DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 82 of 25.2.2016
Decided on: 29.6.2017
Dr.Sanjay Jindal, aged 48 years, son of Er.Rajbir Jindal, resident of H.No.1415, Street No.14, Gurbax Colony, Patiala.
…………...Complainant
Versus
- The New India Assurance Company Limited, Divisional Office: IInd(3615000, Ist Floor, Leela Bhawan, Opp. Income tax Office, Patiala through its Divisional Officer.
- The New India Assurance Company Limited,87, M.G.Road, fort, Mumbai through its authorized signatory.
- Raksha TPA Pvt. Ltd., SCO 359-360, Ist Floor, Sector 44-D, Chandigarh through its Authorized signatory.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.Anand Puri, Advocate, counsel for complainant.
Sh.Sandeep Singh Ahuja, Advocate,
counsel for opposite parties No.1&2.
Opposite party No.3 ex-parte.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Dr.Sanjay Jindal, complainant has filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.) praying for the following reliefs:-
- To pay Rs.48,790/- deposited by him with Medanta Medicity Hospital, Gurgaon for taking treatment
- To pay Rs.1,00,000/- as compensation for causing mental agony and physical harassment
- To pay Rs.50,000/- as litigation expenses and
- To grant any other relief, which this Forum may deem fit.
2. In brief, the case of the complainant is that he had been taking Medi Claim Policy since the year 2009 continuously from OPs no.1&2 and had been paying the premium regularly with them. It is averred by the complainant that he had purchased a Floater Medi-claim policy bearing No.36150034142800000019 in his name and in the name of his wife Smt.Uma Jindal w.e.f.20.4.2014 to 19.4.2015 for a sum of Rs.3,00,000/-. It is further averred that he suffered pain in Right Lower Limb. For this problem he got treatment from Dr.Parveen Garg of Patiala M.S.Ortho, Joint Replacement & Spine Surgeon. When there was no improvement, the said doctor advised the complainant to take neurological opinion and referred him to Medanta, The Medicity, Gurgaon(Haryana). The complainant admitted in the said hospital on 29.9.2014 with the complaint of severe right lower limb pain from last 8-12 months and treated with injectable analgesics and IV fluids .MRI and other various tests i.e. NCV & EMG, Muscle Biopsy were also done. He was treated conservatively with supportive measures, in the said hospital. His medication has been optimized and was discharged in stable condition on 1.10.2014 with advised to follow up in OPD with reports. It is averred that there was tie up of OPs no.1&2 with Op no.3, he submitted all his documents for medical claim with OPs but the OPs denied the cashless treatment of Medi claim, and he was forced to deposit Rs.48,790/- as charges for the treatment, with the Medanta Hospital, Gurgaon.It is stated that at the time of taking the policy in the year 2009-10, from OPs no.1&2, it was made clear to them that he is suffering from left leg polio paralysis and it was mentioned in all the documents already submitted with OPs no.1&2, but these Ops wrongly repudiated his claim on the ground of ‘ post polio progressive syndrome. It is averred that the present complaint is regarding the right leg of the complaint and it has no concern with the problem of his left leg polio. He requested the OPs on number of times to re-imburse the amount of Rs.48,790/-, got deposited by him with Medanta Hospital, Gurgaon but of no avail. He also got sent a legal notice dated 20.11.2015 upon the OPs, for the payment of the amount, but no heed was paid to his request. A false and frivolous reply dated 28.12.2015 to the legal notice was sent by the OPs. Thereafter, the OPs no.1&2 again got insured the complainant for the year 2015-16 by making false assurance. This act of the OPs amounted to deficiency in service on their part for which he was suffering from mental agony and physical harassment. Hence this complaint.
3. On being put to notice, OPs no.1&2 appeared through counsel and filed the written version whereas none has come present to contest the case on behalf of OP no.3, despite service, and was accordingly proceeded against ex-parte.
In the written version filed by OPs No.1&2 preliminary objections have been taken that the complaint is not maintainable and that the complainant has not come with clean hands and has concealed the true and material facts from this Forum. On merits, it is admitted that the complainant had purchased a New India Floater Medi – claim insurance policy bearing No.361500 34142800000019 in his name and his wife’s name. It is stated that on receipt of claim of the complainant, the same was got examined by Op no.3 i.e. M/s Raksha TPA, which after examination of the treatment record, discharge summary and other medical documents, found that the complainant was diagnosed with Post Polio Progressive Paralysis, which was managed with oral tablets during hospitalization only for evaluation which was non payable as per terms and conditions of the policy. It is denied that at the time of taking policy in the year 2009-10, it was made clear to them that the complainant was suffering from left leg by polio paralysis. The sending of legal notice by the complainant and reply to the same by the OPs was admitted. It is stated that policy for the year 2015-16 has no concern with the present case. There is no deficiency of service on their part and the claim of the complainant was rightly repudiated by the OPs. The OPs denied all other allegations going against them and prayed for dismissal of the complaint.
4. On being called to do so, the ld. counsel for the complainant tendered in evidence affidavit of the complainant, Ex.CA alongwith copies of documents Exs.C1 to C21 and closed the evidence.
The ld. counsel for OPs no.1&2 tendered in evidence copies of documents Exs.OP1 to OP4 and closed the evidence.
5. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
6. It is submitted by the ld. counsel for the complainant that at the time of taking the policy in the year 2009-10, the complainant disclosed to Ops no.1&2 that he is suffering from left leg polio paralysis and has also mentioned the said facts in all the documents submitted with the Ops No.1&2. The complainant was having pain in his right lower limb and got treatment from Medanta Hospital, Gurgaon. He was admitted in the said hospital on 29.9.2014 and was discharged on 1.10.2014. He submitted all his relevant documents with the Ops but they denied to provide the cashless facility vide letter dated 10.10.2014 Ex.C9, on the flimsy grounds that Post Polio Progressive Paralysis Hospitalization only for evaluation cashless facility cannot be accorded and he was forced to deposit Rs.48790/- to the said hospital. Thereafter, he lodged the claim with the OP No.1 for reimbursement of Rs.48790/- but till date the said amount has not been paid to him. Hence by not paying the genuine claim to him, the Ops have committed deficiency in service.
7. The ld. counsel for Ops no.1&2 has vehemently argued that on receipt of the claim from the complainant, the same was got examined by OP no.3 and after examination of the treatment record, discharge summary and other medical documents, it was found that the complainant was diagnosed with Post Polio Progressive Paralysis managed only with oral tables during hospitalization and hospitalization was done only for evaluation, which is non payable as per policy terms and conditions. The claim of the complainant was rightly repudiated and there is no deficiency of service on their part.
8. From the copy of mediclaim insurance policy, Ex.C1, it is evident that the complainant was duly insured with the New India Assurance Co. for the period from 20.4.2014 to 19.4.2015. From the bill dated 01.10.2014, Ex.C5, it is apparent that complainant was admitted in the Medanta Hospital on 29.9.2014 and was discharged on 1.10.2014 and had paid an amount of Rs.42790/- to the said hospital. He had also paid a sum of Rs.6000/-to Medanta Hospital vide bill dated 9.10.2014, Ex.C4. In the discharge summary, Ex.C6, under the column Medical History and Presenting Complaints, it is mentioned that “Mr. Sanjay Jindal, 47 years male patient is known case of left lower limb poliomyelitis. He presented with complaints of severe right lower limb pain since last 8-12 months and progressive weakness of other extremities since last 15-18 years. A certificate Ex.C11 to the effect that complainant was admitted in the said hospital on 29/9/2014 and was discharged on 1/10/2014 has been issued by the Doctor concerned of the Medanta Hospital. Thus, from the said documents, referred above, it is evident that the complainant was admitted in the said hospital for taking treatment for his right lower limb as in-door patient. The plea of the OPs was that complainant was suffering from POST POLIO PROGRESIVE PARALYSIS, managed only with ORAL tablets during hospitalization and the hospitalization is done only for evaluation, which is non-payable as per policy terms and conditions. However, to corroborate this fact that the Ops no.1&2 have rightly repudiate the claim of the complainant as per terms and conditions of the policy, they have not placed on record the copy of the terms and conditions of the policy in question. In the absence, thereof, it cannot be ascertained that as to whether the Ops have rightly repudiated the claim of the complainant or not. Be that as it may, we are of the view that the complainant is entitled for reimbursement of the amount incurred by him on his treatment. From the bill cum receipt dt. 1/10/2014 and 09/10/2014, Ex.C-5 & Ex.C-4 respectively, it is evident that complainant paid in total a sum of Rs.48790/- (Rs.42790/- + Rs.6000/-) to the Medanta Hospital, Gurgaon, therefore, Ops are liable to pay Rs.48790/- to the complainant. Not only this, the Ops are also liable to pay compensation for the mental agony and physical harassment caused to the complainant along with litigation expenses.
9. In view of the aforesaid discussion, we allow the complaint and direct the Ops in the following manner:
- To pay Rs.48790/-to the complainant alongwith interest@7% per annum from the date of filing of the complaint i.e. 25/02/2016 till its realization.
- To pay Rs.10,000/- as compensation for causing mental agony and physical harassment to the complainant
- To pay Rs.5000/-as cost of litigation expenses
The Ops are further directed to comply the order within a period of 40 days from the date of the receipt of the certified copy of this order. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:29.6. 2017
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
