Punjab

Ludhiana

CC/14/579

Vishal Khullar - Complainant(s)

Versus

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

Ankur Ghai Adv.

27 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 579 of 22.08.2014

                                                                                                                    Date of Decision: 27.02.2015

                                                                                                                   

Vishal Khullar resident of 381-C, Rajguru Nagar, Ludhiana.

……Complainant

Versus 

The Oriental Insurance Company Limited, Madhok Complex, Opp. Silver Arc, Ferozepur Road, 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.Ankur Ghai, Advocate for complainant.

                   Sh.R.K.Chand, 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.Vishal Khullar resident of 381-C, Rajguru Nagar, Ludhiana (herein-after in short to be referred as ‘complainant’) against The Oriental Insurance Company Limited, Madhok Complex, Opp. Silver Arc, Ferozepur Road, Ludhiana, through its Branch Manager (herein-after in short to be referred as ‘OP’)- directing them to pass the entire claim of Rs.9418/- as well as to pay the damage of Rs.1.00 lac and to pay Rs.10,000/- as litigation expenses to the complainant.

2.                Brief facts of the complaint are that complainant had availed the ‘Happy Family Floater Policy, vide no.233406/48/2014/1156 from OP covering himself, his wife and his dependent child. The said policy was duly renewed by the OP for the period 13.2.14 to 12.2.15. On 3.4.14 the son of the complainant namely Aarush Khullar also covered under the said policy was admitted to DMC and Hospital, Ludhiana due to the severe abdominal pain. The medical expert based on clinical features and investigation considered it possible a case of Appendix. Even the pediatric experts were consulted. Master Aarush Khullar was hospitalized not with the pre-diagnosis of gastritis. Rather the severe abdominal pain persisted for about 7 hours before the child was hospitalized. He had undergone the tests and treatment prescribed by the doctor (which remained unfruitful) before he was hospitalized  at DMC and Hospital. The child was kept in observation for hours and attended and examined by best doctors of the hospital with specialized infrastructural facility available for treatment of Appendix. The complainant incurred an expenses of Rs.9418/- for the treatment of Master Aarush Khullar. The Ops, vide letter dated 12.6.14 has wrongly and illegally with malafide intention refused to entertain the claim of the complainant by declaring it as not admissible. OPs declared that as the hospitalization was not for minimum 24 hours period as such the claim was not maintainable. 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, OP appeared through their counsel and filed written statement taking preliminary objections that this Forum has got no jurisdiction to try and decide the present complaint; there is no deficiency in service or negligence on the part of the OP since the claim was referred to M/s Park Mediclaim TPA Pvt. Ltd. who duly processed the claim file and inform the OP that claim is not admissible under clause 2.3 of Happy Family Floater Mediclaim Policy. Clause 2.3 of Happy Family Floater Policy provides that Expenses on hospitalization are admissible only if hospitalization is for a minimum of 24 hours. The complainant has not come to this Forum with clean hands and has suppressed the material facts from this Forum; the present complaint is not maintainable since complicated question of law and facts are involved, which requires elaborate evidence both oral and documentary and can be decided only by the Civil Court of competent jurisdiction. On merits, denying the contents of all other remaining paras, 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 Sh.Vishal Khullar Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to C21. On the other hand, Ld. counsel for OP has adduced the evidence by way of duly sworn affidavit of Sh.Dinesh Grover, B.M, The Oriental Insurance Company Ltd. Ex.RW1/A, wherein, the same facts have been reiterated as narrated in the written statement and affidavit of Dr.A.K.Batra, Medical Director of M/s Park Mediclaim TPA Pvt. Ltd. Ex.RW2/B and also attached documents Ex.R1 to Ex.R31.

5.                Case was fixed for arguments. Ld. counsel for complainant argued orally that son of the complainant was admitted in DMC and Hospital on 3.4.14 at 6.00 pm due to the excessive pain in abdomen, the medical expert based on clinical features and investigation considered it possible case of Appendix and the son of the complainant was kept in observation for many hours and was examined by doctor of DMC and Hospital, which is equipped with specialized infrastructural facility for the treatment and incurred the expenses of Rs.9418/-. Since the son of the complainant was admitted in the hospital on 3.4.14 and discharged on 4.4.14, meaning thereby that son of the complainant remained hospitalized for 24 hours.

6.                Refuting the allegations leveled by the complainant, Ld. counsel for the OP argued orally that the claim of the complainant was covered under the exclusion clause 2.3 of the policy. So, it was repudiated and no deficiency in service can be alleged on the part of the OP. Ld. counsel for OPs relied upon the judgements passed in cases titled as R.W.H. Ghyaz Ahmed Vs New India Assurance Co. Ltd. and others-I (2013) CPJ 23 (NC), Ramesh Inderchand Kothari and another Vs New India Assurance Company Ltd.-III (2010) CPJ 79 (Maharashtra State Commission, Mumbai), Kanakraj Chimanlal Ajmera and another Vs New India Assurance Co. Ltd.-I (2003) CPJ 342 (Gujarat State Commission, Ahmedabad. The aforesaid judgements relied upon by the OPs where the treatment was taken by the insured person as outdoor patient for dental treatment. As such, it is not applicable.

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

8.                It is evident that the complainant had taken the policy namely Happy Family Floater Policy bearing no.233406/48/2014/1156 for the period 13.2.14 to 12.2.15 covering himself, his wife and his son. Suddenly the son of the complainant, who was covered under the policy was admitted in DMC and Hospital, due to severe abdominal pain and the complainant incurred the expenses of Rs.9418/-. The complaint lodged the claim with the OPs, which was refused by the OP, vide their letter dated 12.6.14. Though the insured remained hospitalized for less than 24 hours, but one night was definitely spent in the hospital, who was admitted from 3.4.14 to 4.4.14 while the disease subsisted for 7 hours prior to hospitalization. The import behind 24 hours is very much covered in this period of hospitalization. Further the judgements referred by the OP in his defence are not applicable in this case, because they are related to insured person as outdoor patient for dental problem.

9.                Sequel to the above discussion, the present complaint is allowed and Ops are directed to settle and pay the claim of the complainant as per terms and conditions of the policy and to refund admissible expenditure. Further Ops are directed to pay Rs.2500/-(Two thousand five hundred only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days of receipt of 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:27.02.2015 

Hardeep Singh