Punjab

Fatehgarh Sahib

CC/71/2014

Virender kumar - Complainant(s)

Versus

OIC LTD - Opp.Party(s)

Sh Sk Garg

05 Feb 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

Consumer Complaint No. 71 of 2014

                                           Date of institution : 26.05.2014                                                  Date of decision    : 05.02.2016

1.         Virender Kumar aged about 39 years S/o Sh. Shankar Lal,

2.         Rakha Gupta aged about 38 years W/o Sh. Virender Kumar,

Both Residents of H.No.140, Sector 20-D, Subhash Nagar, Mandi Gobindgarh, Tehsil Amloh, C/o M/s Virendra Steels, Sai Baba Market, Amloh Road, Mandi Gobindgarh, Tehsil District Fatehgarh Sahib.

……..Complainants

Versus

Oriental Insurance Co. Ltd. Loha Bazar, Mandi Gobindgarh, Tehsil Amloh, through its Senior Branch Manager.

…..Opposite Party

Complaint Under Section 12 of the Consumer Protection Act.                                                

Quorum

Sh. Ajit Pal Singh Rajput, President                                       Smt. Veena Chahal, Member                                                      

Present :  Sh.S.K. Garg, Adv.Cl. for the complainant.                                     Sh. B.L.Gupta, Adv.Cl. for the OP.

ORDER

 

By Ajit Pal Singh Rajput, President

                      Complainants, Virender Kumar and Rakha Gupta,  Both Residents of H.No.140, Sector 20-D, Subhash Nagar, Mandi Gobindgarh, Tehsil Amloh, C/o M/s Virendra Steels, Sai Baba Market, Amloh Road, Mandi Gobindgarh, Tehsil District Fatehgarh Sahib, have filed this complaint against the Opposite Party (hereinafter referred to as the OP) under Section 12 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.           The authorized representative of the OP met with the complainants at Mandi Gobindgarh and induced them to obtain an insurance policy covering all type of medical claims under Hospitalization and Domiciliary Hospitalization Benefit Policy. Accordingly, the complainants agreed to obtain insurance medical claim policy from the OP and paid the requisite insurance premium. The OP issued a cover note No. CHD-0743843 dated 04.12.2012 for the said policy covering the period from 04.12.2012 to midnight of 03.12.2013 covering all type of Hospitalization & Domiciliary Hospitalization Benefits. Thereafter the complainants got the said policy renewed by making additional payment of premium for the further period from 04.12.2013 to midnight of 03.12.2014. It is further stated that the complainants have only received the cover note of the policy treating the same as insurance policy and they have not received any separate policy or terms and conditions of the same. During the subsistence of first Medi Claim Insurance Cover note dated 04.12.2012, complainant No.2 suffered from Ureteric and Kidney problems and as a result of which, she was admitted in Satguru Partap Singh Appollo Hospital, Ludhiana and medically examined, treated and operated by the Urology and Renal Transplant Surgeon Urology Doctors in the said hospital. The requisite insurance medical claim was submitted by the complainant with the OP and the OP paid a claim of Rs.50,985/- to the complainants. Thereafter, again OP No.2 suffered from same problems and got her treatment from RG Stone and Super Specialty Hospital, Ludhiana as well as from Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi. During treatment it was found that there was complete blockage at upper Ureter of complainant No.2 and surgery was conducted for the said problem in the said hospitals. The complainant remained admitted in RG Stone and Super Specialty Hospital Ludhiana from 22.11.2013 to 25.11.2013 and in the Rajiv Gandhi Cancer Institute and Research Centre, Delhi for the period from 28.11.2013 to 04.12.2013 for the same problem, which was found by Satguru Partap Singh Apollo Hospital Ludhiana for which the claim was paid by the OP. The complainants gave necessary intimation to the OP regarding the admission of complainant No.2 in the said hospitals and also submitted an application-cum- claim for insurance benefits amounting to Rs.4,25,000/- along with all the necessary documents to the OP. Thereafter, the complainants several times approached the OP and made many requests to them to pass/clear, finalize and to make the payment of said insurance claim but the OP is putting off and lingering on the matter without any sufficient cause. The OP failed to adhere to the requests of the complainants and failed to settle the claim, which amounts to deficiency in service and unfair trade practice on the part of the OP. Hence, this complaint for giving directions to the OPs to pay Rs.3,50,000/- being the Actual expenses, along with vested bonus + profits + other insurance benefits and Rs.1,00,00/- as special compensation and damages for mental and physical torture, harassment and mental agony suffered by the complainants, Rs.10,000/- as food and journey expenses and Rs.10,000/- as litigation expenses.
3.           The complaint is contested by the OP and in reply to the same it raised certain preliminary objections, inter alia, that the complainant has got no cause of action to file the present complaint; the complainant has not come to the court with clean hands and the claim lodged by the complainants is beyond the scope and purview and terms and conditions of the policy. As regards to the facts of the complaint the OP stated that earlier a claim was lodged by the complainants and the same was paid as the insured was admitted at Satguru Partap Singh Apollo Hospital, Ludhiana as a case of fever, pain abdomen(since 4 days) and diagnosed with UTI with Ureteric Stenosis for which she was treated conservatively with PPI’s, antipyretics, antibiotics and other supportive treatment. The insured had lodged claim of Rs.59,949/- out of which TPA had paid an amount of Rs.50,985/- through NEET on 19.11.2013. The second claim lodged by the  complainants in respect of said treatment for an amount of Rs.4,25,000/-,is not permissible for payment as per the terms and conditions of the policy as the same covers under the Exclusion Clause 4.3(XIV). The insured was admitted at Rajiv Gandhi Cancer institute & Research Centre, Delhi and diagnosed with Retroperitoneal Fibrosis for which Biopsy & Omental Wrapping of Ureter was done during hospitalization. The policy clause 4.3(XIV) excludes treatment of Genitor Urinary System for first 2 years of operation of policy. The first claim was paid as the treatment was conservative and not surgical treatment. The policy Clause 4.3(Sub Clause XIV) excludes Surgery of Genitor Urinary System excluding Malignancy. Accordingly, the second claim was recommended for rejection and the same was repudiated vide letter dated 20.02.2014, which has been duly issued according to law and the terms and conditions of the policy. Hence there is no deficiency in service or unfair trade practice on the part of the OP. After denying the other averments made in the complaint, it prayed for dismissal of the complaint.

5.                   In order to prove his case, the complainants tendered in evidence affidavit of complainant No.1 as Ex. C-1,  attested copy of policy Ex. C-2, attested copy of receipt Ex. C-3, attested copy of advance receipt Ex. C-4, attested copy of final bill Ex. C-5, attested copy of receipt No.26444 Ex. C-6, attested copy of discharge summary Ex. C-7, attested copy of receipt dated 02.12.2013 Ex. C-8, attested copies of bills Ex. C-9 to Ex. 41, attested copy of study requisition form Ex. C-42, attested copy of cash memo Ex. C-43, attested copy of assessment form Ex. C-44, attested copy of referral slip Ex. C-45 and closed the evidence. In rebuttal the OP tendered in evidence affidavit of Gurmeet Singh Chahal, Branch Manager, Ex. OP-1, copy of insurance policy Ex. OP-2, copy of terms and conditions Ex. OP-3, copy of cover note No. 837392 dated 27.11.2013 Ex. OP-4, copy of cover note NO. 743843 dated 04.12.2012 Ex. OP-5, copy of email dated 19.08.2014 Ex. OP-6, copy of email dated 22.08.2014 Ex. OP-7, copy of letter dated 20.02.2014 Ex. OP-8, affidavit of Dr. Arvin Bakshi Ex. OP-9 and closed the evidence.

6.         The ld. counsel for the complainants has made a submission that the medical claim of complainant No.2 was repudiated by the OP in an arbitrary manner. The ld. counsel stated that earlier also complainant had got herself treated and the OP had reimbursed the same. He pleaded that it is well established from the material placed on record, that the second claim of complainant No.2 was rejected in an arbitrary and unethical manner. The ld. counsel further stated that as directed by the OP, the complainant had timely sent the intimation alongwith all the medical record as demanded by the OP. He argued that after receiving the entire medical record the OP with a malafide intention repudiated the claim of complainant No.2, despite the fact that the complainant was fully entitled for reimbursement. He further stated that the OP has dishonestly and fraudulently took insurance premium from the complainants by illegal means and deceived the complainants. The ld. counsel further argued that it is clearly proved from the act and conduct of the OP that they have committed unfair trade practice by rejecting the claim of the complainants, thus complainants deserves to be compensated for the same.

7.                   On the other hand, the ld. counsel for the OP has submitted that the claim of the complainants was repudiated as per the terms and conditions of the Policy. He stated that by repudiating the claim of the complainants, the OP has not committed unfair trade practice. The ld. counsel also stated that the claim was repudiated due to the exclusion clause, which excludes Surgery of Genitor Urinary for first 2 years and the same was also intimated to the complainants on 19.08.2014 i.e Ex.OP-6. The ld. counsel also argued that as per the terms and conditions of the policy i.e Ex. OP-3, the claim was repudiated as per the policy clause 4.3(Sub clause xiv) which excludes “Surgery of Genitor Urinary for first 2 years”. The ld. counsel further argued that the present complaint deserves to be dismissed with special costs as the OP had been dragged into unnecessary litigation.

8.         After hearing the Ld. Counsel for the parties and going through the pleadings, evidence produced by the parties, oral arguments and written submissions, we find force in the submissions made by the ld.counsel for the OP. Perusal of the terms and conditions of policy clearly indicate that the policy clause 4.3 (Sub clause xiv) excludes “Surgery of Genitor Urinary and Malignancy” for first 2 years i.e Ex.OP-3 (colly). From the perusal of the medical record, it is established that complainant No.2 had got surgery for Genitor Urinary. In our opinion the OP had repudiated the claim of the complainant as per the exclusion clause of the Policy.

9.                   Accordingly, in view of the aforesaid discussion, we find that the OP has not committed any deficiency of service, as the claim of the complainant was repudiated, keeping in view the exclusion clause of the Policy. Hence the present complaint is hereby dismissed being denuded of any merits. Parties to bear their own cost.    

 

12.                 The arguments on the complaint were heard on 02.02.2016 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated:05.02.2016

(A.P.S.Rajput)                          President

 

(Veena Chahal)                        Member