Punjab

Fatehgarh Sahib

CC/8/2020

Neha Garg - Complainant(s)

Versus

New India Assurance company limited - Opp.Party(s)

Shri Saurab Sharma

16 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

                             COMMISSION

                      FATEHGARH SAHIB

 

Complaint No.	:	CC/08/2020
Date of Institution	:	03/02/2020
Date of Decision	:	16.05.2023

 

Neha Garg D/o Rajnish  Garg, House no.64 , Sec-20D, Subash Nagar, Mandi Gobindgarh , Tehsil Amloh , District Fatehgarh Sahib..

                                                                                                                     …………....Complainant

                                                Versus

1. The New India Assurance Co. Ltd,Branch office, G.T..Road, near Bus Stand Mandi Gobindgarh, through Branch Manager.
2. The New India Assurance Co. Ltd,  Divisional Office, G.T. Road, Khanna-141401 through Divisional Manager.
3. The New India Assurance Co. Ltd, registered 7 head office:87 , Mahatma Gandhi Road, Mumbai-400001.

                                                                             ..………....... Opposite Parties

 

Complaint under Section 11 to 14of Consumer Protection Act 1986(Old)

Quorum

Sh. S.K. Aggarwal, President

Ms. Shivani Bhargava, Member

Sh.Manjit Singh Bhinder, Member.

 

Present: Sh. Saurabh Sharma , counsel for complainant.

                Pt. Narinder Kumar , counsel for Ops.

 The  complaint has been filed against the OPs (opposite parties) , Under Section 11 to 14 of Consumer Protection Act-1986 (old) alleging deficiency in service with the prayer for giving direction to the OPs  to reimburse  the Medical Claim of Rs.3,00,000/- , to pay  Rs.2,00,000/-  as compensation for harassment to complainant.

1. Brief facts of the complaint are that the grandfather of the complainant had been continuously taking the mediclaim Policy.   The grandfather of the complainant took the Policy vide no.36120034162500000100 from 1/3/2017 to 28/2/2018.  On 16.10.2017 ,  complainant was having mild fever and  felt some trouble in speaking and was having pain in her throat while swallowing, so family member of the complainant admitted her to SPS Hospital, Ludhiana for her treatment and discharged the complainant  at about 7:20 PM on same day.  The complainant applied for Mediclaim  to the Ops but it was rejected by the Ops . The bill of Rs.15,717/- was paid by the complainant. On  23.10.2017 , the complainant again  felt severe onset back pain in her body and having  breathing problem  .  The complainant  applied for cashless Mediclaim for her treatment at DMCH, Ludhiana but the same was rejected by the Ops. The complainant had to pay the bill of Rs.23,519/- and Rs.1560/-  for Laboratory test.  The complainant was discharged on 27.10.2017. On  3.11.2017 , complainant went to Preet Scan centre , Khanna for her tests and paid Rs.3500/-. The complainant was again admitted in  Sir Ganga Ram  Hospital , New Delhi on 13.11.2017  and was discharged on 23.11.2017 and paid Rs.2,49,617/- as medical expenses . The complainant requested Ops to reimburse the amount as medical claim of the complainant. Complainant submitted all medical bills and other documents through  letter on  26.12.2017 but the Ops repudiated the claims  filed by the Ops.  Hence this complaint.
2. Notice of the complaint was given to the OPs through registered Post, OPs appeared through their Counsel and filed written version .
3.    The complaint has been contested by the OPs and filed written version by raising various  preliminary objections. The claim of the complainant was righty decided as per terms and conditions of the Policy.  The complainant has not suffered any loss and was not entitled for any compensation. The amount claimed by the complainant is completely baseless and irrational .  The insurance Ombusdman , Chandigarh rightly dismissed the application of the complainant. The Ops have prayed for dismissal of complaint with cost.
4. In support of  her complainant ,  complainant filed Ex.CW1/A  her affidavit along with copies of documents i.e  Ex.C1 , Ex.C2 and Ex.C7  Policy Schedule,  Ex.C8 to Ex.C59  medical record,  Ex.C60 letter dated  26.12.2017 , Ex.C61  certificate of Sir Ganga Ram Hospital, Ex.C62 Query letter for claim , Ex.C63 Insurance Policy, Ex.C65 letter by  Insurance Ombudsman and closed her evidence
5. In rebuttal, the Ops tendered Ex.OP1 affidavit of Sanjeev Kumar Kalia, Deputy Manager, Ex.OP2 decision of Insurance Ombudsman , Ex.OP3 repudiation  letter dated 15.2.2018.  ExOP4 new mediclaim scheduld and closed their evidence.
6. Heard, Entire record has been perused.
7. Admittedly , the complainant ‘ grandfather took cashless mediclaim health Policy  no.36120034162500000100 from 1/3/2017 to 28/2/2018  as per Ex.C6. The complainant took treatment from three different hospitals as per Ex.C8 to Ex.C59. The complainant applied for reimbursement of medical expenses of Rs.2,49,617/-  but OP rejected her claim  as per Ex.OP3 on the ground that  “C/O paraparesis as per documents of previous two claims it was found that patient is suffer from Psychiatric illness, Psychiatric  related  treatment not covered in Policy  .  All reports are normal , hence claim is non-payable as per Policy conditions and clause 4/4/6/1”.  From the perusal of the record, it transpires that   complainant was diagnosed  with Paraparesis  . Vide Ex.C45  Paraparesis is weakness affecting  both   the lower extremities. It can be described as muscle weakness in lower limbs or disorder in  voluntary movement.   More so , as per Ex.C61 certificate  of Dr. C.S.Aggarwal , Chairman Neurology  , Sir Ganga Ram Hospital,  New Delhi , there was no  previous history of  any  psychiatric illness. As per Ex.C21 discharge summary of DMC Hospital, Ludhiana.  Complainant was  diagnosed with Generalized body aches & Acute stress reaction . As per Ex.C52 discharge summary of SPS Hospital Ludhiana , complainant was  diagnosed with PAFI acute Pharyngitis.
8. The real test must be the  factum of treatment . Insurance companies can not   go beyond the hospital record while deciding the claim. The relevant  authorities are required to be more responsive & can not act in a mechanical manner to deprive the  insured  from  claim . Insurer’ decision to reject a claim  shall be based on some logic and valid grounds. The object of buying a mediclaim Policy is to seek indemnification in respect of sudden illness  that is not expected or imminent.  The OP  did not adduce any cogent evidence on record in order to  prove their plea.  In such a situation , the  repudiation made by the OP regarding  claim of the complainant  appears to have been made without  application of mind. The OPs have not furnished any list showing the payment after deduction as per rules of Policy. Therefore the amount submitted by the complainant is to be taken as correct  with respect to insured amount of Policy. The insured had submitted all the documents   sought by the insurance company but insurance Company failed to settle the claim . Therefore, OPs are held liable for deficiency in service.  
9. As a corollary of our above discussion  and keeping in view the facts & Circumstances  of the present case  , the present complaint is partly allowed. The OPs are jointly & severally directed as under:-

[a] To pay Rs.1,80,000/-/- to the complainant along with interest @ 9% P. A from the date of filing of compliant within 30 days, failing which interest @ 12% shall be payable.

[b] To pay Rs. 30000/- as compensation for harassment and litigation expenses.

Compliance of the order be made by the OPs within a period of 30 days of receipt of certified copy of this order . Failing which the complainant shall be entitled to recover the above said amount through legalprocess. The complaint could not be decided within the statutory period dueto pandemic of Covid-19 and paucity of staff. File be consigned to record Room.

Pronounced 16 May 2023.

                                                           

                                                                  (S.K. Aggarwal)

                                                                      President

                                                                        

                                                                             (Shivani Bhargava)

                                                                     Member

 

                                                                             ( Manjit Singh Bhinder )

                                                                                  Member