Punjab

Ludhiana

CC/14/639

Gurvinder Singh - Complainant(s)

Versus

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

C.L.Vashisht

14 May 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                    Complaint No: 639 of 12.09.2014

                                                                   Date of Decision: 16.04.2015

                    

Gurvinder Singh, aged 62 years s/o Sh.Partap Singh, Resident of House no.1071, SCO 32-A, Tajpur Road, Sanjay Gandhi Colony, Ludhiana.

.…Complainant

Versus 

1. The Oriental Insurance Co. Limited, Regd. & Head Office A-25/27, Asaf Ali Road, New Delhi-110002, through its Chairman/Managing Director.

2. The Oriental Insurance Co. Limited, Branch Office at Miller Ganj, Ludhiana, through its Branch Manager.

…..Opposite parties 

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.Chaman Lal Vashisht, Advocate for complainant.

                   Sh.Rajeev Abhi, Advocate for OPs.

 

 

 

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.Gurvinder Singh s/o Sh.Partap Singh, Resident of House no.1071, SCO 32-A, Tajpur Road, Sanjay Gandhi Colony, Ludhiana (herein-after in short to be referred to as ‘complainant’) against The Oriental Insurance Co. Limited, Regd. & Head Office A-25/27, Asaf Ali Road, New Delhi-110002, through its Chairman/Managing Director and others (herein-after in short to be referred as ‘OPs’)- directing them to pay Rs.1,25,308/- as medical expenses incurred by the complainant on the treatment of his wife alongwith interest, to pay Rs.50,000/- as compensation on account of mental pain, tension and agony and to pay Rs.11,000/- as litigation as well as other expenses to the complainant.

2.                Brief facts of the complaint are that complainant availed medi claim policy namely PNB-Oriental Royal Mediclaim Policy Schedule, bearing no.233902/48/2014/3287 valid for the period 16.12.13 to 15.12.14 from the OPs and complainant taken the policy for himself and his wife Mrs.Parminder Kaur and paid premium of Rs.6830/- to the Ops. All of a sudden, Mrs.Parminder Kaur wife of the complainant suffered pain at midnight on 24.5.14 and immediately taken to Fortis Hospital, Chandigarh Road, Ludhiana and was admitted there for his treatment. Due intimation regarding the treatment of complainant’s wife was given to Ops. On 27.5.14 she was operated by the doctors of the hospital and was discharged on 29.5.14. Thereafter the wife of the complainant remained under the treatment as outdoor patient. The complainant has spent Rs.1,25,308/- for the treatment from this own pocket. The complainant submitted all the relevant documents alongwith medical policy claim form duly signed by the complainant with the OPs on 10.6.14. Thereafter complainant time and again requested the OPs to release the amount of Rs.1,25,308/- to the complainant, but the Ops did not release the amount. On 30.7.14 the complainant received a letter dated 4.7.14 from the OPs, vide which the OPs had stated that the claim is not admissible and further stated that the wife of the complainant was admitted at Fortis Hospital for the treatment of Recurrent Ventral Hernia with Intestinal obstruction Diabetes, Hypertension on 15.10.11 and discharged on 20.10.11. As per the policy terms and conditions, during the period of insurance cover, the expenses on treatment of ailment/diseases/surgeries for Hernia for specified period of 2 years are not payable if the contracted and/or manifested during the currency of the policy and repudiated the claim of the complainant. Infact prior to 24.5.14 Mr.Parminder Kaur was not under the treatment of Fortis Hospital and also was not admitted in the hospital as alleged by the OPs. Further there is no such term and condition supplied to the complainant in respect to the allegations leveled in their letter dated 4.7.14. Therefore the repudiation of the claim of the complainant is totally wrong and against the provisions of the law. The complainant also raised his grievances to the Higher Authorities vide application dated 12.8.14, but nothing has been heard so far. Claiming to the above act as deficiency in service on the part of the OPs, the complainant has filed this complaint.

 3.               On notice of the complaint, Ops appeared through their 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. Punjab National Bank had obtained the mediclaim policy for their account holders/employees of Punjab National Bank and his/her spouse and two dependent children etc. a policy called PNB Oriental Royal Mediclaim policy valid from 16.12.13 to15.12.14. The insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy. It is clearly stated in the exclusion clause no.4.2 and 4.1 that the company is not liable:

Exclusion Clause 4.2 – The expenses on treatment of following ailment/disease/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy. If these diseases are pre-existing at the time of proposal the exclusion no.4.1 for preexisting at the time of proposal the exclusion no.4.1 for preexisting condition shall be applicable in such cases. Iii Surgery of hernia. 2 years; xvi hypertension. 2 years xvii diabetes. 2 years.

Exclusion 4.1 – Pre-existing health condition or disease of ailment/injuries: any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), when the cover incepts for the first time and excluded up to three complete) years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of this mediclaim policy taken from the Oriental Insurance Company shall be considered, provided the renewals have been continuous and without any breach in period”.

                   Further as per the discharge summary Parminder Kaur was a known case of diabetic mellitus and hypertension on regular treatment since two years, known case of erosive escophagitis, GERD on regular treatment and also had cholecystecomy in 1993 and hysterectomy in 2011 and was diagnosed with recurrent ventral hernia with intestinal obstruction, diabetic mellitus and hypertension. The TPA i.e. Medic Assist India TPV Pvt. Ltd. after scrutinizing the document placed in the claim file, after making through investigation and after applying the mind by its doctors had informed the Oriental Insurance Co. Ltd. that the claim is not admissible as per terms and conditions of the policy since the wife of the complainant Parminder Kaur was treated fro recurrent ventral hernia with intestinal obstruction, diabetics and hypertension and as per terms and conditions of the policy, the expenses on treatment of ailment/disease/surgeries for hernia for specified period of two years are not payable if contracted and/or manifested during the currency of the policy and as per the submitted documents, if is evident that the wife of the complainant was suffering from hypertension and diabetics for the past two years and prior to the inception of the policy and as such the claim if repudiated under exclusion clause 4.1 and 4.2 of the policy; the present complaint is not maintainable since complicated question of law and facts is involved which required elaborated evidence both oral and documentary and it is only civil court of competent jurisdiction who can try and decide the present complaint. The complaint cannot be decided by the Forum in a summary manner; the complainant is estopped by his own act and conduct from filing the present complaint. On merits, admitted the facts mentioned in the preliminary objections and denying all other allegations of the complaint, Ops prayed for the dismissal of the complaint.

4.                Ld. Counsel for the complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Gurvinder Singh Ex.CW/A, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C9. On the other hand, Ld. Counsel for OPs has adduced the evidence by way of duly sworn affidavit of Sh.Naresh Gupta, Senior Branch Manager, Oriental Insurance Co. Ltd. Branch Office no.4, Vishwakarma Chowk, Miller Ganj, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and affidavit of Sh.abha Mathur, Branch Manager of Medi Assist India TPA Pvt. Ltd. Miller Ganj, G.T.Road, Ludhiana Ex.RB and also attached documents Ex.R1 to Ex.R14.

5.                Case was fixed for arguments. Ld. Counsel for complainant argued that treatment taken by the treatment taken by the complainant for Laparoscopic Repair of Ventral Hernia (Parietex composite MESH) has no connection with the pre-existing disease nor it was the result of pre-existing disease. Ld. Counsel for complainant relied upon judgements passed in cases titled as H.N.Shankara Shastry Vs The Assistant Director of Agriculture – 2004 (2) Apex Court Judgements 01 (SC) passed by Supreme Court of India, Iffco Tokia General Insurance Company Ltd.- 2012 (I) RCR (Civil) 901, B.V.Nagaraju Vs M/s Oriental Insurance Company Limited- Consumer Protection Cases 1996 (2) Reports- Civil Appeal no.6296 of 1995 passed by Supreme Court of India.

6.                Refuting the allegations of Ld. Counsel for complainant, Ld. Counsel for Ops filed written arguments, whereby reiterating the facts narrated in the written statement at the Point of arguments submitted that the insurance policy is a contract in itself and the parties are bound by the terms and conditions. Nothing can be added or abstracted out of it. Policy alongwith the terms and conditions of the policy was given to the complainant and this fact is clearly mentioned in Annexure C1 produced by the complainant that the policy is “Subject to attached Policy terms and conditions”. The complainant has intentionally withheld the production of the complete policy alongwith terms and conditions which were duly supplied to the complainant alongwith annexure C-1. The complainant has submitted the proposal form at the time of becoming one of the beneficiaries under the policy and the said proposal also forms the contract of insurance. The complainant has become the beneficiary under the policy referred above for the first time which is valid from 16.12.13 to 15.12.14. Mrs. Parminder Kaur was admitted with the history of diabetic mellitus and hypertension and got regular treatment since two years, known case of erosive escophagitis, GERD on regular treatment and also had cholecystecomy in 1993 and hysterectomy in 2011 and was diagnosed with recurrent ventral hernia with intestinal obstruction, diabetic mellitus and hypertension. The claim of complainant was repudiated as no claim vide letter dated 4.7.14 followed with letter dated 27.8.2.14 after due correction of typographical mistakes due to oversight on the grounds that since the same is not admissible under the policy and does not fall within the purview of the policy terms and conditions particularly exclusion clause no.4.1 and 4.2 of the policy. There is no deficiency in service on the part of the OPs. OPs have not adopted any unfair trade practices. The claim of the complainant is repudiated on the grounds which are legal valid, enforceable and are in accordance with the terms and conditions of the policy. The Ops have led reasonable and cogent evidence and as such the complaint filed by the complainant deserves dismissal. Ld. Counsel for Ops also relied upon the judgements passed in cases titled as Ram Sarup Aggarwal and others Vs New India Assurance Co. Ltd.-2014 (I) CPJ 615 NC by Nationla Commission, Sapna Arora Vs Life Insurance Corporation of India & others- 2009 (I) CPJ 588 by Punjab State Commission, Chandigarh, Kulwant Singh Vs United India Insurance Co. Ltd.-2008 (IV) CPJ 196 (NC) by National Commission, Shakuntala R. Khosla Vs Oriental Insurance Co. Ltd.- 2012 (II) CPJ 76 by Maharashtra State Commission, Mumbai, Deewan Surinder Lal Vs Oriental Insurance Co. Ltd.-2009 (I) CPJ 117 by National commission etc. etc.

7.                It is evident that the complainant availed Mediclaim policy namely PNB-Oriental Royal Mediclaim Policy Schedule, which was valid for the period 16.12.13 to 15.12.14 covering himself and his wife Mrs.Praminder Kaur. It is further evident that wife of the complainant all of sudden suffered pain and was brought to Fortis Hospital, Chandigarh Road, Ludhiana, where she was given treatment and operated by the doctors of the hospital and discharged on 29.5.14. The disease for which the complainant underwent treatment was not the result of the pre-existing disease i.e. Diabetes Mellitus and Hypertension and Erosive Esophagitis, GERD. In the present case the complainant underwent medical Procedure as Laparoscopic Repair of Ventral Hernia (Parietex Composite MESH) and OPs have not been able to prove that the treatment taken by the complainant was the consequence of all pre-existing diseases mentioned above. Infact prior to 24.5.14 Mr.Parminder Kaur was not under the treatment of Fortis Hospital and also was not admitted in the hospital as alleged by the OPs. Further there is no such term and condition supplied to the complainant in respect to the allegations leveled in their letter dated 4.7.14. Therefore the repudiation of the claim of the complainant is totally wrong and against the provisions of the law. The complainant also raised his grievances to the Higher Authorities vide application dated 12.8.14, but nothing has been heard so far. Claiming to the above act as deficiency in service on the part of the OPs.

8.                Sequel to the above discussion, the present complaint is allowed and Ops are directed to settle and pay the claim of the complainant, which is allowable as per the terms and conditions of the policy. Further Ops are directed to pay Rs.5000/-(Five thousand only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days from the receipt of the copy of the order, which be made available to the parties, free of costs. File be consigned to record room.

 

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

                   Member                           Member                         President

Announced in Open Forum.

Dated:16.04.2015 

Hardeep Singh