Punjab

Sangrur

CC/478/2015

Uggar Sain - Complainant(s)

Versus

OIC Ltd. - Opp.Party(s)

15 Feb 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  478

                                                Instituted on:    12.06.2015

                                                Decided on:       15.02.2016

 

Uggar Sain aged about 65 years son of Shri Babu Ram, resident of Ward No.5, Lehragaga, Tehsil Lehra, District Sangrur through special power of attorney Sanjay Singla, resident of Ward No.5, Lehragaga, Tehsil Lehra, Distt. Sangrur.

                                                        …Complainant

                                Versus

 

1.     Oriental Insurance Company Limited, Nabha Gate, Sangrur through its Divisional Manager.

2.     Oriental Bank of Commerce, Branch Anaj Mandi, Lehragaga, District Sangrur through its Branch Manager.

3.     Medi Assist India TPA Private Limited, 47/1, Sri Krishna Arcade, 1^st Main, 9^th Cross, Sarakki Industrial Layout, J.P. Nagar, 3^rd Phase, Bangalore, through its Authorised Signatory.

                                                        ..Opposite parties

 

 

 

For the complainant  :       Shri Sanjeev Goyal, Adv.

For OP No.1             :       Shri Ashish Garg, Adv.

For OP No.2             :       Shri Sumesh Garg, Adv.

For OP No.3             :       Exparte.

 

 

 

Quorum:   Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Uggar Sain through his special power of attorney Shri Sanjay Singla, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is having a saving bank account number 04512191083190 with the OP number 2.  It is further averred that in the month of September, 2014, OP number 2 told the complainant their the bank has tie up with the OP number 1 for medi claim insurance policy under which the cashless facility in case of medical emergency is available in around 200 hospitals, as such on the instance of OP number 2 the complainant purchased the policy and paid Rs.4620/- as premium under which the complainant and his wife were insured for Rs.3,00,000/-, of which the OP number 1 also issued policy bearing number 233500/48/2015/1517 for the period from 30.09.2014 to 29.09.2015, but no other terms and conditions were issued.  Further case of the complainant is that on the intervening night of 20/21.10.2014, the complainant went for urination in the bathroom, but unfortunately, he accidentally slipped in the bathroom and sustained grievous injuries in his spine and as such, he was immediately taken to Bansal Hospital, Lehragaga, where he remained admitted from 21.10.2014 to 25.10.2014, but the position did not improve as such he was taken to Dayanand Medical College and Hospital, Ludhiana on 26.10.2014. It is further averred that at the time of admission, the family of the complainant showed the health card to the hospital authorities for availing the cashless facility under the policy and the hospital sent the request to OP number 3 for cashless hospitalisation, but the OP number 3 declined the same. It is further stated that the complainant remained admitted in the DMC Hospital, Ludhiana from 26.10.2014 to 10.11.2014 and spent an amount of Rs.2,00,000/- on his treatment and after the discharge, the complainant lodged the claim with the OP number 3 at Mohali branch and submitted all the relevant documents, but the OP number 3 repudiated the claim vide letter dated 10.4.2015, which is said to be wrong and false. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to release the claim amount of Rs.2,00,000/- along with interest and further claimed compensation and litigation expenses.

 

2.             In reply filed by OP number 1, it is admitted that the medical policy in question was issued in favour of the complainant for Rs.3,00,000/-. It is stated that during the first month tenure of the policy, the insured/complainant wanted the cash less facility through network hospital, Dayanand Medical College and Hospital, Ludhiana and the said hospital sent pre authorization request letter to TPA in which it was stated that the patient would need to be admitted to hospital for Surgery Cervical Lamicenctomy with estimated expenses of Rs.1,35,150/- under claim number 10476670 and after verification it was observed by the TPA that the patient had history of hypertension and diabetes and the above said two ailments has two years exclusion from the date of inception of policy covered, therefore, the request for cash less facilities  was denied.  It is further averred that the insured lodged the claim of Rs.1,85,157/- regarding medical expenses incurred by him during hospitalization on 1.12.2014 under claim number 10605747 and after receiving the papers, the TPA processed the claim and found that  complainant was admitted with alleged fall of 7 days before admission and sustained injury to the cervical region and further observed that the complainant was found to have diffuse idiopathic skeletal hyperstosis with ossified posterior ligament at C-2-C3 level canal steosis and undersent C2-C6 laminectomy and decompression for the same. It is further stated that the complainant would have been suffering from the ailment prior to the inception of the policy which squarely fall under policy exclusion clause 4.1. and it is further stated that the TPA has rightly repudiated the claim of the complainant. 

 

3.             In reply filed by OP number 2,   legal objections are taken up on the grounds that the complainant has no cause of action and locus standi to file the present complaint and that the complainant has unnecessarily dragged the OP into uncalled litigation. On merits, it is admitted that the complainant is having a saving bank account with the OP and as per record the amount of Rs.4650/- was paid to OP number 1 on the request of the complainant by demand draft dated 23.9.2014. However, the other allegations have been denied. 

 

4.             Record shows that the OP number 3 was proceeded exparte on 30.07.2015.

 

5.             The learned counsel for the complainant has produced Ex.C-1 copy of pass book, Ex.C-2 copy of repudiation letter, Ex.C-3 and Ex.C-4 copies of health card, Ex.C-5 copy of power of attorney, Ex.C-6 copy of claim form, Ex.C-7 and Ex.C-8 treatment slips, Ex.C-9 copy of list of bills, Ex.C-10 to Ex.C-90 copies of medical bills and Ex.C-91 affidavit and closed evidence. On the other hand, the learned counsel for OP number 1 has produced Ex.OP1/1 copy of insurance policy, Ex.OP1/2 copy of terms and conditions, Ex.OP1/3 copy of claim intimation, Ex.OP1/4 copy of lab report, Ex.OP1/5 copy of lab report, Ex.OP1/6 discharge summary, Ex.OP1/7 copy of investigation report, Ex.Op1/8 copy of claim form, Ex.OP1/9 copy of letter dated 10.4.2015, Ex.OP1/10 copy of letter dated 23.6.2015, Ex.OP1/11 copy of letter dated 25.5.2015 and Ex.Op1/12 affidavit and closed evidence.  The learned counsel for OP number 2 has produced Ex.Op2/1 affidavit and closed evidence.

 

6.             We have very carefully perused the complaint, version of the opposite parties, evidence produced on the file and written submissions and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

7.             In the present case, it is an admitted fact between the parties that the complainant was having a saving bank account with the OP number 2 and as such he purchased the policy in question from OP number 2 by paying the requisite premium of Rs.4620/- to the OP number 1 for Rs.3,00,000/-.  It is further an admitted fact that the complainant suffered injuries while he slipped in the bathroom and was admitted in the Bansal Hospital, Lehragaga as well as remained admitted in Dayanand Medical College and Hospital, Ludhiana, where he spent lot of amounts.  As such, the complainant lodged the claim for Rs.2,00,000/- with the Ops, but the OP number 3, who is the TPA of the OP number 1 repudiated the claim on wrong and illegal facts.  The learned counsel for the complainant has prayed that the claim be allowed.  On the other hand, the learned counsel for the OP number 1 has contended vehemently that after going through the record submitted by the complainant it was found that he was diffuse idiopathic skeletal hypostasis with ossified posterior ligament at C-2-C3 level canal stenosis and underwent C2-C-6 laminectomy and decompression for the same and the patient would have been suffering from the ailment prior to the inception of the policy, as such the claim was considered by the OP number 1 under exclusion clause 4.1.

 

8.             We have very carefully perused the whole case file and after hearing the arguments of the learned counsel for the parties are of the considered opinion that the complaint of the complainant does not fall under the exclusion clause 4.1 of the insurance policy Ex.OP1/2 and a bare perusal of the clause 4.1 relates to the pre existing health condition or disease or ailment/injuries.  Any ailment/disease/injuries/health condition which are pre existing (treated/untreated, declared/not declared in the proposal form), when the cover incepts for the first time and excluded up to three completed years of this policy being in force continuously.  For the purpose of applying this condition, the date of inception of this Mediclaim Policy taken from the Oriental Insurance Company shall be considered, provided the renewals have been continuous and without any break in period.  But, in the present case, the OPs have not produced any cogent, reliable and trustworthy evidence to show that the complainant was having pre existing disease as mentioned above.  Further we have also perused the investigation report of Medi Assist India TPA Pvt. Ltd. Ex.OP1/7, but we feel that this report also not seem to help the Ops as in the report it is stated that “this seems to be a case of complication of a pre existing disease(DM)”, but this report is not supported by any such evidence that the complainant was suffering from any pre existing disease.  Mere mention of pre existing disease in the investigation report is not sufficient to throw the case of the complainant.  It is worth mentioning here that the case of the complainant is that in the intervening night of 20/21.10.2014 the complainant went for urination in the bathroom, but unfortunately the complainant accidentally slipped in the bathroom and sustained grievous injuries on his spine.  Further the learned counsel for the complainant has also contended that the OP has repudiated the claim on the grounds that the complainant was diagnosed with diffuse idopathic skeletal hyperstosis with ossified ligament at C2-C-3 and as per the medical literature DISH (diffuse idiopthic skeletal hyperstosis) is a form of metabolic disorder and most commonly occurs elderly people with DM and do not develop as a result of fall and the claim falls under exclusion 4.1 of the policy, but the said grounds have been said to be wrong and illegal by the learned counsel for the complainant because the complainant sustained injuries on his spine after fall in bathroom and he was immediately taken to Bansal Hospital, Lehragaga and thereafter to the Dayanand Medical College and Hospital Ludhiana.    As such, we feel that the present case is of accidental nature and the OP is deficient in repudiating the rightful claim of the complainant.

 

9.             Now, coming to the point of quantum of compensation, the learned counsel for the complainant has claimed an amount of Rs.2,00,000/- from the OP, but it is the own case of the OP number 1 that earlier the complainant lodged the claim for Rs.1,85,157/- on 1.12.2014 under claim number 10605747, as is evident from the copy of investigation report, Ex.OP1/7 as such, we feel that the ends of justice would be met if the OP number 1 is directed to pay to the complainant an amount of Rs.1,85,157/-.

 

10.           So, in view of our above discussion, we find it to be a case of deficiency in service and accordingly, we allow the complaint and direct OP number 1  to pay to the complainant an amount of Rs.1,85,157/-   along with 9% interest from the date of filing of the complaint i.e. 10.06.2015 till realisation. We further direct OP number 1 to pay to the complainant a sum of Rs.10,000/- on account of mental tension, agony and harassment and a sum of Rs.5500/- as litigation expenses. This order of ours shall be complied with by the OPs  within a period of thirty days of  receipt of a copy of this order. A copy of the order be issued to the parties free of cost. File be consigned to records.  

                Pronounced.

                February 15, 2016.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member

 

 

                                       

                                                                (Sarita Garg)

                                                                    Member