Haryana

Kurukshetra

231/2017

Rajesh Gupta - Complainant(s)

Versus

OIC - Opp.Party(s)

Gaurav Gupta

12 Sep 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

                                                        Complaint Case No.231 of 2017.

                                                               Date of institution: 30.10.2017.

                                                               Date of decision: 12.9.2019.

 

Rajesh Gupta son of Sh.S.N.Gupta resident of H.No.948, Sector-13, Housing Board Colony, District Kurukshetra.

          …Complainant.

                             Versus

1. The Oriental Insurance Co. Ltd., Railway Road, Near State Bank of India, Thanesar, Kurukshetra, through its Manager.
2. The Oriental Insurance Co. Ltd. Near York Hotel G.T. Road Karnal-132001 through its R/Manager.
3. Medi Assist India TPA Private Limited 47/1 Shri Krishana Arcade 1^st Main 9^th Cross, Sarakari Industrial Layout, J.P. Nagar, 3^rd Phase Banglore 560078, through its authorized signatory.

 

….Opposite parties.

Before:        Smt. Neelam Kashyap, President.

                   Ms. Neelam, Member.

                   Sh. Sunil Mohan Trikha, Member.

         

Present:      Sh. Mohit Tayal, Advocate for complainant.   

                   Sh. Gaurav Gupta, Advocate for opposite parties no.1 and 2.

                   Opposite party no.3 exparte.

                  

ORDER

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Rajesh Gupta against the Oriental Insurance Company Ltd. & others, the opposite parties.

2.                It is stated in the complaint that complainant is subscriber of Medi-claim policy with OPs No.1 and 2 under allurement of Oriental Bank of Commerce after paying the requisite premium to Ops No.1 & 2.  He always paid the premium in time.  It is further averred that the Ops had issued the policy No.261301/48/2015/1753 for the cover period of 17.10.2014 to 16.10.2015 and at the time of issuing the policy to me the opposite parties assured that they will provide all Medi-care facilities to the complainant and provide the cash less facility in Hospital.  The Opposite party had only issued the three pages policy without any terms and condition.  It is further stated that he got checked himself in Max Super Specialty Hospital on dated 8.6.2015 for the problem of pain abdomen and he had intimate the opposite party through Hospital official for providing the cash less facility in hospital for treatment.  But the opposite party had denied for cash less facility on dated 8.6.2015 at about 6.19 P.M. on the ground of denied under 2^nd year exclusion.  This fact was intimate by Medical Superintendent.  It is further stated that he had took the copy of denial from hospital and inquired about the cash less facility but opposite party assured him that they will reimburse the claim as per policy on this he remember them that earlier also one claim was denied by the opposite parties.  It is further stated that in compelling circumstances he got admitted in hospital on dated 10.6.2015 and got treatment as per advice of hospital and after treatment he was discharged on 11.6.2015 and spent the Rs.68040/- on treatment.  He had submitted all treatment record including treatment expenses/bill with opposite parties for re-imbursement of the claim on dated 14.8.2015.  It is further stated that on dated 2.11.2015 he has received a letter from the OP No.3 in which again the opposite party had repudiated the claim on false excuse which has not been disclosed, which amounts to deficiency in service and unfair trade practice on the part of ops. He prayed for to pay a sum of Rs.68040/- alongwith 18% interest per annum.  Hence, this complaint.

3.                On notice, opposite parties appeared and filed written statement taking certain preliminary objections;  that the complaint is false, frivolous and vexatios and has been filed with ulterior motives only to harass and humiliate  the Opposite parties;  that the complainant has not come to this Forum with clean hands and he suppressed the true and material facts;  that the complaint is barred  by limitation;  that the present complaint is wholly misconceived, groundless and unsustainable in law and is liable to be dismissed on this ground alone;  that the Forum has no jurisdiction to entertain and adjudicate upon the dispute involved in the complaint;  that the complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the opposite parties;  that no cause of action has arisen to the complainant against the opposite parties;  that the complaint is bad for mis-joinder of the parties and non-joinder of necessary parties;  that the complainant is estopped by his own act and conduct from filing the present complaint;  that the complainant is bound by the terms and condition of the policy. On merits, the contents of complaint are denied and so, prayed for dismissal of complaint. 

4.                Opposite party no.3 did not appear despite notice sent through registered cover and was proceeded against ex-parte.

5.                The complainant tendered affidavit Ex.CW1/A and documents Ex.C1 to Ex.C18. On the other hand, learned counsel for ops no.1 and 2 tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R3.

6.                We have heard learned counsel for the parties and have perused the case file carefully.    

7.                It is admitted fact that the complainant purchased a medi-claim policy as Ex.C-1.  Learned counsel for complainant has contended that complainant was insured with ops no.1 and 2 which was valid from 17.10.2014 to 16.10.2015. During the subsistence of the policy, complainant got checked in Max Super Specialty Hospital on dated 8.6.2015 for the problem of pain abdomen and the complainant informed the ops regarding the treatment and submitted all the relevant documents to the ops within time. Ld. Counsel for the complainant argued that the complainant again admitted on 10.6.2015 for treatment and discharged on dated 11.6.2015 as Ex.C-2.  Complainant spent of Rs.68040/- on his treatment.  He has also placed reliance on the judgment of the Hon’ble State Commission, Dehradun in case titled as New India Assurance Company Ltd. Vs. Sh.Sanjiv Kumar Goyal and  others, First appeal No.178/2009 decided on 6.1.2012. 

8.                On the other hand, learned counsel for ops has contended that there is no deficiency in service on the part of ops as the complainant was admitted on 10.6.2015 as a case of Cholelithiases with Gangrenous Cholecystitis and underwent Laproscopic Colecystectomy.  Ld. Counsel for the Ops argued that this is the first year of health coverage policy and as per terms and conditions of the policy, there is an exclusion of two years for the treatment expenses related to the present ailment.  Ld. Counsel for OPs has also placed reliance on the judgments of the Hon’ble Supreme Court in case titled as M/s Industrial Promotion & Investment Corporation of Orissa Ltd. Vs. New India Assurance Company Ltd.& Anr., Civil Appeal No.1130/2007 decided on 22.8.2016, M/s Suraj Mal Ram Niwas Oil Mills(P) Ltd. versus United India Insurance Co.Ltd. and another, Civil Appeal No.1375 of 2003 decided on 8.10.2010 and United India Insurance Co.Ltd. versus M/s Harchand Rai Chandan Lal, Civil Appeal No.6277 of 2004 decided on 24.9.2004.   

9.                So, this shows that the complainant was purchased a cashless policy and got treated in the Max Super Specialty Hospital in the policy period.  But the Ops wrongly repudiated the claim of the complainant.  Further, as has been held in the case of New India Assurance Company Ltd. Vs. Sh.Sanjiv Kumar Goyal (supra).  It is the deficiency in service on the part of Ops.  The authorities cited by learned counsel for ops no.1 and 2 are not disputed but same are not applicable in this case.

10.              In view of above, we allow the present complaint and direct the opposite parties to pay the amount of Rs.68040/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% per annum on the insured amount of Rs.68040/- from the date of order till actual realization. We also direct the ops to further pay a sum of Rs.5000/- as compensation and litigation expenses to the complainant. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.

Announced in open Forum:

Dt.: 12.9.2019

                                                                                      (Neelam Kashyap)

                                                                                      President.

 

 

(Sunil Mohan Trikha)                (Neelam)         

          Member                                    Member