BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 531 of 2013

Date of Institution: 26-07-2013

Date of Decision: 24-07-2015

Dr.Sanjeev Kaushal son of late Sh.T.D.Kaushal, resident of 375, Friends Colony, Majitha Road, Amritsar.

Complainant

Versus

1. Oriental Insurance Company Limited, 26, Kennedy Avenue, Court Road, Near PWD Rest House, Amritsar through its Branch Manager.
2. Medi Assist India TPA Private Limited, 47/1, Sri Krishna Arcade, Ist Main, 9^th Cross, Sarakki Industrial Layout, J P Nagar, 3^rd Phase, Bangalore-560078 through its Principal Officer.

Opposite Parties

Complaint under section 12 and 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh.  Updip Singh, Advocate

              For the Opposite Party No.1: Sh.P.N.Khanna, Advocate

              For the Opposite Party No.2: Exparate.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Dr.Sanjeev Kaushal under the provisions of the Consumer Protection Act alleging therein that he is having PNB-Oriental Royal Mediclaim Policy for indemnification of medical treatment expenses of the complainant, his wife Dr.Poonam Kaushal as well as his mother Smt.Naresh Kaushal being dependants of complainant. Complainant alleges that earlier during life time of father of the complainant, his father was holder of policy No. 233390/48/2011/149 with his mother as beneficiary. But after the death of his father in the year 2011, Opposite Party No.1 included Smt.Naresh Kaushal in the policy of the complainant, thus a policy No. 235301/48/2013/45 dated 4.4.2012 was issued in favour of the complainant, with his wife Dr.Poonam Kaushal aged 39 years and mother Smt.Naresh Kaushal aged 65 years as beneficiaries, with insurance cover of Rs.5 lacs. No disease was excluded in the said insurance cover. Rs. 6,830/- was paid by the complainant to Opposite Party No.1 as premium for one year for the said policy and I-Cards under the said policy were issued by Opposite Parties to all the beneficiaries of the policy. In the month of November, 2012 mother of the complainant Smt.Naresh Kaushal had fracture of her leg, for which purpose, she was admitted in Hartej Hospital, Amritsar. Opposite Parties sanctioned her cashless claim, thus her treatment charges were paid under the said policy.  On 26.3.2013, the complainant got renewed his mediclaim policy after making payment of Rs.6,830/-, wherein policy No. 235301/48/2014/4 was issued effective w.e.f. 4.3.2013 i.e. in continuation to the previous policy, in terms similar to the previous policy. However, unfortunately, mother of the complainant Smt.Naresh Kaushal had CVA on 4.4.2013, for which she was admitted in Hartej Hospital, Amritsar and remained admitted over there from 4.4.2013 till 19.4.2013 and then again from 30.4.2013 till 12.5.2013. The hospital tried to seek pre-authorization for treatment from Opposite Parties for the purpose of extending cashless facility to complainant’s mother as beneficiaries, but Opposite Parties refused admitting the claim on the pretext that the claim of Smt.Naresh Kaushal was not tenable under the said policy, as she could not have been insured under the policy in question. Complainant spent Rs.3,78,340/- on the treatment of his mother during the course of two hospitalizations, but Opposite Parties are refusing to entertain the genuine claim, rather refuse to register the claim of the complainant above mentioned. Complainant wrote letter to Opposite Parties with this regard, and personally met officials of Opposite Parties, but of no use. Even legal notice dated 25.4.2013 was got served upon Opposite Party No.1 with regard to first hospitalization, and then a number of e-mails had been sent to Opposite Parties in follow-up. For the above mentioned deficient acts of Opposite Parties of not making payment of genuine claim, the complainant is suffering harassment, mental agony, and financial loss for which Opposite Parties are liable to compensate the complainant. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to make the payment of claim amount of Rs.3,78,340/- alongwith interest @ 18% per annum.  Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party No.1 appeared and filed written version in which it was submitted that the complaint is legally not maintainable as the mother of the complainant Smt.Naresh Kaushal has not been impleaded as party in the present complaint. The nature of the policy as stated in the complaint is PNB Oriental Royal Mediclaim Policy under which coverage is given to the account holder and his family members as opted by the said account holder through PNB. The first policy was obtained on 4.4.2012 to 3.4.2013 and the said policy covered the risk of complainant, his spouse and mother. The mother of the present complainant got admitted in Hartej Hospital, Amritsar with complaint of upper end right tibia from 3.11.2012 to 10.11.2012 and she availed cashless facility through the concerned hospital which was approved and settled by Medi Assist Private Limited TPA. As far as present complaint is concerned, the same has been filed by the complainant on the ground that he further obtained policy from Opposite Party No.1 from 4.4.2013 to 4.3.2014 and her mother Smt.Naresh Kaushal suffered from CVA and remained admitted in hospital on 4.4.2013 to 19.4.2013 and again from 30.4.2013 till 12.5.2013. However, said hospital authorities tried to seek pre authorization for treatment for extending cashless facility, but the same was declined on the ground that the claim of Smt.Naresh Kaushal was not tenable under this policy as she could not have been insured under the policy in question. In fact this information disclosed by the complainant is perfectly correct because in the policy for the period from 4.4.2013 to 3.4.2014, the name of Smt.Naresh Kaushal i.e. mother of the complainant was deleted and in this regard, proper endorsement was also made. However, the complainant never challenged the said act nor made any protest which clearly shows that in fact the complainant had full knowledge that if any policy is obtained directly obtained from the insurance company, then the coverage of person above the age 60 years can not be made without complete medical tests. As the complainant did not opt to get medical tests of her mother as her age was above 60 years i.e. 65 years, therefore, the name of Smt.Naresh Kaushal was rightly deleted in the concerned policy for the period  4.4.2013 to 3.4.2014 and endorsement was also effected in this regard. Moreover, the plea taken by the complainant that this policy starting from 4.4.2013 to 3.4.2014 was the renewal of the earlier policy on the same coverage and terms and conditions, is totally wrong because the first policy is of different category i.e. known as PNB Oriental Royal Mediclaim Policy through PNB, whereas the second policy was obtained directly by the complainant from the Opposite Party No.1. So, the second policy i.e. policy in question can not be considered renewal of the earlier policy, rather it was independent policy obtained by the complainant and the same was issued according to the terms and conditions and the rules of the mediclaim policy under which if the coverage of any family member is to be made whose age is above 60 years, then complete medical tests are required, whereas, in the policy known as PNB Oriental Royal Medical Policy, no medical tests are required irrespective of age of the family members. While obtaining the second policy directly from the Opposite Party, the complainant did not submit the medical tests of his mother as her age was above 60 years, therefore, her name was rightly deleted. Therefore, the claim demanded by the hospital authorities for pre-authorization under the cashless facility was rightly refused by the TPA.  While denying and controverting other allegations, dismissal of complaint was prayed.
3. None appeared on behalf of Opposite Party No.2, so Opposite Party No.2 was proceeded against exparte vide order dated 11.9.2013 of this Forum.  
4. Complainant tendered into evidence the policy schedule Ex.C1, affidavit of complainant Ex.C2 alongwith other documents Ex.C3 to Ex.C23 and closed the evidence on behalf of the complainant.
5. Opposite Party No.1 tendered into evidence affidavit of Sh.R.K.Sharma, Divisional Manager Ex.OP1/1 alongwith documents Ex.OP1/2 to Ex.OP1/7 and closed the evidence on behalf of the Opposite Party No.1.
6. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
7. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got PNB-Oriental Royal Mediclaim Policy from Opposite Party No.1 covering  complainant, his wife Dr.Poonam Kaushal as well as his mother Smt.Naresh Kaushal being dependants of complainant because the father of the complainant expired in the year 2011. So, Opposite Party No.1 included Smt.Naresh Kaushal in the policy of the complainant. Earlier, the mother of the complainant Smt.Naresh Kaushal was in the policy of the father of the complainant policy No. 233390/48/2011/149. Thereafter, policy  No. 235301/48/2013/45 dated 4.4.2012 was issued in favour of the complainant, with his wife Dr.Poonam Kaushal aged 39 years and mother Smt.Naresh Kaushal aged 65 years as beneficiaries, with insurance cover of Rs.5 lacs. Complainant submitted that no disease was excluded in the said insurance cover. In the month of November, 2012 mother of the complainant Smt.Naresh Kaushal had fracture of her leg, and she was admitted in Hartej Hospital. Opposite Parties sanctioned her cashless claim and as such, her treatment charges were paid by the Opposite Parties under the said policy.  On 26.3.2013, the complainant got renewed his mediclaim policy. Resultantly, policy No. 235301/48/2014/4 was issued effective w.e.f. 4.3.2013 i.e. in continuation to the previous policy, in terms similar to the previous policy. Mother of the complainant Smt.Naresh Kaushal had CVA on 4.4.2013, for which she was admitted in Hartej Hospital and remained admitted over there from 4.4.2013 till 19.4.2013 and again from 30.4.2013 till 12.5.2013.  Said hospital tried to seek pre-authorization for treatment from Opposite Parties for the purpose of extending cashless facility to Opposite Parties, but Opposite Parties refused admitting the claim on the pretext that the claim of Smt.Naresh Kaushal was not tenable under the said policy, as she could not have been insured under the policy in question. Complainant spent Rs.3,78,340/- on the treatment of his mother during the course of aforesaid two hospitalizations, but Opposite Parties have refused  to settle the claim of the complainant, rather they refused to register the claim of the complainant. Complainant wrote letter to Opposite Parties with this regard through e-mail Ex.C16, but in vain. The complainant thereafter served   legal notice dated 25.4.2013 Ex.C15 on the Opposite Parties through registered post, but even then, the Opposite Parties failed to settle the claim of the complainant. Ld.counsel for the   complainant  submitted that all this amounts to deficiency of service on the part of the opposite parties.
8. Whereas the case of the Opposite Party No.1 is that the alleged treatment has been taken  by Smt.Naresh Kaushal i.e. mother of the complainant, but Smt.Naresh Kaushal has not been impleaded as party to the present complaint. Moreover, mother of the complainant could not have been insured in the policy in question. The nature of the policy of the complainant PNB Oriental Royal Mediclaim Policy is that it covers the  account holder and his family members as opted by the said account holder through PNB. The first policy was obtained by the complainant on 4.4.2012 to 3.4.2013 and the said policy covered the risk of complainant, his spouse and mother. Earlier, under that policy, the mother of the complainant was admitted in Hartej Hospital, Amritsar with complaint of upper end right tibia from 3.11.2012 to 10.11.2012 and she availed cashless facility through the concerned hospital which was approved and settled by Opposite Party No.1 through Opposite Party No.2-TPA. Complainant further obtained/ renewed policy from Opposite Party No.1 from 4.4.2013 to 4.3.2014 covering the complainant, his wife and his mother Smt.Naresh Kaushal. Mother of the complainant was admitted in  Hartej Hospital, Amritsar on 4.4.2013 to 19.4.2013 as per discharge summary Ex.C7 again from 30.4.2013 till 12.5.2013 as per discharge summary Ex.C19 and the complainant allegedly spent Rs.3,78,340/- on the medical treatment of Smt.Naresh Kaushal, but the claim of Smt.Naresh Kaushal was not tenable under this policy as she could not have been insured under the policy in question. Opposite Party No.1 further submitted that this information in fact disclosed by the complainant is perfectly correct because in the policy for the period from 4.4.2013 to 3.4.2014, the name of Smt.Naresh Kaushal i.e. mother of the complainant was included, but the same was deleted and in this regard, proper endorsement was also made, but the complainant never challenged the said act. The complainant had full knowledge that if any policy is purchased directly obtained from the insurance company, and then the coverage of person above the age 60 years can not be made without complete medical tests. As the complainant did not opt to get medical tests of her mother as her age was above 60 years i.e. 65 years, therefore, the name of Smt.Naresh Kaushal was rightly deleted in the concerned policy for the period  4.4.2013 to 3.4.2014 and endorsement was also effected in this regard. No doubt, the policy Ex.C6 for the period from 4.4.2013 to 3.4.2014 was the renewal of the earlier policy on the same coverage and terms and conditions, is totally wrong because the first policy is of different category i.e. known as PNB Oriental Royal Mediclaim Policy through PNB, whereas the second policy was obtained by the complainant directly from the Opposite Party No.1. So, the second policy i.e. policy in question can not be considered renewal of the earlier policy, rather it was independent policy obtained by the complainant and the same was issued according to the terms and conditions and the rules of the mediclaim policy under which if the coverage of any family member is to be made whose age is above 60 years, then complete medical tests are required, whereas, in the policy known as PNB Oriental Royal Medical Policy, no medical tests are required irrespective of age of the family members. While obtaining the second policy directly from the Opposite Party, the complainant did not submit the medical tests of his mother as her age was above 60 years, therefore, her name was rightly deleted. Therefore, the claim demanded by the hospital authorities for pre-authorization under the cashless facility was rightly refused by the TPA. Opposite Party No.1 further submitted that as the matter was discussed with complainant Dr.Sanjeev Kaushal and he was convinced that his mother could not be covered under the policy. As such, through endorsement the name of Smt.Naresh Kaushal mother of the complainant was deleted. Opposite Party No.1 was justified in repudiated the claim of the complainant for the medical treatment of his mother Smt.Naresh Kaushal.  Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party No.1.
9. From the entire above discussion, we have come to the conclusion that both the parties have admitted that Smt.Naresh Kaushal during the life time  of her husband i.e. father of the complainant who was holder of policy No. 233390/48/2011/149 was insured with her husband. However, father of the complainant i.e. husband of Smt.Naresh Kaushal expired in 2011. Thereafter, Opposite Party No.1 included Smt.Naresh Kaushal in the policy of the complainant  and they issued  policy  No. 235301/48/2013/45 dated 4.4.2012 covering the complainant,  his wife Dr.Poonam Kaushal aged 39 years and mother Smt.Naresh Kaushal aged 68  years as beneficiaries, with insurance cover of Rs.5 lacs. In the month of November, 2012 mother of the complainant Smt.Naresh Kaushal had fracture of her leg, and she was admitted in Hartej Hospital, Amritsar  and the  Opposite Parties sanctioned her cashless claim  under that policy for the year 2012-2013 as is evident from the policy documents Ex.C3 and Ex.C4. Opposite Party No.1 paid Rs.74131/- to Hartej Hospital, Amritsar    for the treatment of Smt.Naresh Kaushal, under the same policy for the previous year. Complainant got renewed same medical policy from Opposite Party No.1 on 26.3.2013 i.e. policy No.235301/48/2014/4  issued  to the complainant effective from  4.3.2013 i.e. in continuation to the previous policy, in terms similar to the previous policy. Mother of the complainant Smt.Naresh Kaushal had CVA on 4.4.2013 and was admitted in Hartej Hospital, Amritsar  on 4.4.2013 and was discharged on 19.4.2013 and thereafter again she was admitted on 30.4.2013 and was discharged on 12.5.2013 from Hartej Hospital, Amritsar.  Opposite Party No.1 refused cashless facility to the hospital this time on the ground that Smt.Naresh Kaushal mother of the complainant could not have been insured in the policy. The complainant  spent Rs.3,78,340/- on the treatment of his mother/ insured i.e. Smt.Naresh Kaushal. Opposite Party did not settle the claim case of the complainant, rather they refused to even entertain the claim case of the complainant on the ground that Smt.Naresh Kaushal mother of the complainant  had crossed the age of 60 years. She could not be insured without medical tests, but she never opted for medical tests. Opposite Party No.1 submitted that in this regard, complainant Dr.Sanjeev Kaushal  was called and convinced that Smt.Naresh Kaushal could not be covered under the policy, but inadvertently she has been covered under the policy in question. Opposite Party No.1 submitted that endorsement  was made in this regard and the name of Smt.Naresh Kaushal was deleted from the policy. But the Opposite Party No.1 could not produce any evidence that complainant  Dr.Sanjeev Kaushal  was called by Opposite Party No.1 and was convinced that name of his mother Smt.Naresh Kaushal has been inadvertently covered in the policy in question, rather Opposite Party No.1 when refused to settle the claim case of the mother of the complainant, the complainant wrote letter dated 11.4.2011 (Ex.OP1/6) to Opposite Party No.1 that he is getting such a bad treatment from the Opposite Party No.1. His mother has been duly covered under the policy, for the year 2012-2013, Opposite Party No.1 had already paid one claim of the treatment of the mother of the complainant Smt.Naresh Kaushal  last year and this fact has been admitted by Opposite Party No.1. Even in the last policy for the year 2012-2013 in which the claim of the mother of the complainant Smt.Naresh Kaushal/ insured was paid  by Opposite Party No.1, she was 68 years old and in the present policy she is stated as  69 years old as is evident from the policy issued by Opposite Party No.1 Ex.C6 and this policy has been issued by Opposite Party No.1 admitting that she has been given insurance coverage by Opposite Party No.1 for the last year policy, when she was 68 years old. Now the Opposite Party No.1 can not be allowed to say that as mother of the complainant i.e. Smt.Naresh Kaushal was more than 60 years old, she could not be covered in the policy.  This plea of the Opposite Party No.1 is not tenable.
10. Other plea taken by Opposite Party No.1 is that mother of the complainant Smt.Naresh Kaushal has been inadvertently given insurance cover  in the policy in question, is also not tenable because she had continuously  been covered by Opposite Party No.1 for the last so many years. Earlier in the policy of her husband and later on when husband of Smt.Naresh Kaushal expired in 2011, she was continuously being covered under the policy of complainant as dependent and this fact has been admitted by Opposite Party No.1.
11. Other plea taken by Opposite Party No.1 is that Opposite Party No.1 called complainant Dr.Sanjeev Kaushal  and he was convinced that Smt.Naresh Kaushal mother of the complainant has been inadvertently covered under the policy and later on endorsement was made by Opposite Party No.1 and the name of Smt.Naresh Kaushal was deleted from the policy is also not tenable, because the Opposite Party No.1 has totally failed  to prove this averment because the Opposite Party No.1 could not produce any evidence to prove that they called the complainant Dr.Sanjeev Kaushal  and convinced him that his mother Smt.Naresh Kaushal has been advertently / wrongly covered under this policy nor the Opposite Party No.1 could produce any letter or any document to prove that they convinced the complainant and he agreed to  delete the name of his mother Smt.Naresh Kaushal from the policy, rather the complainant has written letter Ex.OP1/6 dated 11.4.2011 in which he made protest to Senior Manager of the Opposite Party No.1 for not settling the claim of the mother of the complainant/ insured Smt.Naresh Kaushal. Opposite Party No.1 has also failed to prove on record any endorsement to prove that name of Smt.Naresh Kaushal was deleted from the policy in question nor Opposite Party No.1 could produce any letter written to the complainant or to Smt.Naresh Kaushal stating that the name of Smt.Naresh Kaushal has been deleted from the insurance policy in question nor Opposite Party No.1 could produce any evidence to prove that they have refunded the proportionate premium amount to the complainant or to Smt.Naresh Kaushal because the deletion of name of any insured from the policy requires proportionate refund of premium amount to the insured. So, the Opposite Party No.1 has totally failed to prove on record that Smt.Naresh Kaushal was not covered in the policy in question or that her name was deleted from the policy in question, rather Opposite Party No.1 has concocted this story just to repudiate the claim of Smt.Naresh Kaushal i.e. mother of complainant who is duly insured under the policy in question Ex.C6/ Ex.OP1/7. We therefore, hold that Opposite Party No.1 has wrongly repudiated the claim of Smt.Naresh Kaushal insured.
12. Resultantly, we allow the complaint with costs and the Opposite Party No.1 is directed to pay the amount spent by the complainant on the medical treatment of his mother Smt.Naresh Kaushal amounting to Rs.3,78,340/-, within one month from the date of receipt of copy of this order, failing which Opposite Party No.1 shall be liable to pay interest @ 9% per annum on this amount, from the date of filing the complaint till the payment is made to the complainant. Opposite Party No.1 is also directed to pay the litigation expenses to the complainant to the tune of Rs.2,000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 24-07-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member