DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 272 of 14.7.2017

                                      Decided on: 3.9.2021

1. Om Parkash Mangla S/o Khushbakhat Rai
2. Reeta Rani w/o Om Parkash Mangla

Both R/o C/o Rama Mills & Ice Factory, Police Post Road, Tehsil Samana, District Patiala.

                                                                   …………...Complainants

                                      Versus

New India Assurance Company Limited, Located at Rama Mill Compound, Near Ambedkar Chowk, Tehsil Samana District Patiala through its Branch Manager.

                                                                   …………Opposite Party

Complaint under the Consumer Protection Act

QUORUM

                                      Sh. Jasjit Singh Bhinder, President

                                      Dr.Harman Shergill Sullar, Member

ARGUED BY              

                                      Sh.Gaurav Singla, counsel for complainant.

                                      Sh.D.P.S.Anand, counsel for OP.                                 

 ORDER

                                      JASJIT SINGH BHINDER,PRESIDENT

1. This is the complaint filed by Om Parkash Mangla (hereinafter referred to as the complainant) against New India Insurance Company (hereinafter referred to as the OP/s) under the Consumer Protection Act ( for short the Act).
2. The brief facts of the case are that complainant Om Parkash Mangla has been taking family Medi-Claim policy from the OP before the year 2005 and the same has been  continuing year to year basis and at the time of taking the aforesaid family Medi claim policy the concerned official of the OP had assured the complainants that they will be provided all types of medical, hospitalization, pharmacists etc. benefits. It is averred that the complainant  has been regularly paying the premium of mediclaim policy and has renewed the policy in question vide policy No.36140134162500000014 for the period from 11.12.2016 to 10.12.2017.The complainant paid the premium of Rs.9169/-for the said policy.It is further averred that  Smt.Reeta Rani wife of the complainant is also covered in the policy.
3. It is further averred that in the year 2008, complainant No.2 Smt.Reeta Rani met with a Retina disease namely Branch Retinal Vein Occlusion (BRVO) in her right eye and she took treatment for the same from Dr.G.S.Randhawa, Randhawa Eye Hospital, Patiala and lodged the claim with the OP which was passed and the OP paid Rs.10,000/-to the complainants. It is further averred that complainant No.2 Smt.Reeta Rani again met with aforesaid disease in the right eye, in the year 2012-2013 and the complainant took treatment from the PGI, Chandigarh and spent Rs.3000/-.The complainant approached the concerned official of the OP for the payment of the same, who advised to not to lodge the claim as the expenses incurred are very less. It is further averred that again complainant No.2 Smt.Reeta Rani met with the same disease in her right eye in the month of January,2017 and she again took the treatment from the PGI, Chandigarh and spent Rs.21000/- from their pocket and lodged the claim with the OP having submitted the claim form under the Medi Claim Insurance alongwith details of the bills. But the OP did not pay any heed despite repeated visits to the office of the OP by the complainants. The complainant also got served legal notice dated 24.4.2017 upon the OP but to no effect. There is thus deficiency in service on the part of the OP which caused mental pain, agony and harassment to the complainants. Hence this complaint with the prayer to accept the same by giving directions to the OP to pay the amount of Rs.21,000/- spent on treatment; to pay Rs.50,000/- as compensation and Rs.2500/- as litigation expenses and also to pay any other relief which this Forum(now Commission) may deem fit.
4. Notice of the complaint was duly given to the OP who appeared through counsel and contested the complaint by filing written reply having raised preliminary objections that the present complaint is not maintainable as the claim of the complainant has already been repudiated as the complainant was suffering from Bravo Disease in her right eye which was treated in PGI Chandigarh and she was given Luctins Intravitreal Injection which is permanently excluded under the policy in question and thus the claim is not payable under clause 4.4.23 of the policy and was rejected vide letter dated 27.3.2017.
5. On merits, it is submitted that OP No.1 has issued Medi Claim Policy for the period from 11.2.2016 to 10.12.2017 in favour  of the complainants, for a sum of Rs.1 Lakh each. It is submitted that the policy does not cover treatment of Age Related Macular Degeneration(ARMD), treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP),Hyperbaric Oxygen Therapy .It is further submitted that on receipt of treatment , medical record and bills of treatment of Smt.Reeta Rani of PGI Chandigarh from 23.1.2017 to 23.1.2017, the same were immediately sent to M/s Raksha TPA, third party administrator for consideration, who vide their report have recommended to repudiate the claim on the ground that the Bravo in right eye was treated in PGI Chandigarh and given Lucentis Intravitreal injection, which are permanently excluded under the policy and hence the claim was not payable as per clause 4.4.23 of the policy as no claim will be payable under this policy for treatment of Age Related Macular Degeneration(ARMD), treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP),Hyperbaric Oxygen Therapy and the complainant was informed vide letter dated 27.3.2017.There is thus no deficiency in service on the part of the OP and after denying all other averments, the OP has prayed for the dismissal of the complaint.
6. In support of the complaint, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C17 and closed the evidence.
7. On the other hand, the ld. counsel for the OP has tendered in evidence Ex.OPA affidavit of Rajinder Singh, Sr.Divisional Manager of the OP, Ex.OPB affidavit of Dr.Rakesh Kalra alongwith documents Exs.OP1 to OP2 and closed the evidence.
8. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
9. The ld. counsel for the complainant has argued that the complainant has been taking medi claim policy from the year 2005 on yearly basis. The ld. counsel further argued that the policy in question was renewed for the period from 11.12.2016 to 10.12.2017 and premium of Rs.9169/- was paid .Smt.Reeta Rani wife of the complainant has also covered under this policy. The ld. counsel further argued that Smt.Reeta Rani suffered from Retinal Vein Occlusion (BRVO) in her right eye and she took treatment from Dr.G.S.Randhawa, Randhawa Eye Hospital, Patiala and lodged the claim with the OP and the OP paid Rs.10,000/-to the complainants. The ld. counsel further argued that Smt.Reeta Rani again suffered with aforesaid disease in the right eye in the year 2012-2013 and took treatment from the PGI, Chandigarh and spent Rs.3000/-.The ld. counsel further argued that Smt.Reeta Rani again suffered with the same disease in her right eye in the month of January,2017 and took treatment from the PGI, Chandigarh and spent Rs.21000/- on the same. Claim was submitted which was not accepted. So the complaint be allowed.
10. On the other hand the ld. counsel for the OP has argued that this ailment is not covered under the policy.The ld. counsel further argued that when the ailment is not covered so no claim can be given. So complaint be dismissed.
11. To prove this case, complainant Om Parkash Mangla has tendered in evidence his affidavit,Ex.CA and he has deposed as per the complaint,Ex.C1 is the insurance policy valid from 11.12.2016 to 10.12.2017.Reeta Rani is also covered under this policy and her name is mentioned in the policy.Ex.C2 to C5 are the bills of PGI, Ex.C6 is the bill of Kumar & Company,Ex.C7  is also copy of insurance cover,Ex.C8  and Ex.C9 are  prescription slip of PGI, Chandigarh. As per that Avastin injection was given.Ex.C12 is discharge and follow up card,Ex.C14 is prescription of PGI,Ex.C16 is legal notice and Ex.C17 is postal receipt.
12. On behalf of the OP Sh.Rajinder Singh Mahatam, Sr.Divisional Manager has tendered his affidavit, Ex.OPA and he has deposed as per the written statement, Ex.OPB is the affidavit of Dr.Rakesh Kalra and he has deposed that he is qualified professional doctor and he had minutely examined the medical treatment record of PGI Chandigarh in respect of Reeta Rani and found that claim is not payable and also found that BRVO of the right eye is excluded from the policy of clause No.4.4.23.
13. As per the pleadings, the complainant has been taking regularly insurance policy from the year 2005 from the OP and the complainant No.2  developed disease BRVO and she took treatment from PGI Chandigarh. It is very strange that insurance companies did not give complete details alongwith insurance cover and they gave only cover note and they never inform their clients that which diseases are not covered.
14. When the complainants are taking mediclaim policy from the year 2005 from the OP then they have no right to reject the claim as the treatment was taken by the complainant from the biggest institute of our country i.e. PGI Chandigarh. In the affidavit of Dr.Rakesh Kalra,  he has not mentioned his qualification and has given the affidavit just to help the insurance company from giving the claim and this type of doctors should be removed from the panel of the insurance company. In the affidavit, Ex.OPB he has not mentioned whether he is MBBS, MD , MS or  has done master of surgery in eye.
15. The OP has tendered all the guidelines alongwith insurance policy which is Ex.OP1.At point 4.4.23 it is mentioned as under:

“Treatment of Age Related Macular Degeneration (ARMD), treatment for Sleep Apnoea Syndrome, treatments such as Rotational Field Quantum Magnetic Resonance(RFZMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy and CPAD (Continuous Peritoneal Ambulatory Dialysis)” are excluded.

16. If we goes through the policy of the insurance company and through the ailments which are excluded, it will show that entire ailments have been excluded. So this type of insurance companies are playing fraud with their clients. This insurance company is Govt. aided company and it is not expected from this company to play fraud with their clients and before giving the insurance policy the client should be made aware that these types of diseases are not covered. If the client comes to know that these types of diseases are not covered then no one in our country will  purchase the policy specially  the policy of New India Assurance Co..
17. There must be some evidence or some undertaking of the complainant that he or she was told about all the diseases which are excluded from this policy by the OP. Even by going through the clause  4.4.23 it is clear that BRVO is not excluded. It is just mentioned that Treatment of Age Related Macular Degeneration (ARMD), treatment for Sleep Apnoea Syndrome, treatments such as Rotational Field Quantum Magnetic Resonance(RFZMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy and CPAD (Continuous Peritoneal Ambulatory Dialysis is not covered. On the face of it, the aged persons will be left to the Mercy of God as the insurance company has stated that age related disease is not to be paid by the insurance company. Heaviest penalty should be imposed by the Insurance Regulatory on this type of Insurance companies.
18. As per the insurance policy the following disease are excluded:

1. All internal and external benign tumors, cysts, polyps of any kind, including benign breast lumps
2. Benign ear, nose, throat disorders
3. Benign prostate hypertrophy
4. Cataract and age related eye ailments
5. Gastric/Duodenal Ulcer
6. Gout and Rheumatism
7. Hernia of all types
8. Hydrocele
9. Infectiv Arthritis
10. Piles, Fissures and Fistula in anus
11. Pilonidal sins, sinusitis and related disorders
12. Prolapse inter vertebral disc and spinal disease unless arising from accident
13. Skin disorders
14. Stone in gall bladder and bile duct, exclusing malignancy
15. Stones in urinary system
16. Treatment for menorrhagia / Fibromyoma, Myoma and Prolapsed uterus
17. Varicose Veins and Varicose Ulcer
18. Renal Failure”

19.  If we goes through all these diseases then 99% diseases are not covered under this insurance policy. So it is clear that this claim was wrongly rejected on 9.3.2017 and the OP is liable to pay the claim amount alongwith interest.
20. So due to our above discussion, the complaint has been allowed and the OP is directed to pay the claim amount of Rs.21000/-to the complainant alongwith interest @6% per annum from the date of rejection till realization and also to pay Rs.10,000/-as compensation and Rs.10,000/-as litigation expenses.     

Compliance of the order be made by the OP within a period of 45 days from the date of the receipt of the certified copy of this order.

ANNOUNCED

DATED:3.9.2021         

                                       Dr.Harman Shergill Sullar     Jasjit Singh Bhinder

                                              Member                                      President