Haryana

Kurukshetra

64/2016

Bhupinder Sachdeva - Complainant(s)

Versus

OIC - Opp.Party(s)

W.C.Juneja

23 Jan 2018

ORDER

BEFORE THE  DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

 

Complaint no.64/16.

Date of instt.1.3.16. 

                                        Date of Decision: 23.1.18.

Bhupinder Sachdeva son of Niyamat Rai, resident of Sachdeva Agencies, Punjabi Mohalla, Ismailabad, District Kurukshetra.

                                ……….Complainant.      

                        Versus

1. The Oriental Insurance Company Limited, Registered Office: Oriental House, PB No.7037, A-25/27, Asaf Ali Road, New Delhi, through its Managing Director.
2. Oriental Insurance Company Limited, Branch Office, Railway Road, Kurukshetra,  through its Branch Manager.

………Opposite parties.

 

       Complaint under section 12 of Consumer Protection Act.            

                                                                                      

 

Before                Sh. G.C. Garg, President.    

         Dr. Jawahar Lal Gupta, Member

                         

 

Present :  Sh. Ravinder Sangwan, Adv. for complainant.

                Sh. R.K. Singhal, Adv. for Ops.

                   

 

ORDER

 

                    This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Bhupinder Sachdeva against Oriental Insurance Company Limited and another, the opposite parties.

2.             It is stated in the complaint that the complainant has obtained a cashless medical policy bearing No.261303/48/2014/1280 with family floater for a sum of Rs.5,00,000/- valid for the period w.e.f. 10.12.2013 to 9.12.2014. At the time of purchasing the above said policy, the Ops assured that in case of any treatment with expenses will be paid by the company to the hospital directly and there is no burden on the complainant for payment of treatment charges. The complainant also renewed the said insurance policy bearing No. No.261303/48/2015/1852 vide collection No.CHQ 2265003566 dated 10.12.2014 and further renewed the policy bearing No. No.261303/48/2016/1723 vide collection No.CHQ 2265005241 dated 8.12.2015 valid up to 9.12.2016. On 11.9.2014 the complainant experienced mild chest pain and consequently he was admitted in MAX Superspeciality Hospital, Mohali under the supervision of Max Cardiac Surgery Associates and remained admitted till 19.9.2014. During the said period the Surgeon of the Hospital conducted the by-pass-surgery of complainant. At the time of admission, the attendant of the complainant informed the Hospital Staff that patient is having Oriental Royal Medi Claim policy and after completing all the formalities the claim was submitted on line and assured the attendant that all the formalities have been completed and expenses for operation would be borne by the company but later on at the time of charging the patient a bill for a sum of Rs.2,08,051/- was issued to the complainant for treatment and the Hospital staff informed that insurance company has refused to pay the expenses to the Hospital and on enquiry the hospital staff could not give satisfactory reply and under the pressure the attendant of complainant i.e. brother arranged the amount and paid a sum of Rs.20,000/- vide receipt No.MHD 129697, dated 11.9.2014, Rs.1,60,000/- vide receipt No.MHD129748 dated 13.9.2014 and Rs.22,051/- vide receipt No.MHR120743 dated 19.9.2014. Thereafter, the complainant was discharged from the Hospital. The complainant got served a legal notice through his counsel but the Ops have given a false and bogus reply and flatly refused to pay the expenses incurred by the complainant on his treatment. Hence, it amounts to deficiency in service on the part of Ops. So, the present complaint has been moved by the complainant with the prayer to direct the Ops to pay Rs.2,08,051/- along with interest, Rs.1,00,000/- as damages/compensation for mental agony and physical harassment, Rs.50,000/- for compensation on account of deficiency in service and Rs.22,000/- as litigation expenses.

3.            Upon notice, opposite parties appeared and contested the complaint by filing written statement alleging therein that the complainant has not approached to this Forum with clean hands as he has suppressed the material facts to get the claim; that the true and material facts of the case are that on perusal of documents of claim, it was found that the complainant covered under the policy was admitted at Max Hospital for treatment of CAD on 11.9.2014 and was discharged on 19.9.2014 and as per the policy terms and conditions, during the period of insurance, the expenses of treatment of ailment/disease/surgeries for Hypertension disease for specified periods of 2 years are not payable if contracted and/or manifested during the currency of the policy. The complainant was suffering from ailment for the past 2-3 years and prior to inception of the policy. So, the answering Ops have no liability as per terms and conditions of the policy and the claim was repudiated by the competent as per exclusion clause 4.2 of the policy of insurance. Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of answering Ops and as such, the complaint of the complainant is liable to be dismissed with costs. On merits, the contents of the complaint were denied to be wrong. Preliminary objections were repeated. Prayer for dismissal of the complaint was made. 

4.             Both the parties have led their respective evidence to prove their version.

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

6.            The case of the complainant is that after obtaining the cashless medical policy on 11.9.2014, he experienced mild chest pain and he was admitted in Max Super Specialty Hospital, Mohali and bill of Rs.2,08,051/- was issued to him by the said Hospital to which the complainant is entitled from the Ops. On the other hand, the stand of the Ops is that as per policy of insurance as the hypertension disease was within two years and as such, under clause 4.2 of the policy, the complainant is not entitled to any amount. It is to be noted that the repudiation of claim applying exclusion clause is not justified as held in The Consumer Law Digest 2001-2005 page 1130 in which it was held that when the medi claim policy taken by the complainant was valid from 19.4.1997 to 18.4.1998 and insurer suffered heart problem on 14.7.1997 and he was operated on 17.7.1997 and claim was repudiated on the ground of exclusion clause 4.1 in policy and complaint was dismissed, it was held that the decision was wrong.  In the present case, as is clear from Ex.C1, C4 and C7 the policy was purchased by the complainant for the period 2013 to 2014, then 2014 to 2015 and then 2015 to 2016, so when the policy was being issued by the Ops to the complainant continuously for the said period, it cannot be said that the complainant was not entitled to take the benefit of insurance policy. From Ex.C8, it is clear that the bill of Rs.2,08,051/- was issued by the Hospital to the complainant and as such the complainant is entitled to the said amount.  

7.            In view of our above said discussion, the complaint of the complainant is allowed and the Ops are directed to pay Rs.2,08,051/- to the complainant. This order should be complied within a period of two months, failing which penal action under Section 27 of the Consumer Protection Act, 1986 would be initiated against the opposite parties and in that case the complainant shall also be entitled to the simple interest @ 6% per annum on the amount of Rs.2,08,051/- from the date of order till its payment. The cost of litigation is also awarded to the tune of Rs.2200/- and the complainant is also awarded the compensation for the amount of Rs.5500/- for mental agony and physical harassment. File be consigned to record after due compliance.  Copy of this order be communicated to the parties.

 

Announced:    

Dt.23.1.2018.                                         (G.C.Garg)

                                                            President

                                    District Consumer Disputes Redressal Forum, Kurukshetra.

 

(Dr. Jawahar Lal Gupta)               

Member