BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.

                                                          Consumer Complaint no. 29 of 2014                                                                

                                                          Date of Institution         :    26.2.2014

                                                          Date of Decision   :  17.10.2016.

Gopal Krishan Sarraf (aged about 65 years) son of Sh. Balbhadra Sarraf, C/op Yuvak News Agency, 40 Bishnoi Market, Sirsa.

            ….Complainant.                     

                   Versus

1. Regional Manager, National Insurance Company Ltd., Middleton street, Post Box No.9229, Kolkata- 700071.

2. Divisional Manager, National Insurance Company, Sangwan Chowk, Circular Road, Sirsa.

3. Sanjay Garg (Insurance Agent) s/o Sh. Om Parkash Garg, Gali No.1, Bhim Colony, Sirsa.

4. General Manager, Claim Department, Vipul Medcorp TPA Pvt. 515, Udyog Vihar, Phase-V, Gurgaon- 122016, Haryana.

                                                                             ..…Opposite parties.

            Complaint under Section 12 of the Consumer Protection Act,1986.

Before:        SHRI S.B.LOHIA…………………PRESIDENT

                     SHRI RANBIR SINGH PANGHAL ……….……MEMBER.

Present:       Sh. Ganesh Sethi,  Advocate for the complainant.

    Sh. Ravinder Goyal, Advocate for opposite parties no.1, 2 & 4.

     Sh. Ravinder Monga, Advocate for opposite party no.3.

ORDER

                   Case of complainant, in brief, is that he purchased medi claim policy of the opposite parties for him and his wife through op no.3. He is purchasing the medi claim policy from the ops no.1 to 3 for the last 6-7 years. The last insurance policy no.420700/81/12/0000005601 covering the risk of one year i.e. from 25.1.2013 to 24.1.2014 was purchased by him and the premium of Rs.7052/- was duly paid to the concerned agent. In the month of April, 2013 the complainant felt pain in abdomen at an extreme end. The attendant of the complainant immediately contacted with the doctor Randhir Sood who advised to go to Medanta Hospital. On 23.4.2013, the complainant alongwith other family members was going to Medanta Hospital, but due to critical condition he was admitted in Jindal Institute of Medical Science, Model Town, Hisar. Dr. Kapil Jain, DM Gastro treated the complainant and discharged him on 23.4.2013. He was operated upon and doctor charged the bill of treatment, operation, medicines etc. to the tune of Rs.25,000/26,000/-. There were so many patients of similar disease and a trainee doctor was recording the history of each patient who written wrong history of the complainant which might have related to some other patients. The complainant even never took the taste of alcohol. The matter was reported to the ops alongwith all documents but op no.4 repudiated the claim with non-speaking terms without taking the proper confirmation of investigation and same is illegal. The complainant after few days felt that the operation and treatment given by the doctor of Jindal Institute of Medical Science was not satisfactory and seems to be conducted by inexperienced doctors or the trainee staff and pain in abdomen again started. The complainant immediately rushed to the local Dr. G.K. Aggarwal, who after due investigation advised to approach in Medanta Hospital. On 27.11.2013 complainant went to Medanta Hospital and contacted with Dr. Randhir Sood. The concerned doctor after due investigation conducted the ERCP which revealed chronic calcific pancreatitis and stent removal/ stone extraction was done on 27.11.2013. The Medanta Hospital had charged Rs.34,000/- approximately from the complainant. Accordingly, the matter was reported to the ops with the request for releasing of the amount of present operation as well as earlier operation and submitted the required documents alongwith bill and treatment details. However, ops no.1 to 3 postponed the matter with the assurances that the claims of complainant are in process. The op no.3 told him that the matter has been sent to op no.4 for the purpose of investigation with whom the complainant has no concern as the ops no.1 to 3 are receiving the premium from the complainant. However, the complainant was shocked and astonished when the op no.4 given the intimation about repudiation of claim file no.14RB04NAD0044 dated 26.6.2013, which is illegal and liable to be quashed. The complainant also made a representation wherein it was explained that the matter has not been properly investigated, but to no effect. Hence, this complaint.

2.                On notice, opposite parties No.1,2 and 4 filed their joint written statement pleading therein that after careful examination of the medical prescription, diagnostic slip etc., it was discovered that the complainant was admitted in the hospital with alcohol related pancreatitis, undergone ERCP & stent exchange. This history and diagnose of the disease of the complainant attracted clause 4.8 of the terms and conditions of the insurance policy and so, the claim lodged by the complainant was not maintainable. Thus, the same has been rightly repudiated by the op no.4 vide its letter dated 26.6.2013.

3.                Op no.3 in his separate written statement has asserted that upon receiving the bills and other document, the answering op forwarded the same to the concerned officials for necessary action.

4.                The complainant has tendered in evidence his affidavit Ex.CW1 and documents Ex.C1 to Ex.C29. On the other hand, op no.3 tendered in evidence affidavit Ex.RW1/A. Ops No.1, 2 and 4 tendered affidavit of Inder Singh, Divisional Manager as Ex.R1 and documents Ex.R2 to Ex.R6A.

5.                We have heard learned counsel for the parties and have gone through the case file carefully.

6.                It has been established on record that complainant is having medi claim insurance policy with the opposite parties from the year 2004. The complainant underwent operation of abdomen in Jindal Institute of Medical Scienence, Model Town, Hisar on 23.4.2013 and then submitted the claim to the opposite parties but the claim amount was not disbursed to him. Then again complainant felt pain in the abdomen and on 27.11.2013 he went to Medanta Hospital at gurgaon where ERCP was done on 27.11.2013 which revealed chronic calcific pancreatitis and stent removal/ stone extraction was done on the said date. Then complainant submitted the hospital bills of that operation to the ops and requested to pay both the claim amounts, but the op no.4 vide its letter dated 26.6.2013 has repudiated the claim of the complainant on the ground that “patient admitted with alcohol related pancreatitis, undergone ERCP & stent exchange. Ailment is related to alcohol, so claim is not admissible under clause 4.8.”  The clause 4.8 of the terms and conditions of the policy (Ex.R6A) is reproduced hereunder for ready reference :-

“Convalescence general debility ‘Run Down’ condition or rest cure, congenital external disease or defects or anomalies, sterility, infertility/ sub fertility or assisted conception procedures, venereal disease, intentional self-injury, suicide, all psychiatric & psychosomatic disorders/ diseases, accidents due to misuse or abuse of drugs/ alcohol or use of intoxicating substances.

7.                The opposite parties have made the basis of repudiation the discharge card of Jindal Hospital, Hisar dated 23.4.2013 wherein it is recorded that patient admitted with alcohol related pancreatitis and except this there is nothing on record to prove that complainant was alcoholic. The opposite parties have not proved by cogent and reliable evidence that complainant himself voluntarily disclosed about taking of alcohol to the doctor or doctor himself recorded the said fact. It is pertinent to mention here that prior to 23.4.2013 also, the complainant was operated upon at Medanta Hospital, Gurgaon on 6.9.2011 for chronic pancreatitis with pancreatic divisum and there is no history of alcohol in the said treatment record of the complainant. The claim submitted by the complainant for the said operation was duly paid by the ops. Then on 27.11.2013, the complainant was again admitted in Medanta Hospital, Gurgaon where ERCP was done which revealed chronic calcific pancreatitis, stent removal/ stone extraction was done on 27.11.2013 and in the said treatment record also, there is no history of taking alcohol by the complainant. The complainant claims that he has not taken even the taste of alcohol. The opposite parties have failed to prove on record that how the doctor of Jindal Hospital, Hisar recorded the factum of alcohol in the discharge card. There are various reasons for pancreatitis such as gallstones, metabolic disorders and hereditary pancreatitis etc. Moreover, in our view the clause 4.8 is not applicable in the present case because as per this clause, the claim is not payable if accidents due to misuse or abuse of drugs/ alcohol or use of intoxicating substances occurs but in the present case the complainant suffered from pancreatitis and not met with an accident due to use of alcohol. So, the repudiation of the claim of the complainant is not justified and is illegal.

8.                The complainant has claimed to have spent an amount of Rs.25/26,000/- on his treatment at Jindal Hospital, Hisar but same seems to be on higher side as from the bills placed on record and from the claim submitted by him to the opposite parties, it is evident that he spent an amount of Rs.19,472/- on his treatment in the said hospital. Then it is further the case of the complainant that he spent another amount of Rs.34,000/- on his treatment in Medanta Hospital, Gurgaon and have placed hospital bill Ex.C29 in this regard from which it is evident that he spent total amount of Rs.33,439/- on his treatment in the said hospital. Therefore, the complainant is entitled to the amounts of Rs.19472+33,439/- spent on his treatment, which comes to Rs,52,911/- ( to make it in round figure Rs.53,000/-) .

9.                Thus, as a sequel to our above discussion, we accept the present complaint and direct the opposite parties to reimburse the amount of Rs.53,000/- to the complainant alongwith interest @9% per annum from the date of filing of present complaint i.e. 26.2.2014 till actual payment. We also direct the opposite parties to further pay a sum of Rs.10,000/- as compensation for harassment including litigation expenses. This order should be complied by the opposite parties severally and jointly within a period of one month from the date of receipt of copy of this order, failing which the complainant will be entitled to initiate proceedings under Sections 25/27 of the Act against ops.  A copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance

Announced in open Forum.                                     President,

Dated: 17.10.2016.                                     District Consumer Disputes

                                                                   Redressal Forum, Sirsa.

                                      Member.