BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 192 of 2012
Date of Institution : 14.9.2012
Date of Decision : 04.10.2016.
Rajneesh Watts son of Shri Roshan Lal Watts, resident of Roshan Medical Agency, Sirsa, District Sirsa (Haryana).
….Complainant.
Versus
1. The Chief Regional Manager, National Insurance Co. Ltd., Regional Office-2, SCO 337-340, Sector 35-B, Chandigarh.
2. The Senior Divisional Manager, National Insurance Co. Ltd., Divisional Office, Sangwan Chowk, Sirsa.
3. Vipul Medcorp TPA Private Limited, 515, Udyog Vihar, Phase-5, Gurgaon, through its authorized signatory.
..…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. Jasbir Singh, Advocate for the complainant.
Sh. Ravinder Singh, Advocate for opposite parties no.1 & 2.
Opposite party no.3 already exparte.
ORDER
Case of complainant, in brief, is that he purchased a mediclaim insurance policy named as Misc. Non Traditional Business (Hospitalization Benefit Policy) bearing No.420700/48/11/8500000187 from opposite party no.2 on 20.7.2009 for the period from 20.7.2011 to 10.7.2012. The complainant, his wife Smt. Pooja and daughter Arshita were covered for sum assured of Rs.1,00,000/- each under the said policy. On 25.2.2012 i.e. during the continuation of the policy, wife of complainant Pooja fell ill and she was taken to Medanta The Medicity, Gurgaon for treatment and she was diagnosed Dvt. And Pulmonary Embolism. She remained admitted there from 25.2.2012 to 2.3.2012. A sum of Rs.1,64,216.78/- was incurred by the complainant on her treatment. Since, the policy was cashless, so due intimation of the illness and treatment was given to the complainant. Then the complainant lodged his claim with the ops and supplied all the required documents, but op no.3 rejected the claim of the complainant vide letter dated 2.3.2012 on the ground that as the disease is a complication of pregnancy and pregnancy and its related complications is not payable. The complainant immediately approached the concerned doctor of Medanta hospital and inquired about the nature of said disease, whereupon doctor gave clarification to the effect that “DVT & Pulmonary Embolism has no direct relationship with pregnancy as DVT accrued two months after delivery”. The complainant sent the said opinion of the doctor to op no.3 through fax, but the ops did not take any action on the same. The complainant had to make payment of expenses of hospital. The ops have not yet decided the claim of the complainant and have not made payment of the medical expenses to the complainant. The complainant got served a legal notice upon ops on 28.6.2012 and ops gave total false and evasive reply. Hence, the present complaint for a direction to the ops to make payment of Rs.1,64,216.78/- alongwith interest @12% per annum w.e.f 2.3.2012 till realization, Rs.50,000/- as compensation for harassment and Rs.5500/- as litigation expenses.
2. Upon notice, opposite parties appeared and filed written statement asserting therein that after lodging the claim by the complainant, the documents available to the company were got scrutinized from the Vipul Medicorp TPA Pvt. Ltd. and it was found that the patient was admitted with the complaint in right leg and swelling over the left leg and diagnosed as a case of RA/RV claut (multiple intracardic thrombos). After due verification, it was found that the wife of the complainant was having complication of pregnancy and pregnancy and its related complications are not covered and payable under clause 4.12 of Medi Claim Policy. So, the complaint is liable to be dismissed.
3. The complainant has tendered in evidence his affidavit Ex.C1 and documents Ex.C2 to Ex.C11. On the other hand, ops have tendered affidavit Ex.R1 to Ex.R9.
4. We have heard learned counsel for the parties and have gone through the case file carefully.
5. There is no dispute that complainant was having medi claim policy w.e.f. 20.7.2011 to 19.7.2012 vide which the complainant, his wife Pooja and daughter Arshita were insured with the opposite parties which fact is evident from insurance cover note Ex.C9. The complainant has alleged to have incurred an amount of Rs.1,64,216.78/- for the treatment of his wife at Medanta Hospital where she was admitted on 25.2.2012 and was discharged on 2.3.2012. The claim of the complainant submitted the complainant for the treatment of his wife Pooja has not been settled by the opposite parties on the ground that Pregnancy and its related complication is not payable under clause No.4.12 of the mediclaim policy. The patient Pooja was admitted in the Medanta Hospital with the complaint of pain in right leg and swelling over the left leg and was diagnosed as “DVT and Pulmonary Embolism” and according to the ops said disease is related to pregnancy and therefore, claim is not payable. However, the doctor of Medanta Hospital vide document Ex.D11 (Ex.C11) has clarified that DVT & Pulmonary Embolism has no direct relationship with pregnancy as DVT occurred two months after delivery. So, in our view, the opposite parties have wrongly and illegally not settled the claim of the complainant.
6. Keeping in view the abovesaid discussion, we reached at the conclusion that the complainant is entitled for the hospital expenses incurred by him for the treatment of his wife.
7. Resultantly, this complaint is hereby allowed, with a direction to insurance company i.e. to the opposite parties, to pay hospitalization expenses/ settle the claim of the complainant within a period of two months from today. 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: 4.10.2016. District Consumer Disputes
Redressal Forum, Sirsa.
Member.
