THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 72 of 2015
Date of Institution : 28.1.2015
Date of Decision : 24.08 2015
Charanjit Kaur Wd/o Bhagwan Singh R/o 20/21, East End Estate, G.T.Road, Amritsar
...Complainant
Vs.
Oriental Insurance Co.Ltd., Branch office, Queens Road, Amritsar through its branch manager,Principal Officer
Medi Assist India TPA Pvt.Ltd., 47/1, Sri Krishna Arcade, Ist Main 9th Cross, Sarakki Industrial Layout, J.P.Nagar, 3rd Phase, Bangalore-560078 through its Managing Director/ CEO/General Manager/Principal officer
....Opp.parties
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh.R.P.Singh,Advocate
For the opposite parties No.1 & 2 : Sh. Sandeep Khanna,Advocate
Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member &
Sh.Anoop Sharma,Member
Order dictated by :-
-2-
Bhupinder Singh, President
1 Present complaint has been filed by Charanjit Kaur under the provisions of the Consumer Protection Act alleging therein that her husband Bhagwan Singh got insurance policy bearing cover note No. 920699 dated 24.12.2013 from opposite party No.1 for the period from 26.12.2013 to 25.12.2014. According to the complainant earlier also the complainant and her husband had obtained policy for the period from 26.12.2012 to 25.12.2013 . Complainant has alleged that on 9.11.2014 her husband Bhagwan Singh became ill and he was admitted in Fortis Escorts Hospital, Amritsar and he was diagnosed as case of Cardiac Arrest and treatment was started . Due intimation regarding the admission of deceased was given to the opposite party and also made request for cashless facility. According to the complainant she incurred Rs.38,657/- on the medical treatment of her husband Bhagwan Singh, insured. Claim was lodged with the opposite party. But the opposite party repudiated the claim vide letter dated 30.12.2014 on the ground that as per clause 4.2 (xvii) during the period of insurance cover the expenses on treatment of hypertension for specified period of two years are not payable, if contracted and/or manifested during the currency of the policy period. According to the complainant deceased was having age of 76 years and he died due to Cardiac Arrest . So from the death summary, it is clear that no treatment for hypertension was given to the patient and the deceased was suffered from cardiac arrest and the cause of death has also been shown as cardio pulmonary arrest. As such the repudiation of claim on this ground is not sustainable. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to reimburse the claim amount of Rs. 38,657/- alongwith interest @ 24% p.a. Compensation of Rs. 50000/- alongwith litigation expenses were also demanded.
2. On notice, opposite parties appeared and filed written version in which it was submitted that in the light of terms and conditions of the mediclaim policy, it was found that the claim is not payable as per exclusion clause 4.2 of the policy which reads as under :-
“During the period of insurance cover, the expenses on treatment of Hypertension for specified period of two years are not payable if contracted and/or manifested during the currency of the policy.”
As such the claim was considered as inadmissible vide letter dated 30.12.2014 in which it was clearly mentioned that there is direct relation between hypertension and cardiac arrest and the inception of policy is from 26.12.2012 and this is the second year of policy. As per the terms and conditions of the policy, the treatment related to hypertension is not payable and falls under exclusion of clause 4.2 for two years. The DLA Bhagwan Singh was a known case of hypertension on regular treatment and also had history of Vertigo prior to the inception of the policy in question. Therefore, opposite parties have repudiated the claim on merits and the complainant has been duly informed in this regard vide letter dated 30.12.2014 and there is no deficiency of service on the part of the opposite parties qua the complainant. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence her affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-10.
4. Opposite parties tendered copy of intimation letter Ex.OP1,2/1, copy of death summary Ex.OP1,2/2, copy of letter dated 30.12.2014 Ex.OP1,2/3, copy of cover note Ex.OP1,2/4, affidavit of Sh.Gurdip Singh Ex.OP1,2/5, copy of policy schedule Ex.OP1,2/6, terms and conditions Ex.OP1,2/7.
5. 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 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 and her husband Bhagwan Singh got insurance policy bearing cover note No. 920699 dated 24.12.2013 from opposite party No.1 for the period from 26.12.2013 to 25.12.2014. Earlier also the complainant and her husband had obtained policy for the period from 26.12.2012 to 25.12.2013 . On 9.11.2014 Bhagwan Singh husband of the complainant became ill and he was admitted in Fortis Escorts Hospital, Amritsar and he was diagnosed as case of Cardiac Arrest. Opposite party was informed about the admission of Bhagwan Singh, insured in the aforesaid hospital. However, Bhagwan Singh expired on the same day evening i.e. 9.11.2014. The complainant incurred Rs.38,657/- on the medical treatment of Bhagwan Singh, insured. Claim was lodged with the opposite party. But the opposite party repudiated the claim vide letter dated 30.12.2014 Ex.OP1,2/3 on the ground that as per clause 4.2 (xvii) during the period of insurance cover the expenses on treatment of hypertension for specified period of two years are not payable. Bhagwan Singh, deceased life assured (hereinafter to be called DLA) was having age of 76 years . He died due to Cardiac Arrest . From the death summary Ex.C-2 of Bhagwan Singh, it is clear that no treatment of hypertension was given to the patient and he died due to cardiac arrest and the cause of death has also been shown as Cardio Pulmonary Arrest. The repudiation of the claim on this ground is not genuine. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite parties qua the complainant.
7. Whereas the case of the opposite parties is that exclusion clause 4.2 of the policy in question reads as under :-
“During the period of insurance cover, the expenses on treatment of Hypertension for specified period of two years are not payable if contracted and/or manifested during the currency of the policy.”.
8. Opposite parties submitted that there is direct relation between hypertension and cardiac arrest and the inception of policy is from 26.12.2012 which means it was the second year policy. As per the terms and conditions of the policy, the treatment related to hypertension is not payable and falls under exclusion clause 4.2(xvii) for two years. The DLA Bhagwan Singh was a known case of hypertension on regular treatment and also had history of Vertigo prior to the inception of the policy in question. Therefore, opposite parties have repudiated the claim on merits and the complainant has been duly informed in this regard vide letter dated 30.12.2014 Ex.OP1,2/3. Ld.counsel for the opposite parties submitted that there is no deficiency of service on the part of the opposite parties qua the complainant.
9. From the entire above discussion, we have come to the conclusion that the complainant got Insurance policy in question Ex.C-4 i.e. PNB Oriental Royal Mediclaim policy , cover note of which is Ex.C-4 for the period from 26.12.2013 to
25.12.2014 , from opposite party No.1. Bhagwan Singh, DLA was admitted in Fortis Escorts Hospital on 9.12.2014 where he expired in Emergency room due to cardiac arrest as per death summary of the patient Ex.C-2. Opposite party was informed. Claim was lodged by the complainant regarding the death of her husband Bhagwan Singh, DLA with opposite party No.1. But the opposite party repudiated the claim of the complainant vide letter dated 30.12.2014 Ex.C-3 on the ground that the expenses on treatment of hypertension is not covered for first two years of the policy and DLA Bhagwan Singh died due to cardiac arrest, as a result of hypertension.
10. Death summary of DLA Bhagwan Singh fully proves that he was 76 years old. He was a known case of hypertension on regular treatment. He has also history of Vertigo . The patient has cardiac arrest in Emergency room, endotracheal intubation done and he was revived. On examination, his BP was found 233/136 mmHG, Patient became hypertensive. Patient also went into bradycardia and SPO2 continuously began to fall. However, despite all efforts the patient condition did not improve and ultimately he was declared dead at 8.50 p.m on 10.11.2014. So it stands fully proved on record that the patient was a known case of hypertension on regular treatment. There is direct relation between hypertension and cardiac arrest. DLA died of cardiac arrest due to hypertension with BP as 233/136 mmHG and he was on regular treatment of hypertension . As per exclusion clause 4.2(xvii) of the policy Ex.OP1,2/7, expenses on treatment of hypertension for specified period of two years are not payable if contracted and/or manifested during the currency of the policy. DLA was having policy since 26.12.2012 and he expired on 10.11.2014 i.e. within two years of inception of policy. The opposite party was, therefore, justified in repudiating the claim of the complainant as per terms and conditions of the policy.
11. Consequently we hold that there is no merit in this complaint and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. 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.
24.08.2015 ( Bhupinder Singh )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
/R/ Member Member
