Haryana

Ambala

CC/241/2018

Sushant Varun - Complainant(s)

Versus

NIC - Opp.Party(s)

05 Dec 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                                      Complaint case No.:  241 of 2018.

                                                          Date of Institution           :   01.08.2018.

                                                          Date of decision     :   05.12.2019.

 

Sushant Varun Jain Son of Varun Jain, Resident of H.No.118 Vikas Vihar, Ambala City.

……. Complainant.

                                                Versus

 

1. National Insurance Co. Middleton Street, Prefulla Chandra Sen Sarani, Kolkota, West Bengal 700071.
2. Vipul Med Crop Insurance 515, Udyog Vihar, Phase5, Gurugram, Haryana.
3. Jain International Organisation, Panchsheel Plaza, A Wing Basement, Near Dharam Palace, Huges Road Grant Road (West) Mumbai 400007.
4. Narian Hospital & CT Scan Centre # 42 Manauli House, Ambala City.

 

                                                                   ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.         

                            

Present:       Shri Nikhil Handa, Advocate, counsel for complainant.

Mrs. Suraj Rashmi Sharma, Advocate, counsel for the OP No.1.

OPs No.2 & 3 proceeded against ex parte vide order dated       08.10.2018.

Shri Nikhilesh Bhagi, Advocate, counsel for the OP No.4.

 

Order:        Smt. Neena Sandhu, President

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 ‘OPs’) praying for issuance of following directions to them:-

1. To reimburse the medical expenses spent by the complainant on the treatment of his father along with interest.
2. To pay Rs.1,00,000/- as compensation for the mental agony and physical harassment suffered by the him along with litigation costs.
382.  

Any other relief which this Hon’ble Forum may deem fit.

 

                   Brief facts of the case are that on 23.09.2016, the complainant took medical claim policy no.0602000501610001169 from the OP No.1, through OPs No.2 & 3. Complainant, his father Varun Jain, mother Seema Jain and wife Aashima Jain were duly insured under the said policy and the OPs issued policy card in their name. On 06.08.2017, suddenly the father of the complainant Shri Varun Jain had pain in his left leg and was taken to the hospital of the OP No.4, for medical check-up and treatment. The OP No.4, admitted him in the hospital and advised for lab test & MRI LSSPINE. The MRI LSSPINE test of the father of the complainant was got conducted from P.K.R. Jain Heath Care Institute, for which the complainant spent Rs.1,800/-. His father remained admitted in the OP No.4 hospital, for the period from 07.08.2017 to 10.08.2017, and vide bill No.889 dated 10.08.2017, he paid Rs.12,750/- and also paid a sum of Rs.163/-, vide bill dated 07.08.2017. On 10.08.2017, the OP No.4 referred father of the complainant to PGI Chandigarh for seeking 2^nd opinion and his father visited PGI to get the opinion. Thereafter, his father visited MAX Hospital, where several tests were conducted. On 25.08.2017, his father also visited ARTIMIS Hospital at Gurugram, for his treatment. Complainant spent a sum of Rs.32,472/- on medicines, besides other expenses, thus he is entitled for the amount spent on the treatment of his father. He lodged the claim with the OP No.1 and also provided all the medical bills and other relevant documents as demanded by it. The complainant requested the OP No.1 & 2 repeatedly for payment of the medical bills, but they lingered on the matter for quite some time and ultimately, the OP No.1 refused to pay the claim with the plea that the claim is not maintainable under clause 4.19. However, the OP No.1 to 3 had never disclosed about the said clause and had not provided the cover note of the medical policy inspite of repeated requests to him. The OP No.1 has not gone through the documents of treatment of father of the complainant taken from various medical institutions. He served legal notice dated 19.08.2018, upon the OPs, but of no avail. By not paying the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.

2.                 Upon notice, OP No.1 appeared through counsel and filed written version, raised preliminary objections regarding maintainability, not come with clean hands and suppressed the true & material facts from the Hon’ble Forum. On merits, it is stated that the complainant has never taken an active line of treatment anywhere rather it is an instance of certain check-ups in different hospitals and unnecessarily taking advice of different doctors. The complainant is like a person, who is not having any confidence on any doctor that is why he is wandering to take suggestions/opinions from one doctor to another. The complainant has sought opinions from PGI, MAX Hospital and ARTIMIS Hospital, Gurugram. The complainant is not entitled to any amount because his father had only sought opinions and certain tests. As per the discharge summary of the hospital during hospitalization, no active line of treatment was given, only INJ.METHYLPREDNISOLONE  was given, which can be given on OPD basis. Hence, the claim is not admissible under clause 4.19 of the policy. The complainant is not entitled for any relief as his claim was repudiated on the ground that certain terms and conditions of the policy were not complied with. The insurance company provides the cover note of the policy and medical policy book to every insured. The insurance company is not liable to pay any claim.   There is no deficiency on the part of the OP No.1 and the present complaint may be dismissed against it with costs.

                   Upon notice, none appeared on behalf of the OPs No.2 & 3 before this Forum, therefore, OPs No.2 & 3 were proceeded against ex-parte vide order dated 08.10.2019.

                   Upon notice, OP No.4 appeared through counsel and filed written version, raised preliminary objections regarding jurisdiction; estoppel; cause of action and maintainability. On merits, it is stated that the father of complainant was admitted in the hospital of OP No.4, on 07.08.2017 and the standard treatment required for the said disease was given under proper care and he was discharged on 10.08.2017. The complainant never supplied terms and conditions of the policy having clause No.4.19 and in absence thereof the OP No.4 is not in position to file the proper reply. No notice has been served upon the OP No.4. It gave proper treatment to the father of the complainant and had no concern with the insurance policy and repudiation of claim. The OP No.4 cannot be made liable for acts and conduct of OPs No.1 to 3.  There is no deficiency on the part of the OP No.4 and the present complaint may be dismissed against it with costs.

3.                The ld. counsel for the complainant tendered affidavit of the complainant as Annexure CA alongwith documents as Annexure C-1 to C-34 and closed the evidence on behalf of complainant. On the other hand, learned counsel for OP No.1 tendered affidavit of Shri S.C.Dass, Assistant Manager, National Insurance Company, as Annexure OP1/A alongwith documents Annexure OP1/1 to OP1/6 and closed the evidence on behalf of OP No.1. Learned counsel for the OP No.4 tendered affidavit of Dr.Sachin Jindal, Narain Hospital, Manali House, Ambala City as Annexure OP4/A alongwith document Annexure OP4/1 and closed the evidence on behalf of OP No.4.

4.                We have heard the learned counsel of the parties and have carefully gone through the case file.

5.                Admittedly, OPs repudiated the claim of the complainant vide letter dated 23.06.2018, Annexure C-32, on the ground that “as per discharge summary of the hospital during hospitalization no active line of treatment was given, only INJ.METHYLPREDNISOLONE given which can be given on OPD basis. Hence, claim is not admissible under clause 4.19”.  From the discharge summary, issued by OP No.4, Annexure C-5, it is evident that the father of the complainant, Mr. Varun Jain was admitted in the said hospital on 07.08.2017 and after the procedure was done and thereafter he was discharged from the said hospital on 10.08.2017. It is of a common knowledge that for mere going for an injection, a patient could not be kept admitted in the hospital for four days. No document has been placed on record by the OPs to prove that the father of the complainant was kept in the hospital only for injection. It is therefore, held that during the said four days of admission, father of the complainant was treated at the said hospital.  As such the complainant is entitled for reimbursement of the amount spent by him for the treatment of his father. By repudiating the claim of the complainant, the OP No.1 has committed deficiency in service and is thus not only liable to reimburse the amount to the complainant spent by the him  on the treatment of his father, but is also liable to compensate the complainant for the mental agony and physical harassment suffered by him alongwith litigation expenses. It may be stated here that, the complaint filed against OP No.2 is liable to be dismissed, because it is working for and on behalf of OP No.1, thus no liability can be fastened against it. The complaint filed against OP No.3 and 4 is also liable to be dismissed because neither any specific allegation has been levelled against them nor it has been proved.  

6.                In view of the aforesaid discussion, we hereby dismiss the present complaint against OPs No.2 to 4 and allow the same against OP No.1. OP No.1 is directed in the following manner:-

1. To reimburse the amount spent by the complainant on treatment of his father as per terms and conditions of the policy to the complainant.

          ii)      To pay Rs.5,000/- as compensation for the mental agony and                      physical harassment suffered by the him

          iii)     To pay Rs.3000/- as litigation costs.

                   The OP No.1 is further directed to comply with the aforesaid direction, within the period of 30 days from the date of receipt of the certified copy of this order. Certified copies of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :05.12.2019.

     (Vinod Kumar Sharma)            (Ruby Sharma)     (Neena Sandhu)              Member                                 Member             President