BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

Complaint No.144 of 2014

                                                                     Instituted On:01.12.2014

Decided On: 04.05.2015 

Mahesh Kumar, aged about 58 years son of Salig Ram resident of Nihal Singh Wala Road, Bagha Purana, Distt. Moga.  

……..Complainant

Versus

1.       The New India Assurance Company Limited, Gulabi Bagh, G.T.Road, Near, Income Tax Office, Moga through its Divisional Manager.

2.       Raksha TPA Private Limited, 2^nd Floor  SCO 181,  Sector 7-C, Chandigarh UT 160019 through its Executive Officer.

                                                                   ……… Opposite Parties

Complaint under Section 12 of the

        Consumer Protection Act, 1986.

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Coram:       Sh.S.S.Panesar, President

                   Smt Vinod Bala, Member

Present:       Sh.K.K.Gupta Advocate counsel for the complainant.

Sh.Ajay Gulati, Advocate counsel for opposite party No.1

Opposite party No.2—Ex-parte

ORDER

(S.S.Panesar, President)

The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (herein-after referred to as ‘Act’) against The New India Assurance Company Limited, Gulabi Bagh, G.T.Road,  Near, Income Tax Office, Moga through its Divisional Manager  (herein-after referred to as ‘opposite party No.1’) & Raksha TPA Private Limited, 2^nd Floor  SCO 181,  Sector 7-C, Chandigarh UT 160019 through its Executive Officer (herein-after referred to as ‘opposite party No.2’) directing them to pay a sum of Rs.1,88,797/- as medicine and hospitalization bills etc., which were spent by the complainant on his treatment besides Rs.1,00,000/- as  compensation for causing mental tension and harassment  alongwith interest @12% per annum from the month of October 2013 and also to grant any other relief to which this Forum may deem proper.

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2.                Briefly stated, the complainant had purchased Health Insurance Policy bearing No.36110034130100000067 from opposite party No.1, which was valid w.e.f. 17.09.2013 to 16.09.2014. It was the continuing policy because the complainant had been purchasing the medi claim policies from opposite party No.1 since 17.09.2008 regularly. During the continuation of the policy, complainant suffered some problem and he spent an amount of Rs. 1,88,797/- on his treatment.  The complainant approached the opposite parties and also submitted all the requisite documents with opposite parties for re-imbursement of his medi-claim bill under the policy. But vide letter dated 25.06.2014, the opposite parties repudiated the claim of the complainant without any rhyme and reasons, which amounts to deficiency in service on the part of the opposite parties.  Due to the negligent act of the opposite parties, the complainant is suffering from mental and physical harassment and economic loss.  Hence the present complaint.

3.                Notice of the complaint was given to the opposite parties. Opposite party No.1 appeared through his counsel Sh.Ajay Gulati Advocate and filed written reply contesting the same. It took up preliminary objections that the complaint is not maintainable; that as per Clause 3.4 of the medi-claim insurance policy, the claim is not payable and  that the claim of the complainant was duly entertained and investigated. On merits, it has been pleaded that as per Clause 3.4 of the terms and

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conditions of the medi-claim insurance policy in question, the claim is not payable as the complainant was admitted and diagnosed with chronic hepatitis with related CLD. Injection Interferon was given and that was OPD based procedure, which did not require hospitalization. All other allegations made in the complaint were specifically denied being incorrect and it is stated that the complaint deserves to be dismissed.

4.       Opposite party No.2 was proceeded against ex-parte vide order dated 05.01.2015.

5.                In order to prove his case, the complainant tendered in evidence his affidavit Ex.C-1 and copies of documents Ex.C-2 to Ex.C-62 and closed his evidence.

6.                To rebut the evidence of the complainant, OP No.1 New India Assurance Company tendered affidavit of Sh Anil Chawla Ex.OP1/1, copy of documents Ex.OP1/2 and closed evidence on behalf of opposite party No.1.

7.                We have heard the learned counsel for the parties and have also carefully gone through the record.

8.                It has been vehemently contended by the counsel for the complainant that the complainant purchased health insurance policy bearing No. 36110034130100000067 from opposite party No.1, which was valid w.e.f. 17.09.2013 to 16.09.2014, copy whereof is Ex.C-3. It was the continuing policy as the complainant had been purchasing the medi claim policies from opposite party No.1 since 17.09.2008 regularly. During the

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continuation of the policy, complainant suffered some problem and he spent an amount of Rs. 1,88,797/- on his treatment.  The complainant approached the opposite parties and also submitted all the requisite documents with opposite parties for re-imbursement of his medi-claim bill under the policy. But vide letter dated 25.06.2014, the opposite parties repudiated the claim of the complainant without any rhyme or reason, which amounts to deficiency in service on the part of the opposite parties. The act and conduct of the opposite parties is not consonance with the provisions of the insurance policy and they are deficient in service. It is requested that the complaint may be allowed and an order for re-imbursement of insured amount of Rs.1,88,797/- alongwith Rs. 1,00,000/- as compensation for causing mental tension and harassment besides litigation expenses may be passed in favour of the complainant.

9.                On the other hand, the learned counsel for the opposite parties has vehemently contended that the claim of the complainant has rightly been turned down under Exclusion Clause 3.4. As per Clause 3.4 of the terms and conditions of the medi-claim insurance policy in question, the claim is not payable because the complainant was admitted and diagnosed with chronic hepatitis with related CLD. Injection Interferon was given and that was OPD based procedure, which did not require hospitalization. Terms & conditions of policy document Ex.O.P.1/2 on record clearly establish that no re-imbursement of medical expenditure was allowable,

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even, if,  hospitalization or  day care hospital  is provided in such like disease (s). There is no merit in the complaint. The opposite parties are not deficient in service and the complaint is nothing, but an abuse of the process of law. It is, therefore, contended that the complaint may be dismissed.

10.               We have given thoughtful consideration to rival contentions.

11.              There is no dispute that the complainant has been availing medical insurance policy since 2008 and he has been paying the premium regularly to the opposite parties. It is also not disputed that the complainant suffered from disease known as chronic hepatitis with related CLD and he got himself treated in Dayanand Medical College & Hospital at Ludhiana. There is evidence on record that the complainant remained admitted in Dayanand Medical College & Hopsital, Ludhiana for treatment of disease hepatitis ‘C’ w.e.f. 04.10.2013 to 05.10.2013. However, this disease is an Out Door treatment for which admission in hospital was not necessary. No written advice of a medical practitioner has been adduced on record to prove the fact that Indoor Treatment was required in the case of the complainant. The claim for re-imbursement of medical expenses was repudiated in view of the Clause 3.4 of the Insurance Policy. Clause 3.4 of the policy is reproduced as under for ready reference:-

“HOSPITALISATION means admission in any hospital/Nursing Home in India upon the written advice of a Medical Practitioner for a minimum period of 24 consecutive hours. The time

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limit of 24 hours will not be applicable for following surgeries/procedures.

Or any other Surgeries/Procedures agreed by TPA/Company which require less than 24 hours hospitalization due to subsequent advancement in medical Technology.”          

It becomes evident that in the case in hand, the insured has gone for

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hospitalization for the disease, which did not require admission in the hospital. The only treatment, which was required to be given to the complainant was administration of injection, which is an out patient treatment.  Terms & conditions of the insurance policy are binding inter-se parties & no party can be allowed to wriggle out therefrom. As such no fault can be found with the repudiation order, which has been passed in consonance with the terms & conditions of the policy.

12.              From the aforesaid discussion, it transpires that the claim of the complainant has rightly been repudiated by the opposite parties and no fault can be found in the repudiation order. Consequently, instant complaint fails and the same is ordered to be dismissed. Copies of the order be sent to the parties free of cost immediately and thereafter the file be consigned to the record room.

                                                (Vinod Bala)                   (S.S.Panesar)

                                              Member                         President

Announced in Open Forum.

Dated:04.05.2015.