Haryana

Gurgaon

CC/500/2015

VIPUL JAIN - Complainant(s)

Versus

New India Assurance Co. Ltd. - Opp.Party(s)

SH. Deepak Gupta

03 May 2016

ORDER

                                           DISTRICT   CONSUMER   DISPUTES   REDRESSAL FORUM,GURGAON-122001

                                                                                                    Consumer Complaint No: 500 of 2015                                                                                                                                            Date of Institution: 28.09.2015                                                                                                                                                                     Date of Decision: 03.05.2016

Vipul Jain s/o Shri N.K.Jain, Resident of 63-B, Miyawali Colony, Gurgaon.

                                                                                                                                                                                                                        ……Complainant.

                                                Versus

New India Assurance Co. Ltd Opposite Kamla Nehru Park, Gurdwara Road, Gurgaon through its Divisional Manager.

 

E.Meditek (TPA) Services Ltd, Plot No.577, Udyog Vihar, Phase-V, Gurgaon.

..Opposite parties

                                                                                               

Complaint under Sections 12 & 14 of Consumer Protection Act,1986                                                                 

 

BEFORE:     SHRI SUBHASH GOYAL, PRESIDENT

SMT JYOTI SIWACH, MEMBER

                   SH.SURENDER SINGH BALYAN, MEMBER.

 

Present:        Shri  Deepak Gupta, Adv for the complainant.

                    Ms. Vandana Oberoi, Adv for the OP-1

                    OP-2 exparte

                   

 

ORDER       SUBHASH GOYAL, PRESIDENT.

 

The case of the complainant, in brief, is that he has taken New India Floater Mediclaim Policy from the OP-1 for himself as well as his wife Smt. Shruti Jain and son Viven Jain to the extent of Rs. 8 Lacs and had paid the premium of Rs.11,135/-. The complainant has been paying the huge premium regularly for the last six months but had never reimbursed any amount. However, during the subsistence of the insurance policy, the wife of the complainant Smt. Shruti Jain was admitted in Medicity Hospital, Gurgaon on 03.07.2015 and was discharged on 06.07.2015 as she was diagnosed with palpitation under evaluation and post cholcystectomy. In this regard OP-1 & 2 were immediately informed. However, the cash less facility was denied by OP-2. The complainant submitted the claim with the OPs but the same was rejected on the ground that patient was suffering from psychiatric related problem. However, the wife of the complainant was not suffering from any psychiatric problem and was admitted due to palpitation and palpitation has no concern with any psychological treatment. Thus, the claim of the complainant has wrongly been repudiated by the opposite parties and thus, they are deficient in providing services to the complainant. The complainant prayed that the opposite parties be directed to reimburse the claim of Rs.35,597.27 with interest. He also sought compensation of Rs.40,000/- for harassment and mental agony and Rs.22,000/- as cost of litigation.

2                 OP-1 in its written reply has alleged that on scrutiny of documents it was observed that the wife of the complainant Smt. Shruti Jain was admitted in the hospital  with the diagnosis of sinus Techyardia, depression of the panic attach and the cashless was rejected for the same as psychiatric related treatment is not payable as it comes under Exclusion Clause 4.4.6. which reads as under:=

4.4.6.           –Permanent Exclusion- Convalescene, general debility, ‘Run-down’ condition or rest cure, obesity treatment and its complications, treatment relating to all psychiatric and psychosoamatic disorders, intenditity stenlity venereal disease, intentional self injury and illness or injury caused by the use of intoxicating drugs/alcohol.”

Thus, the claim of the complainant was rightly repudiated by the OP and there was no deficiency in service on the part of the opposite parties. OP-1 in evidence has produced Discharge Summary of patient Ex.R-1.

3                 However, notice of the complaint was also given to the OP-2 OP-2 failed to turn up despite service and thus, was proceeded exparte vide order dated 14.12.2015.

4                 We have heard the learned counsel for the parties and have perused the record available on file.

5                  Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the counsel for the parties, besides written arguments filed by OP-1 it emerges that the complainant has filed the present complaint against the OPs alleging deficiency in service on their part on the ground that complainant has obtained  New India Floater Mediclam policy from OP-1 since 2009. However, during the subsistence of the current policy the wife of complainant. Smt. Shruti Jain was admitted in Medicity Hospital, Gurgaon on 03.07.2015 and discharged on 06.07.2015 where she incurred Rs.35,596.27 and the cashless facility was not provided to the complainant and the complainant paid the expenses from his own pocket. When the complainant submitted the claim along with all relevant documents the same was rejected on the ground of permanent exclusion as contained in clause 4.4.6 of the Policy.

6                 Learned counsel for the complainant has argued that the case was not covered under Permanent Exclusion which  has been made basis of repudiation rather  Exclusion Clause was not applicable in the present circumstances of the case in view of the fact that the complainant was policy holder since last six months and the disease was not covered under Permanent Exclusion Clause rather patient was admitted in the hospital on account of palpitation  and thus, the claim was liable to be reimbursed to the complainant. In support of his contention learned counsel for the complainant has relied upon IFFCO TOKIO General Insurance Co. Ltd Vs Permanent Lok Adalat (Pubic Utility Services) Gurgaon and others 2012(1) RCR (Civil) 901 and Harjeet Kaur Vs National Insurance Co. Ltd & Ors 2009(3) CPJ 196.

7                 Learned counsel for the OP-1 has argued that the claim has rightly been repudiated in view of  exclusion clause 4.4.6 as patient was suffering from depression with panic attack as mentioned in Discharge Summary Ex.R-1 which was psychiatric disorder  and the same falls within the Exclusion Clause.

8                 However, after going through the facts and circumstances of the case and the evidence placed on file it has to be held that there is no history that Smt. Shruti Jain was suffering from psychiatric disorder rather it has come in evidence that she was admitted in the hospital on account of palpitation  which is related to heart on account of anxiety. The complainant was having  Sinus Tachycardia  as mentioned in Discharge Summary (Ex.R-1) and the depression and the alleged panic attach as mentioned in Ex.R-1 which has been made basis for rejection of the claim are the result of anxiety on account of Sinus Tachycardia. The patient was treated for palpitation and Sinus Tachycardia and as such the above treatment was not covered under the Permanent Exclusion Clause as mentioned in Clause 4.4.6 and thus, we are inclined to hold that the repudiation of claim by OP-1 on the recommendation of OP-2 tantamounts to deficiency in service.

9                 Therefore, we allow the present complaint and  direct the opposite parties to reimburse the claim of Rs.35,595.27 as per terms of the policy with interest @ 9 % p.a. from the date of filing of the present complaint i.e. 28.09.2015 till realization. The complainant is also entitled to compensation for harassment and mental agony as well as litigation expenses to the tune of Rs.10,000/-. The OPs shall make the compliance of the order within 30 days from the date of receipt of the copy of this order. The parties be communicated of the order accordingly and the file be consigned to the records after due compliance.

Announced                                                                                                                               (Subhash Goyal)

03.05.2016                                                                                                                                 President,

                                                                                                                                                  District Consumer Disputes

                                                                                                                                                 Redressal Forum, Gurgaon

 

(Jyoti Siwach)        (Surender Singh Balyan)

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