Delhi

New Delhi

CC/141/2017

Apjit Singh Ahluwalia - Complainant(s)

Versus

Oriental Insurance Co Ltd - Opp.Party(s)

10 Jan 2020

ORDER

 

 

                           CONSUMER DISPUTES REDRESSAL FORUM-VI

                         (DISTT. NEW DELHI),

                        ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                           NEW DELHI-110001

 

Case No.C.C.141/2017                                          Dated:

                In the matter of:

Sh. Apjit Singh Ahluwalia,

S/o Late Sh. Gian Singh,

R/o 523/2, Lane No.23B,

Western Avenue,

Sainik Farms,

New Delhi-110063.

 

                 ……..COMPLAINANT

VERSUS

             The Oriental Insurance  Co. Ltd.

                Parliament Street,

               New Delhi.

Opposite Party.

                

NIPUR CHANDNA, MEMBER

 

ORDER

       

The complainant has filed the present complaint against the OP under section 12 of Consumer Protection Act, 1986.  The gist of the complaint is that the complainant is the individual mediclaim policy holder of the OP Co. vide policy bearing No.215601/48/2015/4239 for the period from 27.11.2014 to 26.11.2015 which was continuously renewed since 1995.  On 24.10.2007, the complainant had undergone surgery for bladder cancer in the Indraprastha Apollo Hospital. The surgery was followed by cystoscopy for procedure of bladder cancer twice a year for five years and once a year thereafter.  For this purpose, the complainant every time was admitted in the hospital for cystoscopy for more than 24 hours for the said procedure and in total 12 times the OP has paid the claim of the complainant.  But  the claim of the complainant, during the stay in the above said hospital  from 5.8.2015 to 6.8.2015, for the same procedure, has been repudiated by the OP Co. under clause 4.10 of the policy in question. Thereafter, the complainant also submitted his grievance  to the Insurance Ombudsman, but it also rejected his complaint on the same ground.  Complainant, therefore, approached this Forum for redressal of his grievance.

2.     Complaint has been contested by OP.  In its written statement,   OP has not disputed that complainant had taken policy referred above. OP has stated that there is no deficiency in service on its part as alleged by the complainant.  It has been further stated that the complainant was a known case of carcinoma bladder, underwent surgery in 2007. Now the present claim was pertaining to cystoscopy with bladder biopsy under local anesthesia, the company was not liable to pay the present claim regarding the expenses made in follow-up measure  being squarely covered under exclusion clause 4.10 of the policy in question.    He further prayed for  dismissal of present complaint.    

3.     Both the parties have filed their evidences by way of affidavit,

4.     We have heard argument advance at the Bar and have perused the record.

5.     It is argued on behalf of complainant that the OP had arbitrarily repudiated his claim, despite receiving the premium against the sum insured  and paying the previous claim pertaining to the present ailment.

6.     It is argued on behalf of OP that,  since the claim of the complainant was squarely covered under exclusion clause 4.10 , the claim was rightly repudiated.  In support of its contention he has drawn our attention towards clause 4.10 of policy terms and conditions: Expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed up by active treatment for the ailment during the hospitalized period, hence, the claim was rightly repudiated by the OP.     

7.     Some facts are not disputed by the parties such as the policy documents, treatment taken.  We have gone through the terms and conditions attached with the written statement of the OP, as well as the certificate of the treating doctor placed on record by the complainant. The contents of certificate is reproduced as under:

        Ref. Mr. Apjit Singh Ahluwalia, I.D. 10105887

The above named patient who was diagnosed to have a bladder cancer.  The cyctoscopy which is undertaken in this case is a mandatory follow-up and cannot be considered diagnostic procedure.  Kindly consider the above while deciding on the claim.

8.     The bare perusal of the above certificate makes it clear that the complainant has undergone the mandatory follow-up and the cyctoscopy was done as follow-up treatment for the earlier ailment bladder cancer.  The cyctoscopy was not a diagnostic procedure but a mandatory follow-up treatment to save the life of the complainant.  Moreover, the OP in its written statement already admitted that complainant was a known case of carcinoma bladder and underwent surgery in 2007 but despite knowing the fact that the surgery was already undergone by the complainant in the year 2007, the OP Co. arbitrarily rejected the claim of the complainant by giving it a colour of initial diagnosis whereas the present treatment is a follow-up treatment of surgery underwent in the year 2007.  Therefore the repudiation of claim of the complainant was wholly unwarranted and unjustified on the part of O.P

9.     In view of the above discussion, we are of the considered view that OP had arbitrarily repudiated the claim of the complainant which amounts to deficiency in services on its part. Therefore, we hold OP guilty of deficiency of service and direct it as under:-

1. Pay to the complainant a sum of Rs.30,000/- alongwith 9% interest from the date of filing of complaint i.e. 15/03/2017 till realization.

 

2. Pay to the complainant a sum of Rs. 10,000/- on account pain and mental agony suffered by him, which will also include the cost of litigation.

 

 

 

A copy of this order each be sent to both the parties free of cost by post. This final order be sent to server (www.confonet.nic.in ). File be consigned to Record Room.

Announced in open Forum on 10/01/2020. 

 

 

 

(ARUN KUMAR ARYA)

          PRESIDENT

(NIPUR CHANDNA)                                                  (H M VYAS)

       MEMBER                                                                MEMBER