DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR

Consumer Complaint No. 630-13

Date of Institution : 11.9.2013

Date of Decision : 13.3.2015

Sh.Des Raj Sehgal, son of Sh. Balwant Rai Sehgal, resident of H.No. 1742-C,Gali Ranje Wali, Chowk Katra Khazana,Amritsar

...Complainant

Vs.

Oriental Insurance Company Limited having registered and Head office at A-25/27, Asaf Ali Road,New Delhi 110002 interalia having its branch office at Dwarka Deesh Complex,Queens Road,Amritsar

....Opp.party

Complaint: under section 12/13 of the Consumer Protection Act, 1986

Present : For the complainant : Sh.Kuldip Bawa,Adv.

For the opposite party : Sh.P.N.Khanna,Adv.

Quorum : Sh. Bhupinder Singh, President,

Ms.Kulwant Kaur Bajwa,Member & Sh. Anoop Sharma, Member

Order dictated by :-

Bhupinder Singh, President

-2-

1. Present complaint has been filed by Des Raj Sehgal under the provisions of Consumer Protection Act alleging therein that he obtained health insurance policy bearing No.233300/48/2013/445 for the period from 3.6.2012 to 2.6.2013 from the opposite party. According to the complainant he fell ill and suffered pain in chest and was admitted in Mahajan Hospital on 17.11.2012 and was discharged on 28.11.2012. The complainant incurred a sum of Rs. 1,29,693/- towards his medical treatment. The complainant lodged claim with the opposite party alongwith all the medical bills etc. But the opposite party did not decide the claim case of the complainant and the complainant sent letter to the opposite party on 25.4.2013 . But inspite of that the opposite party has not paid the claim of the complainant. Complainant has alleged that even after discharge from the hospital, he further incurred about Rs. 35000/- towards medicines, but the opposite party did not pay the claim amount to the complainant. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to  pay the amount of Rs. 1,29,693/- alongwith interest. Compensation of Rs. 50000/- alongwith litigation expenses were also demanded.

2. On notice, opposite party appeared and filed written version in which it was submitted that  the claim preferred by the complainant has been repudiated by the TPA vide letter dated 20.12.2012 and the complainant  was duly informed giving detailed reasons of the repudiation of the claim case of the complainant. The policy

-3-

period has been mentioned as 3.6.2012 to 2.6.2013 .However, the complainant has not given reference of any previous policy but on verifying record,  it was revealed that this policy was renewal of earlier policy which was for the period from 3.6.2011 to 2.6.2012. So the relevant policy was running during second year but has not completed the said period. As per exclusion 4.2 of the policy, it has been clearly agreed that treatment of certain diseases is not payable for the first two years  and in the said clause the period pertaining to diabetes has been mentioned being not covered for the first two years of the policy. The concerned TPA after investigating the claim came to the conclusion that during the period of insurance cover, the expenses on treatment of ailment/diseases/surgeries for diabetes disease for specified period of two years are not payable if contracted and/or manifested during the currency of the policy. It was submitted that the Acute Coronary Syndrome & LVF are known complications of diabetes. As such the claim has been rightly repudiated under policy exclusion 4.1 and 4.2 of the policy and there is no deficiency of service on the part of the opposite party.

3. Complainant tendered into evidence affidavit of Sh.Sanjeev Sehgal Ex.CW1/A,copy of death certificate of Des Raj Sehgal Ex.C-1 alongwith documents Ex.C-2 to Ex.C-46.

4. Opposite party tendered into evidence affidavit of Dr. H.S.Sandhu Ex.OP1, affidavit of Sh. Sandeep Thapa Ex.OP2, discharge card Ex.OP3, repudiation letter

-4-

dated 20.12.2012 Ex.OP4, letter dated 26.12.2012 Ex.OP5, policy alongwith terms and conditions Ex.OP6.

5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsels for both the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsels for both the parties.

6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant (insured Des Raj) got health insurance policy bearing No.233300/48/2013/445 for the period from 3.6.2012 to 2.6.2013 Ex.C3 from the opposite party. The complainant alleges that he got ill and suffered pain in chest and was admitted in Mahajan Hospital on 17.11.2012 and was discharged on 28.11.2012 as per discharge card Ex.C-6 and the complainant incurred a sum of Rs. 1,29,693/- as per bill Ex.C-7 towards his medical treatment. The complainant lodged claim with the opposite party alongwith all the medical bills etc. But the opposite party did not decide the claim case of the complainant and the complainant sent letter to the opposite party on 25.4.2013 . But inspite of that the opposite party has not paid the claim of the complainant. Even after discharge from the hospital, the complainant further incurred about Rs. 35000/- towards medicines, but the opposite party did not pay the claim amount to the complainant. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party qua the complainant.

7. Whereas the case of the opposite party is that the claim preferred by the complainant has been repudiated by the TPA M/s. Mediassist India Pvt.Ltd, who was duly authorized by the opposite party to deal with the claim case of the complainant vide letter dated 20.12.2012 addressed to the complainant Ex.OP4 giving detailed reasons of the repudiation of the claim case of the complainant. The complainant has obtained this policy in question as renewal of earlier policy which was issued by the opposite party to the complainant for the period 3.6.2011 to 2.6.2012 Ex.C-2, as such the relevant policy was running during second year but has not completed the second year. As per exclusion clause 4.2 of the policy in question,  has been clearly stated that treatment of certain diseases is not payable for the first two years and in the said clause the period pertaining to diabetes has been mentioned being not covered for the first two years of the policy. So the expenses incurred for diabetes disease for specified period of two years are not payable, if contracted and/or manifested during the currency of the policy is a Coronary Syndrome . Ld.counsel for the opposite party submitted that the claim of the complainant has been rightly repudiated under exclusion clause 4.1 and 4.2 of the policy. Opposite party further submitted that under the policy in question it is a cashless policy, expenses incurred in the hospital are only to be considered as per terms and conditions of the policy. So the complainant is also not entitled to the amount spent by the complainant towards medicines after the discharge from the hospital. Moreover, the complainant has not produced any bill regarding the amount he spent on medicines after the discharge from the hospital. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party qua the complainant.

8. From the entire above discussion, we have come to the conclusion that the complainant has been getting the insurance policy from the opposite party since 3.6.2011. He had earlier taken policy from the opposite party for the period from 3.6.2011 to 2.6.2012 Ex.C-2 and the policy in question for the period from 3.6.2012 to 2.6.2013 Ex.C-3. The complainant became ill and was admitted in Mahajan Hospital on 17.11.2012 and was discharged on 28.11.2012 as per discharge  card of the complainant issued by Mahajan Hospital Ex.C-6 and the complainant was diagnosed Acute Coronary Artery Syndrom with Acute LVF LV Dysfunction with DM.  The complainant paid Rs. 1,29,993/- to Mahajan Hospital as per consolidated bill Ex.C-7/C-46 , the details of which are Ex.C-8 to C-40. The complainant further alleges that he spent Rs. 35,000/- on medicines after the discharge from the hospital but he did not produce any bill or voucher of medicines of any amount that he has allegedly spent on his medical treatment after discharge from the hospital. The complainant lodged claim with the opposite party. The matter was investigated by the TPA M/s MediAssist India Pvt.Ltd and during investigation from the entire treatment record of the complainant of Mahajan Hospital, they have come to the conclusion that the complainant was admitted in Mahajan Hospital for the treatment of Coronary Syndrom with LVF for DM on 17.11.2012 and discharged on 28.11.2012. As per the policy terms and conditions during the period of insurance cover the expenses of treatment of ailment/disease/surgeries for diabetes disease for specified period of two years are not payable , if contracted and /or manifested during the currency of the policy.  The TPA has further mentioned in their repudiation letter Ex.OP4 dated 20.12.2012 that Acute Coronary Syndrome with LVF are known complications of diabetes. So they regret their inability to pay the claim of the complainant as per exclusion clause 4.1 and 4.2 of the policy in question. This letter dated 20.12.2012 Ex.OP4 was issued to the complainant. The complainant could not rebut the averment of this letter nor the complainant could produce any evidence to prove that the aforesaid diseases were not known complications of diabetes . As per exclusion clause 4.1 and 4.2 of the policy in question, the expenses incurred on treatment of ailment/diseases/surgeries for diabetes disease for specified period of two years are not payable if contracted and/or manifested during the currency of the policy. The complainant has not completed two years term of policy with the opposite party . As such opposite party was justified in repudiating the claim of the complainant through their TPA vide letter dated 20.12.2012 Ex.OP4.

9. Consequently we hold that opposite party was justified in repudiating the claim of the complainant. As such we hold that the complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.

10. Case could not be disposed of within the stipulated period due to heavy

pendency of the cases in this Forum.

13.3.2015 ( Bhupinder Singh )

President

( Kulwant Kaur Bajwa) (Anoop Sharma)

/R/ Member Member