Punjab

Ludhiana

CC/20/72

Raman Kumar - Complainant(s)

Versus

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

Gagandeep Singh Adv.

20 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:72 dated 24.02.2020.                                                 Date of decision: 20.11.2023.

 

1. Raman Kumar Jain son of Sh. Vijay Kumar Jain, House No.3196/2, Street No.2, Mahabir Colony, Sunder Nagar, Ludhiana, Punjab-141007.
2. Kiran Jain W/o. Raman Kumar Jain son of Sh. Vijay Kumar Jain, House No.3196/2, Street No.2, Mahabir Colony, Sunder Nagar, Ludhiana, Punjab-141007.                                                                                                                                                              ..…Complainants

                                                Versus

The New India Assurance Co. Ltd., 101-103, Batra Building, 2^nd Floor, Sector 17-D, Chandigarh-160017 and also having its registered head office 87, Mahatma Gandhi Road, Mumbai-400001.                                                                                                                                        …..Opposite party 

Complaint Under section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Sh. Gagandeep Singh Bedi, Advocate.

For OP                           :         Sh. G.S. Kalyan, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant availed medi-claim policy No.36010134162500000087 from the OP w.e.f. 29.09.2016 to 28.09.2017 by paying premium. The complainants stated to have purchasing the policy from the OP regularly from the year 2013-2014 till 2018-2019. On 25.09.2017, complainant No.2 suffered emergency medical problem and was taken to UPSC Jain Hospital where after checking by the doctors, she was referred to DMC Hospital. Complainant No.2 was admitted in emergency ward of DMCH where she was diagnosed as a patient of peripheral vertigo. After conducting tests and examining complainant No.2 by the doctors, she was discharged on 25.06.2017 with advise for regular checkup and medications. According to the complainants, after conducting necessary tests, complainant No.2 was diagnosed as a patient of peripheral vertigo and normal LV function and doctors found that she could be managed by administering medicines. The complainants spent an amount of Rs.17,731/- and lodged a medi-claim with the OP but the OP vide award dated 28.05.2019 repudiated the claim on the ground under clause 4.4.11 and that for conducting medical test, no patient is required to be admitted in the emergency medical ward of the hospital. The repudiation of medi-claim by the OP claimed to have been illegal, arbitrary etc. due to which the complainants suffered harassment, pain and suffering on account of deficiency in service on the part of the OP. In the end, the complainants prayed for issuing directions to the OP to pay medi-claim of Rs.17,731/- along with compensation of Rs.50,000/-.

2.                Upon notice, the OP filed written statement and assailed the complaint by taking preliminary objections on the ground of maintainability of complaint; lack of cause of action; misrepresentation etc.   The OP stated that the complainant approached the office of the Insurance Ombudsman, Chandigarh and filed complaint against It which had been rightly dismissed by the office of Insurance Ombudsman vide award dated 28.05.2019. The operative part of award dated 28.05.2019 is reproduced as under:-

"Result of personal hearing with both parties (observations & Conclusion):

On going through the various documents available in the file including the copy of complaint, SCN submitted by insurance company, discharge summary of hospital and submissions made by both complainant and insurance company, it is seen that the complainant's wife Mrs. Kiran Jain was admitted at Dayanand hospital, Ludhiana on 25.09.2017 and discharged on 26.09.2017 and diagnosed to be a case of vertigo. Certain investigations were done during the complainant's wife stay in hospital and she was managed with tablet vertin, amlong & pantoprazole i.e. the symptomatic treatment for vertigo. MRI brain was found to be normal & cardio was also found to be normal. The insurance company has rejected the claim the claim by invoking clause 4.4.11 according to which the charges incurred at hospital primarily for diagnosis and evaluations are not reimbursable. In the instant case claim being duly covered under said clause wherein no active treatment has been done during stay in hospital, the repudiation of claim is in order. The complaint is dismissed.

AWARD: Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of personal hearing, the complaint is dismissed. Hence the complaint is treated as closed.”

The OP further stated that on receipt of claim intimation, it was duly entertained, registered and referred to M/s. Raksha TPA Pvt. Ltd. to its service provider and the complainants were called upon to submit the documents in support of their claim and M/s. Raksha TPA Pvt. Ltd. duly processed the claim file and in view of the policy terms and conditions and clause no.4.11 which is reproduced are under:

“Clause: 4.11 Charges incurred at Hospital primarily for diagnosis, x-ray or laboratory examinations diagnostic studies not consistent with or incidental to other the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a hospital.”

The OP has repudiated the claim of the complainants vide letter 12.10.2017, operative part of which is reproduced as under:-

"C/o Vertigo, patient admitted only for evaluated purpose only, there is no active line of treatment, hence claim is non payable as per policy conditions and clause 4.4.11

As per clause charges incurred at hospital primarily for diagnosis, x-ray or laboratory examinations other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a hospital.”

 

According to the OP, it has rightly repudiated the claim of the complainant.                              On merits, the OP reiterated the crux of averments made in the preliminary objections and facts of the case. The OP has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                The complainant filed replication to the written statement reiterated the facts mentioned in the complaint and controverted those mentioned in the written statement.

4.                In support of their claim, complainant No.1 tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of insurance policy w.e.f. 29.09.2016 to 28.09.2017, Ex. C2 is the copy of insurance policy w.e.f. 29.09.2014 to 28.09.2015, Ex. C3 is the copy of insurance policy w.e.f. 29.09.2015 to 28.09.2016, Ex. C4 is the copy of insurance policy w.e.f. 29.09.2017 to 28.09.2018, Ex. C5 is the copy of insurance policy w.e.f. 29.09.2018 to 28.09.2018, Ex. C6 is the copy of prescription slip of UPSC Jain Charitable Hospital, Ludhiana, Ex. C7 is the copy of discharge summary issued by DMC Hospital, Ex. C8 is the copy of MRI brain dated 26.09.2017, Ex. C9 is the copy of OPD card of DMC Hospital, Ex. C10 is the copy of in-patient final bill, Ex. C11 and Ex. C12 are the copies of patient deposit receipts, Ex. C13 is the copy of award 28.05.2019 of Insurance Ombudsman and closed the evidence.

5.                On the other hand, counsel for the OP tendered affidavit Ex. RA of Ms. Poonam Sharma, Authorized signatory of the OP along with documents Ex.  R1 is the copy of award 28.05.2019 of Insurance Ombudsman, Ex. R2 is the copy of repudiation letter dated 11.04.2019, Ex. R3 is the copy of report of Raksha TPA, Ex. R4 is the copy of discharge summary of DMC Hospital, Ex. R5 is the copy of MRI brain, Ex. R6 is the copy of X-ray report, Ex. R7 is the copy of prescription slip of UPSC Jain Charitable Hospital, Ludhiana, Ex. R8 and Ex. R9 is the copy of laboratory receipt and x-ray receipts issued by UPSC Jain Charitable Hospital, Ludhiana, Ex. R10 is the copy of claim form, Ex. R11 is the copy of in-patient final bill, Ex. R12 is the copy of insurance policy w.e.f. 29.09.2016 to 28.09.2017, Ex. R13 is the copy of prospectus of insurance policy and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, replication, affidavit and annexed documents and written reply along with documents produced on record by both the parties.

7.                The claim of the complainant has been repudiated by the opposite parties by invoking exclusion clause No.4.11 of the insurance policy Ex. R13 which reads as under:-

“Clause: 4.11 Charges incurred at Hospital primarily for diagnosis, x-ray or laboratory examinations diagnostic studies not consistent with or incidental to other the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a hospital.”

The claim has been repudiated on the premise that the admission primarily for observation and investigation.

8.                Now the point for consideration arises how it is required to be assessed that the admission is primarily for evaluation and investigation purpose only?

9.                The counsel for the complainant has referred to the extract of the discharge summary Ex. C7 = R4 which is reproduced as under:-

“History of Illness: ‘59 years female presented with chief complaints of vertigo few hours prior to admission. No history of palpitation, cough, fever or syncope.”

“Hospital Course: patient was admitted with above complaints. Neurology consultation (Dr. B.S. Paul) was taken and 2D MRI brain was done which showed normal study. ENT consultation (Dr. Rohit Verma) was taken for vertigo and managed accordingly. Patient is now being discharged.”

Ex. C6 shows that the patient was brought in emergency in UPSC Jain Charitable Hospital, Ludhiana with complaint of giddiness, nausea, blurred vision and was referred to CMC/DMC for further management. No prudent person will admit his/her dear one in the hospital conditions where there is risk of contacting infection is more than at home. Moreover, except the affidavit Ex. RA of one Ms. Poonam Sharma, Authorizaed signatory of the opposite party, no other medical evidence has been adduced by the opposite party to rebut the specific opinion of the medical experts that it was fit case for indoor treatment in the hospital. The affidavit Ex. RA is also verbatim reproduction of the averments of written reply. The opposite party has also not relied upon in medical literature or authority to support its claim. In the given facts and circumstances, it cannot be said that the repudiation of the claim is justified and as such, it would be just and appropriate if the opposite party is directed to pay the medical expenses of  Rs.17,731/- spent on treatment of complainant No.2 Kiran Jain along with interest @8% per annum from the date of admission i.e. 25.06.2017 till date of actual payment along with composite costs of Rs.10,000/-.

10.              As a result of above discussion, the complaint is partly allowed with an order that the opposite party shall pay the claim of medical expenses of Rs.17,731/- spent on treatment of complainant No.2 Kiran Jain along with interest @8% per annum from the date of admission i.e. 25.06.2017 till date of actual payment . The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)             (Sanjeev Batra)

Member                         Member                              President        

 

Announced in Open Commission.

Dated:20.11.2023.

Gobind Ram.