Delhi

North East

CC/282/2014

Arun Kumar Srivastava - Complainant(s)

Versus

Oriental Ins. Co. Ltd. - Opp.Party(s)

27 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 282/14

 

In the matter of:

 

		Arun Kumar Srivastava A2/412, Gali No. 19 Near Gyan Sarovar Public School Harsh Vihar, Delhi-93.   Rachna Srivastava A2/412, Gali No. 19 Near Gyan Sarovar Public School Harsh Vihar, Delhi-93.		Complainant No.1         Complainant No.2
		Versus
	1.             2.	Oriental Insurance Company Ltd Oriental House P.B. No. 7037 A-25/27, Asaf Ali Road, New Delhi-110002. Also At: Sunlight Insurance Building 1/28, Asaf Ali Road, New Delhi-110002.   M/s Medi Assist India Pvt. Ltd Shilpa Vidya, 3rd Floor, 49, 1st Main Road, Sarakki Industrial Layout, III Stage, J.P. Nagar Banglore-560078, Also At: B-20, Sector-2, Near Sector 15 Metro Station, Opp. HCL Comnet, Noida Uttar Pradesh-201301.		Opposite Parties
			DATE OF INSTITUTION:		26.05.2014
			JUDGEMENT RESERVED ON :		22.11.2017
			DATE OF DECISION      :		27.11.2017

 

 

 

 

 

N.K.Sharma, President:-

Ms. Sonica Mehrotra, Member:-

 

Order by Ms. Sonica Mehrotra, Member:-

 

 

ORDER

1. The case of the complainant is that he had taken a Mediclaim Policy namely Happy Family Floater Policy bearing No. 215400/48/2014/343 from OP1 and the same was valid from 27.4.2013 to 26.4.2014 for Health Cover to himself, his wife i.e. complainant No.2 and their two children for a basic cover of Rs. 2,50,000/-. That on 17.12.2013 the complainant No.2 was taken to Narinder Mohan Hospital and Heart Centre, Mohan Nagar Ghaziabad for check up as she was suffering from high fever since past few days. Doctor M.M. Tripathi, who was holding OPD at that time suggested few tests to be conducted on complainant No.2 to determine the actual cause of fever and complainant No.2 was sent back home and put on medication for few days. However, her condition only worsened despite medication and seeing no improvement in her condition, complainant No.2 was again taken to the aforesaid hospital on 20.12.2013 where on examination by the Doctor -in- charge (CMO of emergency ward), the complainant No.2 was admitted there immediately on the same day. That apart from fever the complainant No.2 had also developed chronic breathing problem for which the Doctor-in-charge suggested various tests to be done on the complainant No.2 for further investigation. Various tests such as CVC, Digital X-Ray, CT- Scan, ultrasound and FibreoplicBronochoscopy were performed on the complainant No.2, in order to determine the reason for her illness. Also, the complainant No.2 underwent various blood tests. Complainant No.2 was diagnosed with severe Anaemia, Ac. LRIT with Pneumonitis (patient under Koch’s evaluation) and Hepatomegaly (Subclinical). She had to undergo treatment for the above-mentioned disease and was accordingly, admitted in the said hospital for about 4 days i.e. from 20.12.2013 to 24.12.2013. Thereafter, though she was discharged from the hospital, she was directed to continue supportive treatment in OPD.  The complainant No.1 immediately informed OP2 (TPA of OP1) about the admission of complainant No.2 vide e-mail dated 20.12.2013 after receipt of which, on request of the TPA, the complainant No.1 vide letter dated 27.12.2013 provided the TPA with all the relevant documents such as Original Claim Form, Discharge Summary, Original Bill of the hospital, other bills like medicine etc. Vide the above mentioned Claim Form the complainant made a claim of Rs. 42,466/- vide  claim No. 9709520 towards Hospital bill  (Rs. 35,860/- + Hospital Bill, bill of Rs. 6606/- towards purchase of medicines). On specific demand raised by the OP2 for issuance of authority letter, the complainant provided the same dated 23.1.2014 authorising OP2 to seek any medical information / record from the concerned hospital pertaining to complainant No.2. The complainant states that the OP2, in order to further harass the complainant, made a perverse request from the complainant to provide details with regard to duration of the policy despite the same being already attached and submitted by the complainant to OP2 vide letter dated 27.12.2013 but still the complainant, to cooperate with OP2 provided the policy details of last seven years requesting for early settlement of his claim vide letter dated 14.2.2013. Lastly, to the utter shock and dismay of the complainant, a letter dated 25.3.2013 was sent by OP2 rejecting the claim of the complainants in accordance with clause 4.11 of the term and conditions of the policy which was basically an exclusionary clause. Clause 4.11 is as here under :-
2.  

 

The complainant has argued that his case is not where the expenses were incurred only on for “evaluation / diagnostic purposes” which was not followed by active treatment, nor is it a case where expenses were incurred for investigation or treatment irrelevant to the diseases diagnosed. Therefore the complainant has alleged the rejection of his claim by OP is invalid and illegal amounting to gross deficiency in service and extreme negligence. The complainant No.2 was hospitalized and underwent treatment for severe Anaemia, Ac.LRIT with pneumonitis (patient under Koch’s evaluation) and Hepatomegaly (subclinical). As a last ditch effort made by the complainant to convince the OP of the genuineness of his claim, the complainant consulted the treating Doctor namely MM Tripathi for written opinion to OP, who then vide letter dated 3.4.2014 to the OP2 explained the reason for investigation upon complainant No.2 to rule out Koch’s or viral pneumonitis, malaria or G.I.Bleed but even such a letter made no difference to the OP2 in as much as the OP2 neither withdrew the rejection letter nor bother to reply to the above mentioned Doctor’s letter. The complainant lastly wrote a letter dated 14.4.2014 to OP1 requesting that they be given their valid an right full claim but to no avail. Therefore, left with no other alternative the complainant was constrained to file the present complaint vide which the complainant prayed as hereunder:

1. The OPs be held liable for deficiency in service and negligence.
2. Direction to the OPs to pay claim amount of Rs. 42,466/- alongwith interest @ 12% p.a. compounded annually and a further compensation to the tune of Rs. 35,000/- for causing mental harassment and trauma to the complainant.
3. Cost of litigation.  

 

2. Notice was issued upon OPs however OP2 failed to appear and therefore was proceeded against Ex-parte vide order dated 18.12.2015. Written Statement was filed by OP1 in which the factum of the complainant being insured with the OP1 under the ‘Happy Family Floater Policy’ w.e.f. 27.4.2013 to 26.4.2014 was not disputed. However, in defence of its stand of repudiation of claim of the complainant OP1 took the plea that the complainant No.2 was admitted in the concerned hospital during the admission period for test and investigations which were only for diagnostic purposes and therefore the same came under the definition of exclusion clause 4.11 of T&C of the policy and because the claim of the complainant pertained to treatment on an OPD bases, the claim of the complainant was held not payable by the OP2 and the same was accordingly informed to the complainant vide repudiation letter dated 25.3.2014. At this stage the OP2 has drawn our attention to exclusion clause No. 4.11 of the policy terms and conditions and exclusions and has filed the same on record with the written statement. The said clause is as hereunder:

“THE COMPANY SHALL NOT BE LIABLE TO MAKE ANY PAYMENT UNDER THIS POLICY IN RESPECT OF :-  ANY EXPENSES INCURRED AT HOSPITAL OR NURSING HOME PRIMARILY FOR EVALUATION/DIAGNOSTIC PURPOSES WHICH IS NOT FOLLOWED BY ACTIVE TREATMENT FOR THE AILMENT DURING THE HOSPITALISED PERIOD OR EXPENSES INCURRED FOR INVESTIGATION OR TREATMENT IRRELEVANT TO THE DISEASES DIAGNOSED DURING HOSPITALIZATION OR PRIMARY REASONS FOR ADMISSION, REFERRAL FEE TO FAMILY DOCTOR’S OUT STATION CONSULTANTS/SURGEONS FEES, DOCTOR’S HOME VISIT CHARGES/ATTENDANT/NURSING CHARGES DURING PRE AND POST HOSPITALIZATION PERIOD ETC.”

 

Further the OP argued that during the period of admission of complainant No.2 i.e. 20.12.2013 to 24.12.2013 with the concerned hospital, the treatment taken was in the nature of test and investigation for diagnostic / evaluation purpose only and there was no active line of treatment which came under exclusion clause 4.11 as the treatment could be done on an OPD basis and accordingly not payable.

3. Evidence by way of affidavit filed by the complainant and OP1 exhibiting on record the material documentary evidence relied upon by both the parties. Written arguments were filed by both the parties. The complainant relied upon the judgement of Oriental Insurance Company Ltd. Vs Shri Rajeev Bhadani and Oriental Insurance Company Ltd. Vs Ankit Bansal passed by Hon’ble NCDRC in his defence in which The Hon’ble National Commission held repudiation  on grounds of exclusion clause as wrongful. On the other hand the OP2 relied upon judgement of LIC of India vs Ramphal in which The Hon’ble National Commission had held that reimbursement claim by the complainant was rightly declined by LIC on ground that policy did not cover OPD treatment more so when the terms and conditions attached to the policy were duly provided to the complainant and was therefore bound by the same.
4. We have heard the rival contentions of the parties and have carefully perused the case file and documentary evidence placed on record thereof by both the parties. On the face of it, at the cost of over simplification, it can be seen from the medical treatment documents of complainant No.2 that probably there was no emergency which required treatment by way of a surgery or any operative procedure to be conducted upon the complainant No.2 which may find support and suit the exclusion policy / clause of OP1. But on close scrutiny of discharge summary dated 24.12.2013, it can be seen that the complainant No.2 was diagnosed with severe anaemia, Ac.LRIT with Pneumonitis and Hepatomegaly (subclinical) and complainant No.2  was admitted with dyspnea II-III fever with chills & rigox, bodyaches and weakness which required elaborate tests as can be seen from the record and the gravity of the same was fortified by the treating Doctor MM Tripathi letter to OP2 that the ailment was such that the complainant No.2 had to be admitted in emergency OPD and investigation had to carried out to rule out suspicion of malaria or TB or G.I.Bleed specially in an emergency patient with anaemia which, if went undetected / ruled out could have fatal results. A very pertinent point was made by the said Doctor that the complainant No.2 was earlier treated in Chest OPD on 17.12.2013 but only on deterioration of her condition, was she admitted for indoor treatment and investigation on 20.12.2013 with the concerned hospital. We also see that the complainant No.2 has not sought any claim for the previous period of ailment i.e. 17.12.2013.
5. Therefore we opine that the treatment undergone by the complainant No.2 during hospitalization for four days (4 Days) at the concerned hospital could not be over simplified or trivialized as mere evaluatory/diagnostic in nature not requiring active treatment. Therefore, to repudiate the claim of the complainant under refuge and garb of exclusion clause is not only unjustifiable, erroneous but also perverse to the letter and spirit of the exclusion clause in as much as evaluation and diagnosis of complainant No.2 was for the purpose of treatment of the complainant No.2 in the concerned hospital. Even otherwise it was not a pre-existing disease / ailment / illness and the complainant No.2 would not have known of the existing of any disease or any symptoms thereof which she was diagnosed with during the course of investigation/ diagnose and treated upon for the same in the concerned hospital.
6. In light of the forgoing reasons, fact findings and medical opinion of the treating doctor and supportive documents of tests and treatment undergone by the complainant No.2 in emergency OPD of the concerned hospital, we rule that the repudiation of claim of the complainant by the OP1vide letter dated 25.3.2014 is not justified, wrongful and improper and the claim is genuinely payable to the complainant. We therefore hold the OPs jointly and severally liable to pay the Mediclaim expenses of the complainant accordingly allowing the complaint of the complainant and hereby direct the OPs to pay a sum of Rs. 42,466/- towards medical expense alongwith interest @ 9% p.a. to the complainant from the date of filing of the complaint till realization. We further award a sum of Rs. 10,000/- for mental harassment and trauma and Rs. 7,000/- towards cost of litigation payable by the OPs within 30 days of receipt of this order, failing which the rate of interest on the medical expenses shall be enhanced to 12% p.a.  
7. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
8. File be consigned to record room.

(Announced on  27.11.2017)                                                                              

 

(N.K. Sharma) President

(Sonica Mehrotra)      Member