Punjab

Ludhiana

CC/15/297

Sukhwinder PalSingh - Complainant(s)

Versus

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

D.S.Chawla Adv.

20 Jan 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA

 

Consumer Complaint No. 297 of 04.05.2015

Date of Decision            :   20.01.2016

 

Sukhwinder Pal Singh aged 53 years, s/o Late Sh.Gurdial Singh r/o H.No.7937, Street No.9, Durga Puri, Haibowal Kalan, Ludhiana.

….. Complainant

Versus 

1.The Oriental Insurance Company Limited having its office at Vishawkarma Chowk, G.T.Road, Miller Ganj, Ludhiana (Punjab) through its branch manager.

2.Medi Assist India TPA Pvt.Ltd., Office at 47/1, Sh.Krishna Arcade, Ist Main, 9^th Cross-Sarakki, Ludhiana, Industrial Layout, JP Nagar 3^rd Phase, Bangalore, 560078.

..…Opposite parties

 

 

                             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.SAT PAUL GARG, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                     :       Sh.D.S.Chawla, Advocate

For OP1                        :        Sh.B.S.Rampal, Advocate

For OP2                        :        Ex-parte

 

 

PER G.K DHIR, PRESIDENT

 

1.                          Complainant, an Assistant Manager in Central Tool Room, Focal Point, Ludhiana filed complaint under Section 12 of the Consumer Protection Act, 1986(hereinafter referred to as ‘Act’) against the OPs by claiming that he along with his family members namely Smt.Kuldeep Kaur(wife), Pavneet Kaur(daughter) and Prabhdeep Singh(son) initially got PNB-Oriental Royal Mediclaim Policy No.233902/408/2012/1520 from OP1 with validity thereof from 3.10.2011 to 2.10.2012. After expiry of the said policy, got for the entire family, complainant deposited premium amount with OPs and got mediclaim policy bearing No.233902/48/2013/1914 with validity from 3.10.2012 to 2.10.2013 and subsequently, on payment of further requisite premium, policy No.233902/48/2014/2134 with  validity  from  3.10.2013  to  2.10.2014  was  got issued. After expiry of latest mentioned insurance policy, the complainant got mediclaim policy No.233902/48/2015/2564 dated 25.9.2014 with validity from 3.10.2014 to 2.10.2015. OPs are liable to pay every type of hospital expenses including room rent, boarding expenses, nursing, ICU, medical practitioner fee, operation theatre charges etc, qua treatment of complainant and his family members in the event of suffering health problem. On 12.7.2014, the son of the complainant felt pain in his lower abdomen at the time of passing urine  and thereafter, he was taken to RG Stone Hospital, 510-L, Model Town, Ludhiana for check up and treatment. After examining him, Dr.Anand Sehgal M.S.M.C.H.(Urology) advised for ultrasound test of full abdomen. After getting said test conducted, treatment of Sh.Prabhdeep Singh was started by Dr.Anand Sehgal on 12.7.2014 and same continued up to 6.12.2014. On 6.12.2014, Dr.Anand Sehgal advised for ultrasound scan of abdomen and of both testicular and same was got conducted. Report was received in terms “Impression: Acute Left Testicular Torsion”. Thereafter, Dr.Baldev Singh Aulakh M.S.M.Ch.(Urology) examined Sh.Prabhdeep Singh for his admission in emergency wing of Dayanand Medical College & Hospital, Ludhiana(hereinafter referred to as ‘DMC & H, Ludhiana’) and there Prabhdeep Singh was operated  on 7.12.2014 itself for his left Orchidectomy with right orchiopexy under SA. Sh.Prabhdeep Singh remained admitted in DMC & H, Ludhiana from 7.12.2014 to 10.12.2014 for conduct of operation and routine tests as an indoor patient. Then complainant lodged cashless medical claim of the treatment charges of his son namely Sh.Prabhdeep Singh at the office of the hospital, but the OPs illegally denied that facility by claiming as if disease is congenital. Letter dated 9.12.2014 for denying the legal and valid claim of the complainant was sent by OP2. Complainant even submitted an application with OP2 stating therein that disease is not congenital, but OPs failed to consider the genuine representation of the complainant by denying the cashless facility. Then complainant was left with no option but to deposit entire treatment charges of Rs.51,097/- with DMC & H, Ludhiana. Then claim was lodged with OPs, but after registration of the same Op sent letter dated 22.01.2015 for calling upon the complainant to submit more documents. Through that letter, OP2 asked the reason for delay in submission of the documents, original discharge summary, original X-ray report with film etc. After receipt of the said letter, complainant sent reply on 28.1.2015, but thereafter another letter dated 9.2.2015 was received by the complainant from OP2. Through that letter, some other information was sought from the complainant including original pre-numbered hospital bill payment receipts and certificate of treating doctor etc. Complainant submitted the required documents with OPs on 16.02.2015 and thereafter, he (complainant) received letter dated 25.2.2015 from OP2 to the effect that claim of the complainant was denied for the reasons mentioned in that letter. Denial of the claim was as per clause 5.8 of the terms and conditions of the policy on the ground that disease was congenital in nature. Wrong allegations were levelled against the complainant and his son namely Prabhdeep Singh qua concealment of the material facts, even though fact qua disease was never concealed. Son of the complainant never happened to have the problem in question until 12.7.2014. Earlier Prabhdeep Singh participated in Sport Meet at Baba Banda Singh Bahadur Engineering College, Fatehgarh Sahib from 4.4.2014 to 7.4.2014 as well as from 31.7.2010 to 26.9.2010 and got the participation certificate from concerned institution. Rejection of the claim alleged to be illegal and by pleading deficiency in service on the part of OPs, complainant seek relief qua payment of Rs.92,000/- with interest @18% p.a. till the recovery along with costs. Rs.51,097/- the amount spent by the complainant from his own pocket on treatment of his son Prabhdeep Singh also sought along with compensation for mental pain and suffering of Rs.30,000/- and Rs.11,000/- as litigation expenses.

2.                In the written statement filed by OP1, it is pleaded interalia as if the present complaint is not maintainable, complainant has not approached    this Forum with clean hands; complainant is estopped by his act and conduct from filing the present complaint; complaint is bad due to non-joinder and mis-joinder of necessary parties and that complaint is time barred. It is further claimed that due services were rendered in this case by the OPs to the complainant and repudiation of the claim was as per clause 5.8-9 of terms and conditions of Mediclaim Insurance Policy. Admittedly, the policy in question was issued to the complainant subject to the terms and conditions incorporated therein. Admittedly, on receipt of the reimbursement of the claim from OPs, the case was sent for settlement to OP2 by writing letters dated 22.01.2015 and 9.2.2015. Some of the documents were sent by the complainant and after perusal of the same, it was found by the TPA as if claimed amount is not payable and that is why claim was repudiated. Intimation was sent by the competent authority vide letter dated 25.02.2015 to the son of the complainant. As per letter dated 08.12.2015 issued by Sr.Registrar DMC & H, Ludhiana, the disease is not confirmed as non congenital in nature. However, as per letter dated 14.02.2015 issued by DMC & H, Ludhiana, the patient was having history of similar complaints suggestive of recurrent testicular torsion in past. It is claimed that complainant with malafide intention obtained the insurance policy without disclosing the true facts. Each and every other averment of the complaint denied by praying for dismissal of complaint with exemplary costs.

3.                OP2 is ex-parte in this case.

4.                Counsel for the complainant tendered in evidence affidavit Ex.CA of  complainant  and  Ex.CB  of  Sh.Prabhdeep  Singh, son of complainant along with documents Ex.C1 to Ex.C61, Ex.C1/A, Ex.C58A, Ex.C58B and Ex.C59A and then closed the evidence.

5.                On the other hand, counsel for the OP1 tendered in evidence affidavits Ex.RA of Sh.Naresh Singla, Branch  Manager  of  OP1  and      Ex.RB of Smt.Abha Mathur, Signing Authority of Medi Assist India TPA Pvt. Ltd and even tendered documents Ex.R1 to Ex.R7 and thereafter, closed the evidence of OP1.

6.                          Written arguments not submitted by any of the parties, but oral arguments alone addressed and were heard. Records gone through minutely. 

7.                Ex.C1, Ex.C1/A and Ex.C3 to Ex.C5 are the documents produced by the complainant to establish that he purchased mediclaim insurance policies continuously for the period from 03.10.2011 to 02.10.2015. Through latest policy Ex.C1, complainant got  insured  his son namely Sh.Prabhdeep Singh also. Same is revealed by Ex.C1/A. Ex.R1 the insurance cover note even has been produced by OP1 to establish that insurance policy for medical claim of son of the complainant was purchased by the complainant from OP1. Undisputedly, the medical claim qua treatment of Sh.Prabhdeep Singh(son of the complainant) was submitted by the complainant and the same was processed and that is why, letters Ex.R2 and Ex.R3 were sent by OPs to the complainant for seeking documents and further information. After receipt of those letters, Ops found that as per the opinion of Senior Registrar of DMC & H, Ludhiana dated 8.12.2014, disease, for which, Sh.Prabhdeep Singh got treatment may or may not be congenital in nature. Letter Ex.R4 in this respect has been produced by OP1 and besides letter Ex.R5 dated 14.2.2015 has been produced by OP1 to establish that as per certificate of treating doctor, Sh.Prabhdeep Singh had history of similar complaints suggestive of recurrent testicular torsion in the past and that is why, it was found as if he was suffering from congenital disease. After holding the disease in question to be congenital one, the claim of the complainant was repudiated through letter Ex.C6. The bone of contention remains as to whether the disease, for which, Sh.Prabhdeep Singh got treatment is congenital in nature or not.

8.                It is the case of complainant put forth through this complaint as well as through affidavits Ex.CA and Ex.CB that patient Sh.Prabhdeep Singh felt pain in his lower abdomen for the first time on 12.7.2014 at the time of passing urine and thereafter, conduct of ultrasound scan tests, it was found as if he was suffering from acute left testicular torsion. That denial of claim of the complainant contested as   projected   through   letter Ex.C7 dated 9.12.2014 because        said Sh.Prabhdeep Singh earlier had been participating in game of badminton during the period from 4.4.2014 to 7.4.2014 as revealed from certificate Ex.C28 issued by Baba Banda Singh Bahadur Engineering College, Fatehgarh Sahib and also by certificates Ex.C29 to Ex.C34. After going through Ex.C29, it is made out as if Sh.Prabhdeep Singh had participated in Mahindra NBA Challenge during the period from 31.7.2010 to 26.09.2010, whereas, after going through Ex.C30, it is made out that he participated in Basketball event at Zonal level during period from 26.7.2010 to 27.7.2010. However, after going through Ex.C31, it is made out that said Sh.Prabhdeep Singh participated in District Level tournaments at Ludhiana during period from 5.10.2007 to 7.10.2007 in Basketball event. After going through certificate Ex.C32, it is made out that said Sh.Prabhdeep Singh participated in Basketball event during period from 16^th November to 18^th November during session of 2006-2007. However, contents of certificate Ex.C33 establishes as if Sh.Prabhdeep Singh participated in District Level tournament held in Guru Nanak Stadium during period from 22.8.2006 to 25.8.2006 in basketball event. Had really the disease in question  been  congenital in nature, then certainly Sh.Prabhdeep Singh would not have been in a position to participate in the events of badminton and basketball during the above referred spell. So, contents of affidavits Ex.CA and Ex.CB are correct that actually after feeling abdomen pain on 12.7.2014, the disease in question was detected only after conduct of tests for the first time. As the disease acute testicular torsion was not known to the son of the complainant or his father(the complainant) prior to 12.7.2014 and as such, there was no concealment of fact in that respect. Besides, the disease in question cannot be considered as congenital one because it is not proved to be since from the birth of Sh.Prabhdeep Singh.

9.                If through Diagnostic Result Ex.C19 dated 7.12.2014, impression of acute left testicular torsion gathered, before that this impression was not gathered through report Ex.C15 of dated 21.7.2014 because right and left kidney as well as pancreas, spleen, gall bladder, liver and urinary bladder were found normal in size through report Ex.C15. So, virtually acute testicular torsion disease impression was found for the first time on 7.12.2014 through report Ex.C19 and as such, this impression gathered after purchase of policy Ex.C1 on 3.10.2014. Admission for the treatment of this disease took for the period from 6.12.2014 to 10.12.2014 and as such, treatment for the alleged congenital disease got from 7.12.2014 to 10.12.2014 only as revealed by Ex.CA and Ex.CB. In Ex.C14 and Ex.C15 of dates 12.7.2014 and 21.7.2014, the alleged congenital disease is not found. Through report Ex.C20 of 7.12.2014 and clinical examination of 7.12.2014 alone, the disease in question was    found by treating Dr.Gurdeep Singh as revealed by Ex.C19. Ex.C23, case discharge summary slip of Sh.Prabhdeep Singh for period from 7.12.2014 to 10.12.2014,  mention that Sh.Prabhdeep Singh complained of pain and    swelling in the scrotal region for the last 7 days prior to admission and as such, if contents of Ex.C23 taken into consideration, then they shows as if swelling   in the scrotal region was complained by the patient just 7 days prior to 7.12.2014 i.e. on 1.12.2014 or 30.11.2014 only and not before that. Ex.C25 the report dated 12.12.2014 shows as if Histomorphological features are consistent with Ischaemic Necrosis (Gangrene) and as such same also shows as if before December 2014, the disease in question actually was not diagnosed. So, in case treating doctor through certificate Ex.C27=Ex.R5 found Sh.Prabhdeep Singh to be having history of complaint of pain suggestive of recurrent testicular torsion in the past, then the same at the most establishes as if of factum of complaint of pain alongwith  the recurrent testicular disease was found. Since when recurrent testicular torsion was found qua that contents of Ex.C27=Ex.R5 are silent and as such these documents do not at all establish that disease in question was since from the birth of the son of the complainant. So, these certificates Ex.C27=Ex.R5 do not at all establish that disease in question was congenital in nature. Rather, through Ex.R4, it was found as if the complained of disease may or may not be congenital    in nature. So through Ex.R4 definite opinion qua the disease in question as non congenital in nature have not been given. Rather cause of disease mentioned due to injury or the same may have taken place during sexual intercourse or may occur while sleeping as per contents of Ex.R4. If this acute testicular torsion disease may have occurred due to injury or during sexual intercourse as per Ex.R4, then those circumstances leans in favour of holding that disease actually is not congenital even as per Ex.R4. So, repudiation of the claim due to disease being congenital in nature is quite unjustified, particularly when through Ex.C15, everything   was found normal earlier on 21.7.2014. The medical claim bills and record of discharge summary as well as reports have already been put forth on record as Ex.C23 to Ex.C26 as well as Ex.C35 to Ex.C61 including Ex.C58A, Ex.C58B and Ex.C59A and as such, due documents have been produced on record by the complainant for assessing the claim. As repudiation of the claim is unjustified because due to conjectures or surmises alone, the disease has been found congenital and as such, complaint deserves to be allowed with directions to OPs to reconsider the claim of the complainant. As repudiation of the claim is unjustified and as such, for mental pain and suffering, compensation of Rs.5000/- and litigation costs of Rs.3000/- also deserves to be granted in favour of the complainant and against OPs.

10.              Therefore, as a sequel of the above discussion, the present complaint partly allowed in terms that Ops will reconsider the claim of the complainant and decide the same within 40 days from the date of receipt of copies of order. Due amounts (if found after reconsideration) be disbursed to the complainant within 30 days of order of reconsideration, failing which, complainant will be entitled to interest @7% per annum after 30 days of the order of reconsideration to be passed by OPs, till recovery. Compensation of Rs.5000/- and litigation costs of Rs.3000/- also allowed in favour of complainant   and against OPs. Liability of OPs will be joint and several. Payment of these amounts be made within 30 days from the date of receipt of copies of order. Copies of order be supplied to the parties free of costs as per rules.

11.                        File be indexed and consigned to record room.

 

                                      (Sat Paul Garg)                            (G.K.Dhir)

                                   Member                                            President

Announced in Open Forum

Dated:20.01.2016

Gurpreet Sharma.