Delhi

North East

CC/147/2015

Sh. Jitendra Kumar - Complainant(s)

Versus

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

17 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. 147/15

 

In the matter of:

 

		Jitendra Kumar H/o WB 180, 2nd floor, Street No. 9, Ganesh Nagar Extn.2 New Delhi-110092.		Complainant
		Versus
		Oriental Insurance Company Ltd CBO-17, 57/204, Manjusha Building Nehru Place, New Delhi-110019.		Opposite Party
			DATE OF INSTITUTION:		27.04.2015
			JUDGEMENT RESERVED ON :		06.11.2017
			DATE OF DECISION      :		17.11.2017

 

 

N.K.Sharma, President:-

Ms. Sonica Mehrotra, Member:-

 

Order by Shri N.K.Sharma, President:-

 

 

 

ORDER

1. Briefly stated the case of the complainant is that he purchased a “Happy Family Floater Insurance policy” from OP covering himself and his wife Mrs. Alka Patel for the period effective 29.7.2013 to 28.7.2014  for a sum assured Rs. 10 Lakh on account of accidental cover and Rs. 5 lacs on account basic cover vide policy            No. 272102/48/2014/1119. The complainant stated that the insurance cover was given to him by OP when his health condition was perfect in all respects and after proper medical examination to the satisfaction of the OP.  However, in April 2014 the complainant felt back pain for which he visited Vashishta Clinic and hospital for orthopaedics at Malviya Nagar which is a network hospital of the TPA where the complainant underwent several test like X-ray, MRI and blood tests. The doctors of the said hospital diagnosed the complainant with Prolapsed Inter Vertebral Disc L4/L5 with B/L Sacroiliac Joints Dysfunction. Accordingly the complainant was given medicine and injection under day care program of the hospital three times after an interval of 15 days (i.e. on 7.5.2014, 22.5.2014 and 5.6.2014), instead of 24 hours hospitalization;  that on treatment the complainant recovered from the ailment and has placed on record discharge summaries dated 07.05.2014, 22.05.2014, 05.06.2014; that the complainant stated that he had incurred a sum of Rs. 1,21,263/- on Hospital bills and other expenses incurred like X ray, MRI, Blood Test and medicines etc. The complainant stated that the he had preferred a reimbursement claim to opposite party however the OP repudiated his claim vide letter dated 10.02.2015 citing following reason. We have processed the above claim in accordance with the terms and conditions, exclusions and limitations of Mediclaim policy issued to you. We regret to inform you that, your above claim fails to meet the following criteria and is considered non – admissible; Rejected under clause No. 2.3, C (III).

That aggrieved by the alleged illegal and arbitrary repudiation of the genuine claim of the complainant by the OP, the complainant was constrained to file the said complaint, holding OP liable for gross negligence, deficiency in service and unfair trade practice and his legal entitlement to medical insurance as per policy. The complainant has prayed before this forum for directions to the OP to:-

1. Pay Rs. 1,21,263 against medical claim with 18% interest. 
2. Pay Rs. 50,000/- on account of compensation for mental agony and harassment due to delay in processing the claim of the complainant
3. Pay Rs. 20,000/- against cost of litigation expenses.

 

2. Notice was issued to the OP and written statement was filed by the OP where the factum of the policy was not disputed. The OP however took the plea that since the complainant was hospitalized for the diagnosis of “PROLAPSED INTER VERTENRAL DISC L4/L5 WITH B/L SACROILIAC JOINTS DYSFUNCTION” under day care treatment vide discharged summary dated 7.5.2014, 22.5.2014 and 5.6.2016, therefore the condition of minimum 24 hours hospitalization was not fulfilled since the surgery procedure was a day care treatment and that too done under local anaesthesia. Had the surgery been done under general anaesthesia condition of minimum 24 hours hospitalization would not have applied. The OP therefore repudiated the claim vide letter dated 10.2.2015 in accordance with policy clause 2.3 C (iii) to which the OP has drawn the attention of this Forum. The clause is reproduced as here under:-

“2.3C says other then treatments mentioned under 2.3 (A), the condition of minimum 24 hours Hospitalization SHALL also not apply provided

(i) The treatment is such that it necessitates hospitalization and the procedure involves specialised infrastructural facilities available only in hospital OR

(ii) Surgical procedure involved has to be done under General Anaesthesia BUT (iii) Due to technological advances hospitalization in either of the case is required for less than 24 hours”.

Clause 2.3 dealt with treatments for which the condition of hospitalization for a minimum 24 hours did not apply so both the clauses 2.3A and 2.3C had to be read with together as per the stand of OP and in light of which the OP argued that the claim of the complainant was rightfully repudiated since his treatment did not fall under the treatments laid out in clause 2.3A i to xxvi.

The OP also took the plea that the present complaint was not maintainable as this Forum had no territorial jurisdiction to adjudicate upon the same since the policy in question was issued to the Complainant by the OP by its Branch            Office-17 situated at 57/204, Manjusha Building, Nehru Place, New Delhi and therefore outside the territorial jurisdiction of this Forum.

3. Evidence by way of affidavit were filed by both the parties placing on record the policy documents, medical treatment documents, repudiation letter for the relevant period.
4. Written arguments were filed by both the parties.
5. We have perused the case filed very carefully and have thoroughly gone through the documentary evidence placed on record.
6. With respect to the territorial jurisdiction, it has been observed that though bare perusal of memo of parties clearly and unequivocally establishes that the policy issuing office of the OP was located at Nehru place- South Delhi which was outside the teritoral jurisdiction of this Forum and as such the condition stipulated in section 11 sub clause 2 (a) or (b) or (c) of CPA were not fulfilled, however the OP did not strongly oppose or question / dispute the jurisdiction of this Forum at the inception of the case and therefore in accordance with proviso 11 (2) (b) (ii), it was deemed as acquiescence on the part of the OP with respect to jurisdiction of this forum and therefore as per section 11 (2) (b) (i), this Forum admitted the complaint and granted permission to the complainant for being heard on the said complaint.
7. In the written submission filed by the complainant the complainant has placed on record and has drawn our attention to the case of Oriental Insurance Company Ltd Vs Ranbir Sharma and Anr vide civil writ petition No. 12621 of 2013 decided by the Hon’ble High Court of Punjab and Haryana on 31.5.2013 by Hon’ble Justice Mr. Rajiv Narain Raina which dealt with facts, similar and relevant to the present complaint. In this case also the Oriental Insurance Co. Ltd had repudiated the claim in accordance of clause 2.3 of the policy which laid down that expenses on hospitalization are admissible only if hospitalization is for a minimum period of 24 hours. The High Court had observed that this clause was an unfair one and stay in hospital is only for a purpose of treatment. Further if a medical problem is solved in few hours such a claim should not be thrown out on fortuitous circumstance of hospitalization for less than the minimum 24 hours prescribed. A grave and deadly medical problem may be solved in an hour yet the expenses involved may be heavy. Insurance policies are brought for this purpose alone to save a policy holder and his family from sudden illness which may manifest itself without warning. The Hon’ble High Court held that claim of the party was based on equity, justice and good conscience of which the repudiation was improper and that too by an instrumentality of State thereby dismissing writ of the insurance company.
8. We have given a thoughtful consideration and application of judicial mind to the given complaint. Even for the sake of arguments if we uphold the OPs case of defence taken under the refuge of clause 2.3 proviso (C) (sub clause i &iii), the same very clearly states that expenses on hospitalization are admissible only if the hospitalization is for a minimum period of 24 hours. However, this condition shall not apply as per proviso sub clause(i) the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructure facilities available only in a hospital and sub clause (iii) thereof which states that due to technological advancement, hospitalization in either of the case is required to less than 24 hours. In the present case at hand the treatment for “PROLAPSED INTER VERTENT AL DISC L4/L5 WITH B/L SACROILIAC JOINTS DYSFUNCTION” was though done under local anaesthesia but the same necessitated hospitalization and due to technological advancement of treatment for the same could be done as day care treatment in three sittings due to advanced medical solutions instead of routine/ stereo typed 24 hours hospitalization. So therefore even as per the policy issued by the OP to the complainant the repudiation was bad, no-est and patently erroneous and not in accordance to the letter and spirit of proviso in clause 2.3 (c) (i) (iii) of the terms and conditions of the policy.
9. Further it is seen from the earlier order sheets that the OP had offered settlement to the complainant in 2015 but despite proposal put forth by OP to seek empanelled Doctors opinion to rule out necessity for 24 hours hospitalization of the complainant for facilitating approval of his claim, the OP could not place it on record of this Forum and even in Lok Adalat did a volte face.
10.   We therefore  find no merit or force in the arguments/defence of OP and allow the present complaint of the complainant and award a sum of  Rs. 1,21,263/- against medical claim towards expenses incurred by the complainant on medical treatment alongwith interest @ 9% p.a. from the date of filing of the complaint till realization. We also award a sum of  Rs. 15,000/- on account of compensation for mental agony and harassment due to delay on the part of OP in processing the claim of the complainant ultimately repudiating the same without any valid or cogent reason totally unsupported by their own policy condition and proviso. We also award Rs. 8,000/- as cost of litigation. The order shall be complied within 30 days from the date of copy of receipt of this order.
11.  Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
12.  File be consigned to record room.

                  (Announced on 17.11.2017)

                       

(N.K. Sharma) President		(Sonica Mehrotra)                      Member