Punjab

Ludhiana

CC/14/607

Harmeet Kaur - Complainant(s)

Versus

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

G.S.Manners

27 Mar 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 607 of 02.09.2014

                                                                                                                    Date of Decision: 27.03.2015

                                                                                                                   

Harmeet Kaur d/o S.Balwinder Singh Dhir, r/o B-IX, 844, Khud Mohalla, Sikandari Road, Ludhiana.

……Complainant

Versus 

Oriental Insurance Co. Ltd. CBO-IV, Vishkarma Chowk, G.T.Road, Miller Ganj, Ludhiana, through its Branch Manager.  

…..Opposite party 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                     Sh.Sat Paul Garg, Member

                    Smt.Babita, Member

 

Present:       Sh.G.S.Maurya, Advocate for complainant.

                   Sh.Rajeev Abhi, Advocate for OP.

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Harmeet Kaur d/o S.Balwinder Singh Dhir, r/o B-IX, 844, Khud Mohalla, Sikandari Road, Ludhiana (herein-after in short to be referred as ‘complainant’) against Oriental Insurance Co. Ltd. CBO-IV, Vishkarma Chowk, G.T.Road, Miller Ganj, Ludhiana, through its Branch Manager (herein-after in short to be referred as ‘OP’)- directing them to disburse the claim amount of Rs.63,515/- to the complainant alongwith interest @ 12% p.a. from the date when the complainant lodged the claim till its payment, to pay Rs.25,000/- as compensation on account of mental tension, torture, agony, financial loss to the complainant alongwith any other additional or alternative relief to which the complainant may be found entitled.

2.                Brief facts of the complaint are that the complainant purchased a Happy Floater Policy from the OP, vide policy no.233902/48/2013/3838 valid from 9.3.13 to 8.3.14. Father of the complainant namely Balwinder Singh was also covered in this policy. All of sudden Balwinder Singh father of the complainant suffered from chest pain. He was admitted and treated by the doctors of CMC Hospital, Ludhiana. He remained admitted in hospital from 29.12.13 to 4.1.14 and incurred expenses of Rs.63,515/- on the treatment. The doctors of CMC Hospital noted the present illness as “Restrosternal chest pain x 3 days” and finally they diagnosed the case of CAD-ACS-Anterior Well Stemi (Thrombolysed with STK), LV Dysfunction, Hypertension, which clearly means that the Balwinder Singh felt pain just 3 days before the admission prior to that he was absolutely normal. The complainant lodged claim with the OP and complied with all the requirements of the OP for settlement of the claim, but the OP alleged that Balwinder Singh was suffering from hypertension from last 5 years, hence the decease is not covered under exclusion clause 4.1 and 4.8. The complainant made enquiry with the doctors of CMC Hospital, where it was revealed that somebody has told the doctors that Balwinder Singh was suffering from Hypertension for the last five years. Whereas the Balwinder Singh never suffered from Hypertension. Balwinder Singh requested the doctors of CMC Hospital to correct the record. As per requirement of hospital, Balwinder Singh sworn an affidavit and the CMC Hospital corrected the record in this regard. The complainant again requested the OP to settle the claim in view of amended record of hospital. But ultimately the OP closed the claim file as ‘no claim’ on 12.5.14. Claiming the above act as deficiency in service on the part of the OP, the complainant has filed this complaint.

3.                On notice of the complaint, OP appeared through his counsel and filed written statement taking preliminary objections that the present complaint is barred u/s 26 of the Consumer Protection Act; the present complaint is not maintainable since immediately on the receipt of the claim it was duly registered, entertained and processed. After the receipt of the claim papers the same was sent to M/s Park Mediclaim TPA Pvt. Ltd. for processing the said claim. The doctors of the TPA made thorough investigation, inspected the record of CMC and Hospital, Ludhiana and as per the said inpatient cases note of CMC and Hospital, Ludhiana, Sh.Balwinder Singh Dhir was a known case of hypertension for last five years and was on regular medication. The said fact is mentioned by the doctors of CMC and Hospital, Ludhiana under the head past medical. After the receipt of patient file of Balwinder Singh Dhir and after scrutinizing the documents placed in the claim and after applying the mind by the doctors of Park Mediclaim TPA Pvt. Ltd. the claim of Mr.Balwinder Singh Dhir with date of admission as 29.12.13 and date of discharge as 4.1.14 at CMC & Hospital, Ludhiana was rejected as no claim, vide letter dated 6.5.14 sent to Senior Branch Manager, Oriental Insurance Co. Ltd. G.T.Road, Vishwakarma Chowk, Ludhiana. After the receipt of the entire file alongwith the decision of M/s Park Mediclaim TPA Pvt. Ltd. dated 6.5.14 and after applying the mind by the officials of Oriental Insurance Co. Ltd. in terms of the insurance policy the claim of the complainant was repudiated as no claim by the OP, vide their letter dated 12.5.14 on the grounds that Happy Family Floaters Mediclaim Policy does not cover the expenses incurred on pre existing hypertension and its listed complications coronary artery disease under exclusion clause 4.1. There is as such no deficiency in service on the part of the OP. The claim of the complainant has rightly been repudiated as no claim and the grounds of repudiation are legal valid and enforceable and are in accordance with terms and conditions of the insurance policy. The complainant is estopped by his own act and conduct from filing the present complaint. On merits, admitting the facts mentioned in the preliminary objections and denying the contents of all other paras of the complaint, OP prayed for the dismissal of the complaint.

4.                Ld. Counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Smt.Harmeet Kaur Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached the documents Ex.C1 to Ex.C9. On the other hand, Ld. Counsel for OP has adduced the evidence by way of duly sworn affidavit of Sh.Naresh Singla, Branch Manager, Oriental Insurance Co. Ltd. Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and affidavit of Dr.A.K.Batra, Medical Director of Park Medicliam TPA Pvt. Ltd. Ex.RB and also attached documents Ex.R1 to Ex.R17.

5.                Case was fixed for arguments. During the course of arguments Ld. Counsel for complainant argued that the complainant had purchased a Happy Family Floater Policy bearing no.233902/48/2013/3838 valid from 9.3.13 to 8.3.14, vide which, the father of the complainant was also covered.  Suddenly Balwinder Singh, father of the complainant suffered from chest pain and admitted in the CMC and Hospital, where he remained admitted from 29.12.13 to 4.1.14 and  complainant was noted the illness as ‘Restrosternal Chest Pain x 3 days and finally they diagnosed it a case of CAD-ACS-Anterior Wall Stemi (Thrombolysed with STK), LV Dysfunction, Hypertension and spent an amount of Rs.63,515/- on his treatment. OPs made enquiry and found that father of the complainant was suffering from Hypertension for the last 5 years, whereas father of the complainant was never suffered from the said disease. In the record of the hospital, it was wrongly mentioned that patient was suffering the hypertension for the last 5 years, however, he was not suffering from Hypertension for the last 5 years. As per the record of the hospital, it was wrongly mentioned as 5 years, which was corrected on application by the doctor, which is placed on file Ex.C5. So, the claim of the complainant has been wrongly rejected by the OPs and even there is no nexus of Hypertension with the said disease for which, he underwent the treatment. Even for the sake of arguments, it is presumed that he was suffering from Hypertesnion since the last 5 years and he was on medication for the same.

6.                Ld. counsel for the OP filed written arguments, wherein, reiterating the facts of the written statement at the point of arguments submitted that insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy. The complainant was the known case of hypertension for the last 5 years and was on regular medication, as is evident from Ex.R4. The complainant has concealed and suppressed the material facts at the time of obtaining the insurance policy. As per available information Balwinder Singh is covered under Happy Family Floater Policy since 9.3.11 only. The said policy does not cover the expenses incurred on pre existing hypertension and its listed complication i.e. coronary artery disease vide exclusion clause 4.1. The doctors of Mediclaim TPA Pvt. Ltd. had made thorough investigation, examined the record of CMC Hospital, Ludhiana particularly inpatient cases notes. As per the said inpatient cases notes, it is clearly stated under past medical as under:-

R/C/O HTN X 5 years on regular medication.

The doctors of the Park Mediclaim TPA Pvt. Ltd. vide their letter dated 6.5.14 and informed the OP that the claim is not admissible since “Mr.Balwinder Singh Dhir was hospitalized from 29.12.13 to 4.1.14 with diagnosis acute coronary syndrome with anterior wall myocardial infarction with LV Dysfunction with hypertension. He was thrombolysed immediately and underwent coronary angiography which revealed double vessel disease. Verification of inpatient record of the patient was done and it has been observed that the patient is a known case of hypertension for 5 years on regular medication. As per the available information, the patient is covered under Happy Family Floater Mediclaim Policy since 9.3.11 only. Happy Family Floater Mediclaim Policy does not cover the expenses incurred on pre-existing hypertension and its listed complications coronary artery disease vide exclusion clause 4.1”.

                   The inpatient notes of the patient file of Sh.Balwinder Singh is attached, which is self explanatory and cannot be corrected on the basis of any affidavit or by the hospital of their own after the discharge of the patient from the hospital without giving any cogent and reasonable reasons of alleged amendments. The alleged amendment of the record after the discharge of the patient from the hospital has no relevancy and evidential value in the eyes of law. The ground of the repudiation is legal, valid and enforceable and are in accordance with the terms and conditions of the insurance policy. There is as such no deficiency in service or negligence on the part of the OP in processing and repudiating the claim. Ld. counsel for OP also relied upon the judgements passed in cases titled as Ram Swarup Aggarwal and other Vs New India Assurance Co. Ltd.-2014(I) CPJ 615 NC passed by National Commission, Sapna Arora Vs Life Insurance Corporation of India and others-2009 (I) CPJ 588 passed by Punjab State Commission, Chandigarh, Kulwant Singh Vs United India Insurance Co. Ltd.-2008(IV) CPJ 196 (NC) passed by National Commission, Shakuntala R. Khosla Vs Oriental Insurance Co. Ltd.- 2012 (II) CPJ 78 passed by Maharashtra State Commission, Mumbai, Ram Swaroop Aggarwal and other Vs New India Assurance Co. Ltd.- 2014 (I) CPJ 615 (NC) passed by National Commission etc. etc.

7.                We have gone through the pleadings of the complainant as well as defence taken by the OPs and have also gone through the written arguments submitted on behalf of OP and the entire record placed on file. After going through the preliminary objections, the complaint was found to be maintainable.

8.                It is evident that father of the complainant was suffered chest pain  and he was admitted in CMC Hospital, Ludhiana for the treatment of the said illness and noted as ‘Restrosternal Chest Pain’ and remained in the hospital from 29.12.13 to 4.1.14 and incurred expenses of Rs.63,515/-. It is also evident that as per Ex.R4 page no.84 the patient was suffering from Hypertension since the last 5 years and on regular medication. But it is not proved by the OP that the said disease Restrosternal Chest Pain x 3 days, which was further diagnosis a case of CAD-ACS-Anterior Wall Stemi (Thrombolysed with STK), LV Dysfunction was the result of pre-existing disease or has any nexus or the result of the Hypertension, which is a pre-existing disease and the simple fact of the medication does not constitute it to be the pre existing disease.

9.                Sequel to the above discussion, the present complaint is allowed and OP is directed to settle and pay the claim of the complainant, which is allowable as per the terms and condition of the policy. Further OP is directed to pay Rs.4000/-(Four thousand only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days of receipt of the copy of the order, which be made available to the parties, free of cost. File be consigned to record room.

 

          (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

          Member                           Member                         President

Announced in Open Forum.

Dated:27.03.2015 

Hardeep Singh