from 3.3.2015 till 4.3.2015 and the hospitalization and treatment cost came to Rs.81,221/- and later again the wife of the complainant for the same  ailment was to be hospitalized at K.D.Hospital, Amritsar and  the hospitalization and treatment cost came to Rs.83,253/- and the claim bill was filed with the Opposite Party which was repudiated by the Opposite Party  on the frivolous ground that the patient does not require hospitalization of 24 hours. Said repudiation of genuine claim of the complainant without ascertaining the correct facts by the Opposite Party is the arbitrary act of the Opposite Party. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to pay the claim of Rs.1,64,474/- alongwith interest @ 12% per annum from the date of payment till its realization. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party appeared and filed written version in which it was submitted that the  present complaint is  not maintainable as the wife of the complainant was hospitalized for multiple Sclerosis, chemotherapy and as per the submitted documents it is evident that taken treatment does not require hospitalization for more than 24 hours, so as per the terms and conditions of the insurance policy, the hospitalization of the wife of the complainant is not justified and as such the claim is rightly repudiated. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C11 and closed the evidence on behalf of the complainant.
4. Opposite Party tendered into evidence affidavit of Sh.Sukhdev Singh Gill, Senior Divisional Manager Ex.OP1, affidavit of Dr.Padmnabh Shradhkar Ex.OP2, copy of policy schedule Ex.OP3 and closed the evidence on behalf of the Opposite Party.
5. 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.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got Health Insurance Policy from the Opposite Party for himself, his wife and two children vide policy No.1112700/34/14/04/00000062 covering risk period from 7.9.2014 to 6.9.2015, for a sum assured Rs.2.5 lacs. The wife of the complainant namely Ranjit Kaur  became ill and was hospitalized at K.D.Hospital, Amritsar for the treatment of multiple Sclerosis for the  period  from 3.3.2015 till 4.3.2015, copy of discharge card Ex.C5  and the hospitalization and treatment cost came to Rs.81,221/-. Thereafter, the wife of complainant namely Ranjit Kaur insured, was again   hospitalized for the same ailment at K.D.Hospital, Amritsar for the period from 3.5.2015 to 4.5.2015 as per discharge card Ex.C8 and  the complainant spent Rs.83,253/- on hospitalization and treatment cost. In all,  the complainant spent Rs.1,64,474/- on the treatment of insured Ranjit Kaur. The claim was lodged with the Opposite Party, but the Opposite Party repudiated the claim  and information in this regard was received by the complainant through Net Ex.C4 on the ground that from the submitted documents, it is evident that said procedure does not require 24 hrs.  inpatient stay also not listed under day care procedure. Hence claim is declined. Ld.counsel for the complainant submitted that Dr.Prabhjeet Singh, treating doctor  has given certificate dated 24.4.2015 Ex.C6 that the  patient  is known case of multiple Sclerosis and her admission in the hospital atleast for 24 hours at ICU as necessary to monitor any allergic reaction for envy infusion, but the Opposite Party has wrongly repudiated the claim of the complainant and all this amounts to deficiency of service on the part of the opposite party.
7. Whereas the case of the Opposite Party is that the wife of the complainant namely Ranjit Kaur insured was hospitalized for multiple Sclerosis, chemotherapy and as per the submitted documents it is evident that taken treatment does not require hospitalization for more than 24 hours. As such,  the hospitalization of the wife of the complainant is not justified and as per the terms and conditions of the policy, the claim of the complainant has rightly been repudiated by the Opposite Party. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party.
8. From the entire above discussion, we have come to the conclusion that  the complainant got Health Insurance Policy from the Opposite Party for himself, his wife and two children vide policy No.1112700/34/14/04/00000062 covering risk period from 7.9.2014 to 6.9.2015, with sum assured Rs.2.5 lacs. The wife of the complainant namely Ranjit Kaur  became ill and was hospitalized at K.D.Hospital, Amritsar for the treatment of multiple Sclerosis for the  period  from 3.3.2015 to 4.3.2015 as per  copy of discharge card Ex.C5  and the hospitalization and treatment cost came to Rs.81,221/-. Again the wife of complainant namely Ranjit Kaur insured was  hospitalized for the same ailment at K.D.Hospital, Amritsar for the period from 3.5.2015 to 4.5.2015 as per discharge card Ex.C8 and this time, the  complainant spent Rs.83,253/- on hospitalization and treatment charges of Ranjit Kaur insured.  In all,  the complainant spent Rs.1,64,474/- on the treatment of insured Ranjit Kaur. The claim (Ex.C7) was lodged with the Opposite Party, but the Opposite Party repudiated the claim and even did not inform to the complainant and the complainant came to know about this fact from the website of Opposite Party through net Ex.C4, on the ground that from the submitted documents, it is evident that said procedure does not require 24 hrs. in patient stay also not listed under day care procedure. Whereas the treating doctor Dr.Prabhjeet Singh, M.D (Medicine) D.M.Neurology has issued certificate dated 24.4.2015 Ex.C6 in which he has categorically stated that patient Ranjit Kaur was  treated with Inj.Tysabria (Monthly). Patient has to be admitted at hospital for atleast 24 hours at ICU to monitor any allergic reaction for every infusion. The Opposite Party could not rebut this documentary evidence produced by the complainant. All this shows that the admission of insured Ranjit Kaur, wife of the complainant for more than 24 hours was necessary  in hospital and that too at ICU to monitor any allergic reaction for every infusion.
9. Consequently, we hold that the Opposite Party was not justified in repudiating the claim of the complainant on the ground  that 24 hours hospitalization of the patient was not necessary  for the treatment she has undergone.
10. Resultantly, we allow the complaint with costs and the Opposite Party is directed to reimburse this amount of Rs.1,64,474/-, to the complainant within one month from the date of receipt of copy of this order, failing which the Opposite Party shall be liable to pay  interest @ 9% per annum on the aforesaid amount, from the date of filing of the present complaint till the payment is made to the complainant. Opposite Party is also directed to pay the costs of litigation to the complainant to the tune of Rs.2,000/-. Copies of the order be furnished to the parties free of cost. 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: 04.03.2016.                                                                (Bhupinder Singh)                                                                                                                                                                                                      President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

                                                         Member                         Member