BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 247 of 2013

Date of Institution: 2.4.2013

Date of Decision: 01.10.2015  

Achala Khullar wife of Shri Vipan Khullar, resident of Shri Durgawood Industry, Outside Gali No.2, G.T.Road, Putlighar, Amritsar. 

Complainant

Versus

1. Oriental  Insurance Company Limited, 28 Second Floor, Dharam Singh Market, Amritsar through its Branch Manager/ Divisional Manager/ Principal Officer.
2. E-Meditech (TPA) Services Limited, Regional Office S.C.No.62, Second Floor, Sector 30-C, Chandigarh-163030, through its Principal Officer.

Opposite Parties

Complaint under section 12 and 13 of the Consumer Protection Act.

Present: For the Complainant: Sh. R.K.Mehra, Advocate.

              For the Opposite Party No.1: Smt.Neelam Khanna, Advocate

              For the Opposite Party No.2: Exparte.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Smt.Achala Khullar under the provisions of the Consumer Protection Act alleging therein that husband of the complainant Vipan Khullar obtained mediclaim policy bearing No.235302/ 48/2013/283 from Opposite Party No.1 valid for the period from 20.5.2012 to 19.5.2013  and as per this policy, three persons were insured namely Vipan Khullar (self), Mrs.Achala (complainant) and Master Chanakya Khullar  were insured for Rs.5 lacs each. The husband of the complainant has been getting medi claim policies for the last so many years in which complainant is also insured. The complainant was admitted in Dayanand Medical College & Hospital, Ludhiana on 10.9.2012. The husband of the complainant was admitted in Dayanand Medical College & Hospital, Ludhiana where his kidney was transplanted. The complainant had to donate her kidney being the spouse and she was admitted in the said hospital. The complainant had suffered stroke after she underwent nephrectomy. Said stroke has got  no relation with survival procedure, the complainant underwent. On account of the said stroke, the complainant remained admitted in hospital w.e.f. 10.9.2012 to 27.9.2012 and during this period, she spent Rs.2,42,474/-. She also spent Rs.38,821/- from the date of discharge till 60 days. The complainant also remained admitted in Bajwa Hospital, Amritsar and  an amount of Rs.21,384/- were spent on her treatment. In this way, total amount of Rs.3,02,679/- was paid by the complainant for the medical treatment.  The complainant submitted claim form with the Opposite Party No.1 for  reimbursement and she also made various requests to Opposite Parties, but the Opposite Parties  have repudiated the claim of the complainant without any reason.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to pay Rs.3,02,679/- towards medical treatment charges alongwith interest @ 12% 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 insurance was limited to over all sum insured of the insured person as the recipient has already exhausted the same in the previous claim and as per section 1 scope of cover 1.2 note 2 clearly evident that hospitalization expenses incurred  for donating an organ by the donor (excluding cost of organ, if any) to the insured person during the course of organ transplant will be payable. However, in case of the liability of the company will be limited to all the sum insured of the insured person and in the present case, the same has already been exhausted by the recipient in the previous claim, as such, this claim is not maintainable. As per the medical record and the previous claim record the patient underwent nephrectomy as a donor and she  was declared fit for the procedure with no underline co-mobibility i.e. no previous disease condition with no h/s seizure nozia vomiting, nephrectomy was done on 11.9.2012 following which, on second post operative day 03:00 A.M she developed right hemiearesis. This claim can not be paid from the sum insured of the donor, but from that of the recipient which is already exhausted in the previous claim and as such, this claim is not sustainable. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Party No.2 served, but non appeared on behalf of Opposite Party No.2, so Opposite Party No.2 was proceeded against exparte vide order dated 16.5.2013 of this Forum.
4. Complainant tendered into evidence her affidavit Ex.CW1/A alongwith documents Ex.C1 to Ex.C185 and closed the evidence on behalf of the complainant.
5. Opposite Party No.1 tendered into evidence affidavit of Sh.A.S.Dhingra, Senior D.M. Ex.OP1 alongwith documents Ex.OP2 to Ex.OP5.
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 husband of the complainant namely Vipan Khullar got medical insurance policy from Opposite Party No.1 bearing  No.235302/ 48/2013/283 Ex.C82/ Ex.C183 on 5.5.2012 which was valid for the period from 20.5.2012 to 19.5.2013 vide which three persons namely Vipan Khullar (self), Mrs.Achala (complainant) and Master Chanakya Khullar were insured to the extent of Rs.5 lacs with domiciliary hospitalisation  limited upto Rs.50,000/- each. On 10.9.2012 the complainant Achala Khullar wife of Vipan Khullar was admitted in Dayanand Medical College & Hospital, Ludhiana.  The husband of the complainant was admitted in Dayanand Medical College & Hospital, Ludhiana where his kidney was transplanted and the  complainant had to donate her kidney being the spouse and she was also admitted in the said hospital. Thereafter, the complainant had suffered stroke after she underwent nephrectomy. On account of the said stroke, the complainant remained admitted in hospital w.e.f. 10.9.2012 to 27.9.2012 and during this period, she spent Rs.2,42,474/-. She also spent Rs.38,821/- from the date of discharge till 60 days on her medical treatment. The complainant also remained admitted in Bajwa Hospital, Amritsar and  spent  an amount of  Rs.21,384/- on her treatment. In this way, in all she spent a sum of  Rs.3,02,679/- on her medical treatment.  The complainant submitted claim form with the Opposite Party No.1 alongwith all the relevant documents, bills/receipts, etc. with the Opposite Parties  for the   reimbursement, but the Opposite Parties repudiated he claim of the complainant vide letters Ex.C80 and Ex.C81 on the ground that this claim is for the donor nephrectomy (kidney donor). As per policy terms and conditions, the expenses of donor need to be paid from the sum insured of the claimant only. In this case both husband and wife are covered in the same policy, so the separate claim can not be entertained for kidney donor. Further sum insured of the policy is Rs. 5 lacs and amount of the patient’s claim is Rs.4,38,616/-, (claim No. 103091200011), so some of the expenses can not be paid, but under the claim of the patient and not that of donor. Further the Opposite Parties  have not received  the complete documents from the complainant,  so they treated the claim of the complainant as ‘no claim’. The complainant submitted that the complainant as well as  her husband Vipan Khullar have been insured separately for Rs.5 lacs each and have paid consolidated premium. The doctor of the Dayanand Medical College & Hospital, Ludhiana who treated the complainant has given categorical opinion/ certificate dated 11.1.2013 Ex.C2 that stroke suffered by the patient/ complainant has got no relation with the surgical procedure  the patient/ complainant underwent. Ld.counsel for the complainant submitted that the Opposite Parties  have  wrongly treated the claim of the complainant as  no claim vide letters Ex.C80 and Ex.C81 and   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 insurance was limited to over all sum assured of the insured person as the recipient Vipan Khullar has already exhausted the same in the previous claim and as per section 1 scope of cover 1.2 note 2, it is   clearly evident that hospitalization expenses incurred  for donating an organ by the donor (excluding cost of organ, if any) to the insured person during the course of organ transplant will be payable. As Vipan Khullar has already exhausted the insured sum in the previous claim, as such this claim is not maintainable. The patient underwent nephrectomy as a donor and she  was declared fit for the procedure with no underline co-mobibility i.e. no previous disease condition, nephrectomy was done on 11.9.2012 following which on second post operative day she developed right hemiearesis. This claim can not be paid from the sum insured of the donor, but from that of the recipient which is already exhausted in the previous claim and as such, this claim is not sustainable. Ld.counsel for Opposite Party No.1 has rightly treated the claim of the complainant as ‘no claim’, so there is no deficiency of service on the part of Opposite Parties  qua the complainant.
9. From the entire above discussion, we have come to the conclusion that Vipan Khullar husband of the complainant obtained medi claim policy from Opposite Party No.1 bearing  No.235302/ 48/2013/283 Ex.C82/ Ex.C183 on 5.5.2012 which was valid for the period from 20.5.2012 to 19.5.2013 vide which three persons namely Vipan Khullar (self), Mrs.Achala (complainant) and Master Chanakya Khullar were insured to the extent of Rs.5 lacs each with domiciliary hospitalisation  limited upto Rs.50,000/- each. The record produced by the complainant proves that the complainant, her husband and child were insured with Opposite Party No.1 for the period from 20.5.2010 to 19.5.2011 vide policy Ex.C181, for the period from 20.5.2011 to 19.5.2012 vide policy Ex.C182, for the period from 19.5.2011 to 20.5.2012 vide policy Ex.C185 and the Opposite Parties  did not deny these facts. Husband of the complainant was admitted in Dayanand Medical College & Hospital, Ludhiana where his kidney was transplanted. The complainant was also admitted in that hospital on 10.9.2012 as she had to donate her kidney to her spouse. After nephrectomy, the complainant suffered stroke and she remained admitted in Dayanand Medical College & Hospital, Ludhiana from 10.9.2012 to 27.9.2012 as per case Summary & Discharge Summary Ex.C12. During this period, she spent Rs.2,42,474/- at Dayanand Medical College & Hospital, Ludhiana as per bills and receipts Ex.C15 to Ex.C79. Thereafter, she spent  Rs.38,821/- from the date of discharge on her medical treatment from aforesaid Dayanand Medical College & Hospital, Ludhiana till 60 days, as per detailed chart Ex.C84, detail /bills receipts of which are Ex.C85 to Ex.C97. Thereafter, the complainant was admitted in  Bajwa Hospital, Amritsar on 6.11.2012 and was discharged on 10.11.2012 as per discharge card Ex.C100  and  spent  an amount of  Rs.21,384/- on her treatment. In this way, she spent a sum of  Rs.3,02,679/- on her medical treatment as per bills Ex.C99, Ex.C103 to Ex.C110 and in all, the complainant spent an amount of Rs.3,02,679/- on her medical treatment. The  complainant submitted claim form Ex.C5 alongwith all the relevant documents including bills, receipts, etc. with the Opposite Parties  for reimbursement, but the Opposite Parties repudiated the claim of the complainant vide letters Ex.C80 and Ex.C81 on the ground that this claim is for the donor nephrectomy (kidney donor). As per the policy terms and conditions, the expenses of donor need to be paid from the sum insured of the claimant only. In this case both husband and wife are covered in the same policy, so the separate claim can not be entertained for kidney donor. The sum insured of the policy is Rs.5 lacs and claimed amount  of the patient’s (Vipan Khullar) claim is Rs.4,38,616/-, so some of the expenses can be paid, but under the claim of the patient and not that of donor. Further, the Opposite Parties  have not received  the complete documents. So, the Opposite Parties  treated the claim of the complainant as ‘no claim’.
10. As per the policy Ex.C82/ Ex.C183 all the 3 insured i.e. Vipan Khullar (Self), Achala Khullar (complainant) and Master Chankya Khullar were insured for Rs.5 lacs each. So, the complainant herself is entitled to separate claim upto Rs.5 lacs as per this policy. Further, the complainant has produced  on record certificate dated 11.1.2013 Ex.C2 of the doctors of Dayanand Medical College & Hospital, Ludhiana i.e. from doctors who treated the complainant at Dayanand Medical College & Hospital, Ludhiana in which it has been categorically certified by those doctors that patient Achala Khullar had stroke after she underwent nephrectomy. The stroke has no relation with the surgical procedure this patient underwent. The Opposite Party No.1 could not produce any evidence to rebut this certificate issued by Dayanand Medical College & Hospital, Ludhiana Ex.C2. So  it stands fully proved on record that the complainant suffered stroke after she underwent nephrectomy and that too on the next day of nephrectomy and this fact has been admitted by the Opposite Party No.1  in their written version in para No.3 that patient underwent nephrectomy on 11.9.2012 and she suffered stroke on the second post operative day. It has been fully established from the certificate Ex.C2  issued by Dayanand Medical College & Hospital, Ludhiana that this stroke has no relation with the surgical procedure this patient underwent i.e.nephrectomy. So, the Opposite Party No.1 was bound to pay the claim of the complainant amounting to Rs.3,02,679/- and the  Opposite Party No.1 has wrongly treated the claim of the complainant as ‘no claim’ vide letters Ex.C80 and Ex.C81.
11. Resultantly, we hold that the Opposite Party No.1 is in deficiency of service qua the complainant.
12. Consequently, we allow the complaint with costs and the Opposite Party No.1 is directed to pay this amount of Rs.3,02,679/- to the complainant alongwith interest @ 9% per annum from the date of filing the complaint i.e. 2.4.2013 till the payment is made to the complainant. The Opposite Party No.1 is also directed to pay to the complainant the litigation expenses 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: 01.10.2015.                                                                 (Bhupinder Singh)                                                                                            President

hrg                                                                   (Kulwant Kaur Bajwa)   

                                  Member