Haryana

Ambala

CC/86/2017

Lal Chand Mittal - Complainant(s)

Versus

OIC - Opp.Party(s)

Deepak Kumar

21 May 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 86 of 2017.

                                                          Date of Institution         : 20.03.2017.

                                                          Date of decision   : 21.05.2018.

 

1. Lal Chand Mittal son of Shri Siri Ram aged 61 years.
2. Santosh Kumari wife of Shri Lal Chand Mittal aged 57 years both residents of house No.18, A/D, Rani Bagh, Ambala Cantt.

……. Complainants.

                                      Versus

 

The Oriental Insurance Company Ltd. through its Authorised Signatory LIC Building, Ground Floor, Ambala City.

                                                                             ….…. Opposite party.

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER         

                   MS. ANAMIKA GUPTA, MEMBER                 

 

Present:       Sh.Deepak Kumar, counsel for complainants.

                   Sh.Raj Kumar Jindal, counsel for OP.

 

ORDER

                   The complainants have filed the present complaint under Section 12 of the Consumer Protection Act, 1986 with the averments that they had purchased a medi-claim policy and the Op had issued policy certificate No.261101/ 48/ 2015/ 1754 having validity from 16.02.2015 to midnight of 15.02.2016. On 20.03.2015, the complainant no.2 suffered paralysis stroke and she was admitted in Fortis Hospital, Mohali and Rs.110489/- were spent on her treatment. As per the directions and requirement, the complainants submitted all the claim papers with OP on 22.05.2015 but till now the OP has not settled the claim of the complainant without any sufficient cause or reason. The complainants have visited the OP many a times but it failed to consider the legal and valid claim. The act and conduct of the OP clearly deficiency in service on its part as due to non settlement of the claim, the complainants have to face great hardship, mental pain and agony besides suffering loss on account of unfair trade practice. The complainants in evidence have tendered affidavit Annexure CX and documents Annexure C1 to Annexure C41.

2.                On notice, OP appeared and filed reply to the complaint wherein preliminary objections such as maintainability, locus standi, jurisdiction and concealment of material facts from this Forum, jurisdiction etc. have been taken. As per the terms and condition of Clause 4.10 “Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalize period or expenses incurred for investigation or treatment irrelevant to the disease diagnose during hospitalization or primary reason for admission, referral fees to family doctor, outstation / consultants / surgeon fees, doctor home visit charges / attendant / nursing charges during pre and post hospitalization period etc. are not payable. Admittedly, the complainant No.2 was admitted in Fortis Hospital Mohali on 20.03.2015 and diagnosed as a case of Transient Ishemic attack Type 2 Diabetes mellitus, Hypertension, CAD, Osteo Arthritis and old CVA. As per doctor certificate the patient was almost OK by the time she reached hospital. The active line of treatment is very less and only detailed investigations were done. It is not that the admission was done for diagnostic purposes as well as for evaluation purpose.  On the basis of above findings as per present policy in question the claim was denied under exclusion Clause 4.10 and nothing was payable to the complainants, therefore, the claim of the complainants was legally repudiated by the OP. There is no deficiency in service on the part of OP. Other contentions have been controverted and prayer for dismissal of the complaint has been made. In evidence, the OP has tendered affidavits Annexure RA, Annexure RB and documents Annexure R1 to Annexure R3.

3.                We have heard learned counsel for the parties and gone through the case file very carefully.

4.                 It is not disputed that the complainant No.2 alongwith complainant No.1 was insured with Op under medi-claim policy Annexure C41. The ground of the complainants are that complainant No.2 fell ill during the subsistence of the policy on 20.03.2015 and was hospitalized on 20.03.2015 in Fortis Hospital, Mohali for paralysis stroke where she remained under treatment till 23.03.2015 as per discharge summary Annexure C14 and on the treatment an amount of Rs.1,10,489/- were spent but the insurance company has repudiated the claim vide repudiation letter dated 20.08.2015 Annexure R1 on the ground that as per the terms and condition of Clause 4.10 Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalize period or expenses incurred for investigation or treatment irrelevant to the disease diagnose during hospitalization or primary reason for admission, referral fees to family doctor, outstation / consultants / surgeon fees, doctor home visit charges / attendant / nursing charges during pre and post hospitalization period etc. are not payable.

5.                          On the other hand the OP has come with the plea that the claim is barred under Section 4.10 of the terms and condition of the policy and the insurance company has rightly repudiated the claim as the admission in the hospital was done for diagnostic purposes as well as for evaluation purposes.

6.                          It is established on the case file that complainant No.2 had remained admitted in hospital for three days where she was thoroughly investigated as per Annexure C14 and the course of hospitalization was also very well explained in this very document.  The treating doctor has also issued certificate Annexure C17 wherein he has authenticated that the complainant No.2  admitted in the hospital from 20.03.2015 to 23.03.2015. Undisputedly, the complainant had obtained mediclaim policy and it is the boundened duty of the insurance company to reimburse the expenses if spent on treatment during the subsistence of the policy. It is strange that the Op has declined the claim of the complainants by mentioning that as per clause 4.10 of the terms and conditions of the policy the claim is not maintainable and was repudiated but this ground is not justified as there is nothing on the case file to show that the complainant No.2 was not treated and cured and even her admission in the hospital was done for diagnostic purposes as well as for evaluation purposes. As per Annexure C14 & Annexure C15 (discharge summary) the hospital has clearly mentioned the course in the hospital followed by medications alongwith preventive aspects of care and the treating doctor has diagnosed the patient with Diffuse disc bulge with bilateral ligamentum flavum hypertrophy and bilateral facet arthopathy causing thecal sac indentation and several narrowing of bilateral neural foramina with bilateral lateral recess narrowing causing impingement of L2 existing nerve roots on right side, Spinal canal stenosis from L2-3 to L5-S1 levels whole spine MRI-diffuse disc bulge at D9-19 and D10-11 Levels. Urinalysis Protien + WBC-01. 25-hydroxy Vitamin D-64 86, Vitamin B12 levels- 900. Patient was managed with insulin as per sliding scale for hugh sugar levels. Chest and limb physiotherapy. Also 24 hour holter was advised. Neurosurgery consult was advised under Dr.Anil Dhingra and was advised for lumber decompression after 6 weeks. ENT consult was done under Dr. Ashish Gupta for difficulty in hearing and patient was audiometry on OPD basis. Ortho consult was advised under Dr.Sen for lower backache and left knee pain and advised for lumber belt while walking. Patient is haemodynamically stable and patient is being discharged under following advise.  The patient was advised follow up in the OPD after 7 days   and also prescribed the medicines as mentioned in Annexure C15, therefore, it cannot be said that the complainant No.2 was admitted in the hospital only for diagnostic purposes as well as for evaluation purposes rather it is established that she got herself admitted in the hospital as per the requirement of treatment to cure the disease. The treating doctor had also issued a certificate regarding the treatment and tests of the complainant No.2 and had there been any doubt and query it was open for the OP to get the witness summoned for cross-examination but it has not been done so. It is strange that the Op insurance company at its own concluded that the complainant No.2 was admitted in the hospital for diagnostic purposes as well as for evaluation purposes without submitting any opinion from the panel doctor who conducted medical examination before commencement of the policy. In the present case it appears that the insurance company being in dominating position is trying to avoid the genuine claim of the complainants in this way or that way without leading any concrete evidence. Learned counsel for the complainants has rightly argued that the Op has repudiated the rejections of claim purely on technical ground in a mechanical fashion and will result in policy holder losing confidence in insurance industries. It was a flagrant deficiency in service and amounts to indulgence to unfair trade practice. In general if somebody falls ill then he/she surrenders himself/herself  to a treating doctor and the further treatment never remains under his/her control and he/she has to follow the advice and to go through the tests which the treating doctor suggests, therefore, the plea of the Op that the claim is barred under clause 4.10 of terms and conditions of the policy is not tenable and the same is hereby rejected. The complainants have produced the bills annexure C3 to Annexure C19 except Annexure C14, Annexure C16 and Annexure C17 wherein it has been mentioned that an amount of Rs.100242/- and even the Op has failed to rebut the above said bills by leading any evidence that the amount was in exaggeratedly claimed by the complainants.

7.                In view of the discussion, it is clear that the complainants have been able to prove the case by leading cogent and reliable evidence. Accordingly, we allow the present complaint with costs which is assessed at Rs.5,000/-. The Op is further directed to pay an amount of Rs.100242/- spent by the complainant No.2 on her treatment alongwith interest @ 9 % per annum from the date of filing of the complaint till its realization besides Rs.5,000/- on account of mental agony, harassment and cost of litigation etc. The order be complied within 30 days from the date of receiving of the copy of this order. Copy of this order be supplied to both the parties free of costs.  File be consigned to the record room after due compliance.

ANNOUNCED ON:      21.05.2018

 

                                               

(PUSHPENDER KUMAR)     (ANAMIKA GUPTA)      (D.N.ARORA)            MEMBER                        MEMBER                       PRESIDENT