BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.386 of 2014

Date of Instt. 03.11.2014

Date of Decision :04.05.2015

Krishan Lal aged about 61 years son of Sahia Ram R/o 97, Adrash Nagar, Jalandhar City.

..........Complainant

Versus

1. New India Assurance Company Limited, through its authorized signatory, New India Assurance Building, 87, Mahatma Gandhi Road, Fort, Mumbai-400001.

2. New India Assurance Company Limited, through its Branch Manager, 16, Patel Chowk, Jalandhar.

3. Raksha TPA Pvt Ltd, through its authorized signatory, 2nd Floor, SCO181, Sector-7C, Chandigarh-160019.

.........Opposite parties

Complaint Under the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.Gagandeep Adv., counsel for complainant.

Sh.Raman Sharma Adv., counsel for opposite parties.

Order

J.S Bhatia (President)

1. The complainant has filed the present complaint under the Consumer Protection Act against the opposite parties on the averments that the complainant is handicap. He purchased a mediclaim policy 2007 (hospitalization benefit policy) bearing policy No.36100234130100000045 from the opposite party No.2, which was renewed on 2.5.2014 and valid upto 1.5.2015. The policy number issued to him on renewal of policy is 36100234142500000020 and Id of the complainant is 8H3238885. Since the beginning of the policy only cover note was provided to the complainant without actually providing the policy document to him. The insurance policy also cover the wife and son of the complainant. He was not fine during April 2014, so he got himself examined and treated from Sardana Labs, 50, Mahavir Mart, Jalandhar, The Good Health Clinic Medical & Dental, 78 Cool Road, Jalandhar, Ranjit Hospital, Jalandhar, Endolite Ludhiana and American Scan & Diagnostic Centre, Jalandhar. Rite wife of the complainant was not fine during June 2014, so she got herself examined and treated from Satyam Hospital & Trauma Centre, Kapurthala Chowk, Jalandhar. Rita wife of the complainant was treated by Satyam Hospital & Trauma Centre from 22.6.2014 to 28.6.2014. The complainant lodged two claims with the opposite party No.2. One claim is lodged of Rs.14,537/- with the opposite party No.2 in the month of June 2014, for the treatment of the complainant and second claim was for Rs.50,736/- with the opposite party No.2 on 7.7.2014, for the treatment of Rita wife of complainant. The opposite party No.3 is third party administrator. The complainant despite providing the documents as requisite by the opposite party No.3, was astonished to see that only claim of Rs.3470/- was passed by the opposite party No.3, despite the fact that the complainant lodged first claim of Rs.14537/- with the opposite party No.2. The opposite party No.3 wrongly deducted the claim amount of the complainant. The opposite party No.3 has not even cared to give the reason of alleged deduction. With regard to the second claim of Rs.50736/-, he was astonished to see that claim lodged by the complainant was refused by the opposite party No.3. The opposite party No.3 wrongly rejected the claim amount of the complainant. On such like averments, the complainant has prayed for directing the opposite parties to pay him the deducted amount of Rs.11,067/- with regarding to the claim of Rs.14,537/- and second claim amount of Rs.50,736/- alongwith interest. He has also claimed compensation.

2. Upon notice, opposite parties appeared and filed a written reply pleading that the complainant is intermixing the two claims in one complaint. The claim for Rs.14,537/- pertained to complainant Krishan Lal for himself whereas the claim for Rs.50,736/- to Rita wife of Krishan Lal/complainant. The first claim lodged for Rs.14,537/- was settled as per terms and conditions of the insurance policy and Rs.3470/- was paid to the complainant. The remaining amount was not payable as the same were expenses on consumables and on Essa Liner not payable. The second claim of the complainant for Rs.50,736/- qua the treatment of Rita wife of complainant was repudiated as the same pertained to treatment of Rita for Psychosomatic disorders which is not payable as per exclusion clause 4.4.6 of the insurance policy terms and conditions and the complainant was informed accordingly. As per discharge summary of the Satyam Hospital and Trauma Centre, Jalandhar Rita wife of the complainant was admitted in the hospital on 22.6.2014 and was discharged on 28.6.2014 and decease of patient Rita was diagnosed as TIA with Psychosomatic disorder which falls in the exclusion clause 4.4.6 of the insurance policy, as such the claim was not payable as per terms and conditions of the insurance policy and the same was repudiated and the complainant was informed accordingly. They denied other material averments of the complainant.

3. In support of his complaint, complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C31 and closed evidence

4. On the other hand, learned counsel for opposite parties has tendered affidavit Ex.OA alongwith copies of documents Ex.O1 to Ex.O8 and evidence of opposite parties closed by order.

5. We have carefully gone through the record and also heard the learned counsels for the parties and further gone through the written arguments submitted on behalf of complainant.

6. The real dispute between the parties is regarding the claim amount of Rs.50,736/- in respect of wife of the complainant namely Rita. Ex.C9 is discharge summary in respect of Rita wife of the complainant, which has been produced by the complainant himself. As per discharge summary, the diagnosis was TIA with Psychosomatic disorders. The opposite party insurance company has repudiated the claim of the complainant in respect of his wife Rita as per permanent exclusion clause 4.4.6 which is as under:-

"Convalescence, general debility, run-down condition or rest cure, obesity treatment and its complications, congenital, external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorder, infertility, sterility, use of intoxicating drugs/alcohol, use of tobacco leading to cancer".

7. Ex.O2 are terms and conditions of the mediclaim policy. So as per above exclusion clause any medical expense incurred for or arising out of psychosomatic disorders are not payable. As per discharge summary Ex.C9 produced by the complainant, his wife was suffering from psychosomatic disorders. So the claim was not payable as per above said exclusion clause and was rightly repudiated by opposite party insurance company. So far as second claim of Rs.14537/- is concerned, the opposite party insurance company has paid Rs.3470/- to the complainant as remaining amount was disallowed as the same related to expenses of consumable and Essa Liner. So the complainant has failed to prove any deficiency in service on part of the opposite party insurance company.

8. In view of above discussion, we hold that there is no merit the present complaint and same is hereby dismissed with no order as to cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

04.05.2015 Member Member President