Haryana

Ambala

CC/260/2018

Sunil Mital - Complainant(s)

Versus

OIC - Opp.Party(s)

07 Oct 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                                      Complaint case no.         :  260 of 2018

                                                          Date of Institution           :  14.08.2018

                                                          Date of decision     :  07.10.2019.

 

Sunil Mittal (aged about 52 years), son of Sh. Panna Lal Mittal, Resident of House No.1353/6, Opp. Aggarwal Dharamshala, Ambala City.

……. Complainant.

 

Oriental Insurance Company Limited, LIC Building, Ground Floor, Near Vijay Cinema, Ambala City through its Branch Manager.

 

                                                               ….…. Opposite Party.

         

Before:        Ms. Neena Sandhu,  President.

                   Ms. Ruby Sharma, Member,

Sh. Vinod Kumar Sharma, Member.          

                            

Present:       Shri. Rajbir Singh, Advocate, counsel, for complainant.

Ms. Upma Bhalla, Advocate, counsel, for OP.

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Party (hereinafter referred to as ‘OP’) praying for issuance of following directions to it:-

1. To reimburse the amount of Rs.1,65,834/-, the expenses incurred upon the medical treatment of the son of complainant alongwith interest @ 24% per annum from April 2015 till the realization of the amount.
2. To pay Rs. 2,00,000/- as compensation for the mental agony and physical harassment suffered by him.
3. To pay Rs.50,000/- as litigation charges. 
4.  

Any other relief which the Hon’ble Forum may deem fit.

 

Brief facts of the case are that the complainant being the account holder of the Punjab National Bank had availed the PNB-Oriental Royal Mediclaim cashless policy (with family floater) from the OP-company vide policy number-261101/48/2016/27 valid from 11.04.2015 to the midnight of 10.04.2016, covering the other family members of the policy holder. The entire premium as demanded by the OP, amounting to Rs.6,830/- was paid by complainant and the same was accepted by the OP after due verification of the entire facts. He is holding the PNB-Oriental Royal Mediclaim policy since 2012,  as mentioned below:

S.No.	Policy Number	Valid From	Till Midnight
1.	261101/48/2013/19	11.04.2012	10.04.2013
2.	261101/48/2014/50	11.04.2013	10.04.2014
3.	261101/48/2015/51	11.04.2014	10.04.2015
4.	261101/48/2016/27	11.04.2015	10.04.2016
5.	261101/48/2017/30	11.04.2016	10.04.2017
6.	261101/48/2018/83	07.04.2017	06.04.2018

 

On 28.04.2015, the son of the complainant namely Ashit Mittal was admitted in Fortis Hospital, Mohali (Punjab) as he was having severe stomach pain due to kidney stone, which required surgery immediately as advised by the Doctor and subsequently, his son was operated upon. Before operation, the official of Fortis Hospital intimated the official of the OP about taking of cashless mediclaim policy by the complainant, who told him that firstly the complainant had to pay the entire bill expenses of the operation/treatment and thereafter, he can claim the same from it. As the life of his son was at stake, having no other option, in forcible circumstances, he paid the entire amount as demanded by the hospital. Expenses incurred upon the surgery of his son amounted to Rs.1,65,834/- which were duly intimated to the OP and also sent all the relevant bills and documents through mail, for the release of medical claim. The OP kept on delaying the release of the medical claim on one pretext or the other and ultimately vide Email dated 20.08.2015, declined to provide cashless facility and advised to lodge of claim alongwith documents, for reimbursement on the expenses incurred on the treatment of his son. Accordingly, he again submitted the claim documents with the OP through mails, but nothing was done. Thereafter, on 18.07.2017, he again submitted an application which was duly received by the OP vide receipt No.42. However, the OP vide letter dated 19.07.2017 refused to pay the claim amount on the ground that “any claim arising within the first 30 days of policy is not payable” and “surgery for stone is not covered within two years of taking of policy”. In the said letter, it was stated that the policy was taken on 11.04.2015 and the son of the complainant was admitted in the hospital on 28.04.2015, therefore, as per terms and conditions of the policy the claim is not payable. Since, the complainant had taken the policy w.e.f 11.04.2012, and the same was periodically renewed on yearly basis, therefore, as per terms and conditions of the policy, he is entitled to get the claim amount.  Due to non payment of the genuine claim by the OP, he has suffered a lot of mental agony and physical harassment. Hence, the present complaint.

2.                 Upon notice, OP appeared through counsel and filed written version, raising preliminary objections qua complaint is not maintainable, bad for mis joinder and non joinder of necessary party, no cause of action, has not come to the Learned Forum with clean hands, suppressed and concealed the true and material facts, barred by limitation. On merits, it is stated that the MEDI ASSIST (service provider of the OP received the request for the cashless claim of the policy no.261101/48/2016/27 for patient name Sh. Ashit Mittal from FORTIS Hospital. However, after going through the documents submitted by the hospital/insured, the cashless facility was denied on 30.04.2015, by the MEDI ASSIST (the service provider) on the ground that the “Patient neither student nor working”. As per clause 3.15 of terms and conditions of the policy “Patient should be full time student” hence cashless claim denied. However, it was duly informed to the policy holder and the hospital that he may submit the claim for reimbursement alongwith the documents required for reimbursement and with a proof that his son Mr. Ashit Mittal is a full time student and not working, then the claim will be processed as per the terms and conditions of the policy by the MEDI ASSIST. However, the complainant has not submitted the complete required documents i.e. the consent form, new reimbursement claim form etc. so the complaint is pre mature and prayed for dismissal of the present complaint denying other averments of the complaint.

3.                 To prove his version complainant tendered affidavits as Annexure C-A along with documents as Annexure C-1 to C-32 and closed his evidence. On the other hand, learned counsel for OP tendered affidavit of Shri Ashish Bhatnagar, Branch Manager, Oriental Insurance Company Limited and affidavit of Shri Suresh Kumar Gupta, Medi Assist Insurance TPA Private Limited as Annexure OPA and OPB alongwith documents Annexure OP1 to OP2 and closed the evidence on behalf of OP.

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

5.                From the perusal of policy document Annexure C-9, it is evident that the complainant, for the first time had taken the policy No.261101/48/2013/19 in the year 2012 and got the same renewed continuously on yearly basis. In the year 2015, the son of the complainant underwent a surgery for removal of Kidney stone and for which incurred the total expenses of Rs. 1,65,834/- as is evident from the bills issued by the Fortis Hospital, Annexure C-16 to Annexure C-19. Accordingly, the complainant lodged the claim with the OP but the OP refused to pay the claim amount on the ground that “as per policy condition any claim arising within first 30 days of the policy is not payable and surgery for stone is not covered within two years of taking of policy”. It may be stated here that the complainant took the policy in question for the first time in the year 2012 and got the same renewed in the year 2015, for the third time. Admittedly, the son of the complainant underwent surgery in the year 2015. Meaning thereby the surgery of the son of the complainant was conducted in the third year from the date of inception of the policy in question. Therefore, the OP cannot be said to be justified in repudiating the claim of the complainant and is liable to reimburse the amount which the complainant has incurred on the medical treatment of his son. From the bills of the Fortis Hospital, it is evident that an amount of Rs. 1,65,834/- has been incurred on the treatment of the son of the complainant. The OP is thus not only liable to reimburse the said amount but is also liable to compensate the complainant for the mental agony and physical harassment suffered by him along with litigation expenses. 

6.                In view of the aforesaid discussion, we hereby allow the present complaint and direct the OP in the following manner:-

1. To reimburse the amount of Rs.1,65,834/-, the expenses incurred upon the medical treatment of the son of the complainant along with interest @ 7% per annum w.e.f. 19.07.2017 i.e. the date of repudiation of the claim till its realization.
2. To pay Rs.5,000/- as compensation to complainant for mental agony and physical harassment suffered by him.
3. To pay Rs.3,000/- as litigation expenses to the complainant.

 

                    The OP is further directed to comply with the aforesaid directions within the period of 45 days from the date of receipt of the certified copy of this order. Certified copies of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :07.10.2019.

 

 

          (Vinod Kumar Sharma)            (Ruby Sharma)               (Neena Sandhu)

              Member                                   Member