Punjab

Ludhiana

CC/14/390

Sanjeev Jain - Complainant(s)

Versus

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

16 Jan 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 390 of 21.05.2014

                                                                                                                    Date of Decision: 11.02.2015

                                                                                                                   

Sanjeev Jain s/o Sh.Kimti Lal Jain, resident of House no.43, Street no.7, New Madhopuri, Ludhiana.

……Complainant

Versus 

1. Oriental Insurance Company Ltd., having its registered and head office at A-25-27, Asaf Ali Road, New Delhi-110002, through its Managing Director.

2. Oriental Insurance Company Ltd., having its Branch office at B.O.-III, Feroze Gandhi Market, Ludhiana, through its Manager.

3. M/s Park Mediclaim TPA Pvt. Ltd., 702, Vikrant Tower, Rajendra Place, New Delhi-110008, through its Director/Manager.

…..Opposite parties 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                    Sh.Sat Paul Garg, Member

 

Present:       Sh.Alok Mohindra, Advocate for complainant.

                   Sh.Rajneesh Lakhanpal, Advocate for OP1 and OP2.

                   OP3 exparte.

                   

                        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.Sanjeev Jain s/o Sh.Kimti Lal Jain, resident of House no.43, Street no.7, New Madhopuri, Ludhiana (herein-after in short to be referred as ‘complainant’) against Oriental Insurance Company Ltd., having its registered and head office at A-25-27, Asaf Ali Road, New Delhi, through its Managing Director and others (herein-after in short to be referred as ‘OPs’)- directing them to pay the amount of Rs.33,333/- to the complainant incurred by him on his treatment and purchase of medicines and investigations in CMC and Hospital, to pay the interest @ 12% p.a. from the date of treatment till the full and final payment of the amount, to pay an amount of Rs.50,000/- as compensation and damages for causing harassment, mental pain and agony to the complainant, to pay the cost of complaint alongwith any other additional or alternative relief to which the complainant is found entitled.

2.                Brief facts of the complaint are that complainant is holder of the Medi Claim Policy issued by the Op1 and OP2 since the year 1998 continuously. The detail of the policies obtained by the complainant during the last four years are as follows:-

            a) Policy no.233406/48/2010/804 effective from 28.7.2009 to 27.7.2010.

            b) Policy no.233406/48/2011/745 effective from 28.7.2010 to 27.7.2011.

            c) Policy no.233406/48/2012/612 effective from 28.7.2011 to 27.7.2012.

            d) Policy no.233406/48/2013/518 effective from 28.7.2012 to 27.7.2013.

 

                   That the complainant had obtained the policy no.233406/48/2013/518 from the Ops, which was effective from 28.7.12 to 27.7.13. The said policy covers the health risk of the complainant and his family consisting of his wife Smt.Meenakshi Jain minor Children i.e. Ms.Yashika Jain and Master Chirayu Jain. During the subsistence of the above said policy, which is effective from 28.7.12 to 27.7.13, the complainant suffered from severe headache and redness of eyes and he went to CMC and Hospital, Ludhiana for consultation and treatment. The concerned doctors had examined the complainant and advised that he should be admitted in the hospital for further treatment. At the time of admission, the complainant was diagnosed with cluster headache due to which his treatment was carried out in the Hospital. The complainant was admitted in the Hospital on 21.01.13 and was discharged on 24.01.13. During the course of his treatment, MRI of his brain with angiogram was done and he was also referred to Ophthalmology and Orthopaedics Department and was given the treatment due to the said ailments. In the discharge summary issued by the CMC and Hospital, Ludhiana duly mentioned that it has been finally diagnosed that the complainant was suffering from cluster headache and by way of follow up treatment, various medicines were advised to him and he was also directed to get himself examined in the Neurology Ortho and Eye OPD in the hospital and complainant paid an amount of Rs.33,333/- spent on his treatment as per the bill raised by CMC and Hospital. After getting discharged from the hospital, the complainant submitted his claim to the OP1 and OP2 for reimbursement of the same. The complainant duly submitted all the documents as required by the OPs as nothing remained to be done by the complainant. But the claim of the complainant was repudiated by the OP2, vide their letter dated 6.5.13 on the following grounds:-

            “Happy Family Floater Mediclaim policy does not cover the expenses incurred at Hospital or Nursing Home primarily for evaluation/diagnostic purpose, which is not followed by active treatment followed by ailment during the hospitalized, vide exclusion clause 4.11. Thus the claim is not admissible.”

 

                   The repudiation of the claim is totally wrong. The contention of the complainant is fortified from the fact that even after his discharge, the complainant was advised regular medication, which included as many as six types of medicines for a period of 2 weeks. Not only that the complainant was also advised to come for checkup and consultation in the OPD of three department i.e. Neurology, Orthopedics and Eyes. Thereafter, the complainant was found to be suffering from serious ailment which required a constant follow up treatment by way of medication and medical checkup. Further alleged that after the repudiation of the claim, the complainant approached CMC and Hospital, Ludhiana for requisite clarification. The Hospital Authorities again certified that the complainant was suffering from the severe headache, which is a neurological problem and was given treatment for the management of the pain. Claiming 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, OP1 and OP2 appeared through their counsel and filed written statement taking preliminary objections that complaint is not maintainable in the present form; the complaint is false and frivolous and is liable to be dismissed u/s 26 of the Consumer Protection Act; the complainant was hospitalized for evaluation/diagnostic purposes, which was not followed by active treatment for the ailment, which falls under the exclusion clause 4.11 of the insurance policy namely Happy Family Floater Medicliam Policy taken by the complainant. The policy does not cover the expenses incurred at hospital or Nursing Home primarily for evaluation/diagnostic purposes, which is not followed by active treatment for the ailment during the hospitalization and given oral tables only for headache, which could have been given in OPD. The complainant has not come to the Forum with clean hands and has suppressed the material facts from this Forum. On merits submitted that the contents of para no.1, 2, 6 to 9 are matter of record and contents of para no.4 and 5 are to be proved by the complainant by leading cogent evidence and further denied the contents of all other remaining paras.  

4.                Notice of the complaint sent to OP3, through registered post on 14.8.14. But no report was received. As such, after expiry of 30 days waiting period, OP3 was proceeded exparte, vide order dated 26.09.14 of this Forum.

5.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Sanjeev Jain Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C12. On the other hand, Ld. counsel for OP1 and OP2 has adduced the evidence by way of duly sworn affidavit of Sh.Parvesh Verma, Divisional Manager, DO-1, Oriental Insurance Co. Ltd. Gill Road, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and mainly deposed that the complainant was not admitted in the hospital for active treatment and as such the complainant is not entitled for the claim as per the exclusion clause 4.11 of the policy and also attached documents Ex.R1 to Ex.R4.

6.                Case was fixed for arguments. Ld. counsel for complainant argued orally and stressed upon Ex.C4 i.e. the discharge summary and Ex.C10. The Hospital Authorities again certified that the complainant was suffering from the severe headache, which is a neurological problem and was given treatment for the management of the pain. The Department of Neurology, CMC and Hospital, Ludhiana, through Dr.Vineeth Jaison, D.M. in the said Department issued the certificate dated 14.08.13 mentioning therein ‘this is to certify that Mr.Sanjeev Jain, our Hospital Unit no.C-7107233 was admitted on 21.01.13 to 24.01.13 presented with severe headache, which was interminttent and open intolerable at home for which, he needed admission in Hospital for management and active treatment of acute pain. In Hospital, he was given analgesics for the management of pain. He responded well to the treatment and was diagnosed with cluster headache and discharged on medication.

7.                Similarly, Ld. counsel for OP1 and OP2 argued orally mainly averring that complainant was hospitalized for evaluation/diagnostic purposes, which was not followed by active treatment for the ailment, which falls under the exclusion clause 4.11 of the insurance policy namely Happy Family Floater Medicliam Policy taken by the complainant. The policy does not cover the expenses incurred at hospital or Nursing Home primarily for evaluation/diagnostic purposes, which is not followed by active treatment for the ailment during the hospitalization and given orally the tablets only for headache, which could have been given in OPD.

8.                We have gone through the pleadings of the complainant as well as defence taken by the Ops and also perused the entire record placed on file.

9.                It is evident that the complainant underwent treatment after getting himself admitted with CMC and Hospital from 21.01.13 to 24.01.13 with severe headache which was diagnosed with cluster headache as per Ex.C10, which is a report of the medical specialist of CMC and Hospital that the complainant underwent active treatment for the management and active treatment of acute pain in the hospital, he was given analgesics for the management of pain, which was the result of complicated various reasons. He responded well to treatment and was diagnosed with cluster headache and not simple headache, meaning thereby that the patient was not admitted for evaluation/diagnostic purposes only. The certificate dated 14.8.13 is self explanatory and clearly shows that the complainant was given active treatment and was suffering from the medical ailment, which needed admission in the hospital and it was only because he responded well to the treatment that he was diagnosed with cluster headache and was discharged. The certificate was issued by a highly qualified neurological specialist whose medical competence cannot be doubted. Therefore, it is not essential that whether any ailment has been detected through diagnosis or diagnostic methods or by evaluation but the only thing, which is important that the complainant duly required hospitalization and medication and the Hospital Authorities were sure that the complainant required treatment in the above said manner. It is not for the complainant or for any other patient that which medicines are given to him or how he has to be treated as it is the job of the medical specialist. Therefore, the contention of the Ops is totally incorrect and is liable to be ignored. At the same time there was no medical opinion adduced by the OPs that the patient was not given active treatment of the said disease “Cluster headache”. Further to that it is not proved that this ‘Cluster headache’ is not covered under the terms and conditions of the policy. Without any expert opinion, the averments of the OPs are not tenable. Hence the present complaint is maintainable.

10.              Sequel to the discussion, the present complaint is allowed and we hereby quash the repudiation letter of the OPs and direct the Ops to settle and pay the claim of the complainant, as per the terms and conditions of the policy. Further Ops are directed to pay Rs.2500/-(Two thousand only five hundred) as compensation and litigation expenses compositely assessed. 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.

 

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

                     Member                                             President

Announced in Open Forum.

Dated:11.02.2015 

Hardeep Singh