Haryana

Ambala

CC/258/2019

Jagdish Chander - Complainant(s)

Versus

Oriental Insurance Co. LTd. - Opp.Party(s)

Navneet Gupta

11 Apr 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                          Complaint case No.:   258 of 2019

                                                          Date of Institution           :    20.08.2019.

                                                          Date of decision    :    11.04.2022.

 

 

1.       Jagdish Chander son of Late Sh. Manohar Lal

2.       Smt. Kamlesh Kumari wife of Shri Jagdish Chander,

          Both residents of H.No.244, Sector-1, Jail Land, HUDA, Ambala City.

 

                                                                                      ……. Complainants.

                                                     Versus

1.       Oriental Insurance Co. Ltd., through its Branch Manager, Ground Floor, LIC       Building, Ambala City-134001.

2.       Raksha Health Insurance, TPA Pvt. Ltd. through its Manager/authorized    signatory, First Floor, 14/3, Mathura Road, Faridabad-121003.

 

               ..…. Opposite Parties.

         

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.         

                            

Present:       Shri Navneet Gupta, Advocate, counsel for the complainants.

Shri R.K. Jindal, Advocate, counsel for the OPs.

 

Order:        Smt. Neena Sandhu, President

 

Complainants have filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay Rs.19,760/-, alongwith interest @ 18% per annum, from the date of lodging of the claim, till its realization.
2. To pay Rs.50,000/-, as compensation as mental agony and physical harassment suffered by the complainant.

 

2.                Brief facts of the case are that complainants have been regularly purchasing medi-claim policy from the OP No.1 since 2015, by making payment of insurance premium on yearly basis. A mediclaim policy (family floater) No. 261101/48/2018/1390 for a sum of Rs. 5,00,000/- was taken by the complainants from the insurer i.e. The Oriental Insurance Company Ltd. w.e.f. 18.11.2017 to 17.11.2018 by making premium payment of Rs.7173/-, for a period of one year. On 03.08.2018, complainant No.1, suffered severe urinary tract infection and acute urinary retention and, for taking treatment, he went to Dr. Pankaj Garg, MBBS, M.D. (Medicine)c/o Aggarsain Hospital, Ambala City. At that time, complainant was suffering from fever and considering his condition, the concerned doctor admitted him as indoor patient for his betterment and cure. Complainant remained as indoor patient in Aggarsain Hospital, Ambala City from 03.08.2018 to 9.08.2018 for treatment and recovery. During hospitalization, several tests i.e. ultrasound of whole abdomen, blood test, urine test etc. were conducted. Complainant incurred a sum of Rs.11,000/- as room charges and hospitalization charges, post hospitalization expenses Rs.1,067/- and medi-claim bill/pharmacy bills amounting to Rs.7,640/- in total Rs.19,707/- on his medical treatment. After discharge from hospital, complainant No.1 lodged the claim for the reimbursement of the medical expenses, but OPs repudiated the claim vide letter dated 22.11.2018 and e-mails dated 21.09.2018 and 10.10.2018, under Clause 4.10 of the Policy, arbitrarily and unlawfully. As a matter of fact, the sole ground of repudiation of claim that ‘there was no need of hospitalization was un-tenable in the eyes of law and against the bonafide rights of policy holder and beyond the condition of mediclaim policy which was relied upon by the insurer and it is a matter of great mental agony and harassment. Complainant visited Dr. Hambir Mazumdar Ex.CMO Civil Hospital, Ambala City and had 2^nd opinion from him regarding his ailments and illness. The said doctor opined that hospitalization was necessary for proper monitoring and check up of the patient in such like case. Complainant vide letter dated 06.03.2019, requested the OPs to review the claim and to release the claim amount. To the utter surprise, on receipt of letter dated 6.03.2019, the OPs vide letter dated 08.04.2019 wrongly written as 08.04.2018 again repudiated the claim of the complainant on another ground by mentioning clause 5.7 of policy. The repudiation letters dated 22.11.2018 and 08.04.2019 are contradictory and are based on different clauses of the policy, which is against law and facts. By not paying the claim amount, OPs have committed deficiency in service. Hence, the present complaint.

3.       Upon notice, OP No.1 appeared and filed written version and raised preliminary objections with regard to maintainability, jurisdiction, not come with clean hands and concealed the true and material facts, non-joinder and mis-joinder of the necessary parties etc.  On merits, it is stated that complainant alleged that on 03.08.2018, he suffered severe urinary tract infection and acute urinary retention and for treatment gone to Dr. Pankaj Garg, MBBS MD Medicine C/o Aggarsain Hospital, Ambala City and doctor advised him for the admission in the hospital after diagnosis his disease. Allegedly, at that time complainant was suffering from fever and doctor admitted him as indoor patient and he remained there from 03.08.2018 to 09.08.2018 and spent Rs.19,707/-, on his medical treatment. After receiving the claim form and medical treatment bills from the complainant, the matter was investigated by the answering OPs and during investigation it was found that as per vital Chart, temperature was normal and there was tempering in the vital chart which created suspense. As per Urine Analysis Report dated 03.08.2018 Pus Cells are 100 Pus Cells/HTF but as per urine complete report dated 06.08.2018 pus cells are 4-6 pus Cells/HPF. As per Indoor Case papers no complaint noted on daily basis which supports diagnosis, no pre and post record attached with the file, as such there was no need of hospitalization of complainant. On further investigation, it was also observed that no active line of treatment was done during hospitalization of complainant and patient was admitted for evaluation/diagnosis purpose, which could be managed on OPD basis, as such the alleged expenses incurred by complainant are not payable as per the exclusion clause 4.10 and 5.8 and 7 of the terms and conditions of the policy and the answering OPs have legally and rightly repudiated the claim vide Letter dated 22.11.2018 and confirmed vide letter dated 08.04.2019 (wrongly typed as 08.04.2018) which were duly communicated to the complainant. Rest of the averments of the complainant were denied by the answering OPs and prayed for dismissal of the present complaint with costs. 

4.                Upon notice, OP No.2 appeared and filed written version reiterated the same facts as mentioned in the reply filed by the OP No.1.

5.                The learned counsel for the complainants tendered affidavit of complainant No.1 as Annexure CA along with documents as Annexure C-1 to C-40 and closed the evidence on behalf of complainants. On the other hand, learned counsel for OPs tendered affidavit of Shri Ashish Bhatnagar, Senior Branch Manager, The Oriental Insurance Company Limited, Ambala City and Dr. Rakesh Kalra (R.M), Raksha Health Insurance TPA Pvt. Ltd. as Annexure OP-A and OP-B respectively alongwith documents Annexure OP-1 to OP-10 and closed the evidence on behalf of OPs.

6.                We have heard the learned counsel for parties and have carefully gone through the case file.

7.                Admittedly, complainants were duly insured with the OPs for the period from 18.11.2017 to 17.11.2018, vide policy schedule Annexure C-1. The learned counsel for the OPs pleaded that complainant No.1 was admitted in the hospital only for evaluation/diagnoses purposes and no active line of treatment was done during that period, which could be managed without hospitalization. Therefore, the amount incurred by the complainant was not payable as per exclusion clause 4.10, 5.8 and 7 of the terms and conditions of the policy. On the other hand, the learned counsel for the complainants have pleaded that complainant was suffering from severe urinary tract infection and acute urinary retention and also from fever and the concerned doctor admitted him in the hospital for monitoring and giving proper treatment. In the certificate dated 23.05.2019, issued by Civil Surgeon Ambala, it is clearly mentioned that this was an emergency case. From the medical record, it is quite clear that the concerned doctor after thorough investigation had  given medicines to the complainant No.1, under his observation. Since, the complainant No.1 was hospitalized in the hospital for taking treatment for severe urinary tract infection and acute urinary retention, therefore, complainants are duly covered under the terms and conditions of the policy. From the perusal of prescription slips dated 03.08.2018, Annexure C-3 and C-4, it is evident that complainant No.1, was suffering from fever, severe urinary tract infection and acute urinary retention. Complainant No.1 was admitted in the aforesaid hospital for investigation and treatment. All the medicines were given to the complainant No.1, as per investigation and vital monitoring chart was also prepared. From the perusal of medical certificate Annexure C-10, it is evident that by Dr. Hambir Mazumdar M.D (Medicine) of Ishwar Hospital has opined that patient with acute urinary retention with pyrexia with increased TCL (>16,000) would require admission. In the emergency certificate Annexure C-11, issued by  the Civil Surgeon, Ambala, it is categorically mentioned that this was an emergency case. From the aforesaid certificates, it is quite clear that complainant No.1 was required to be hospitalized for treatment. In this view of the matter, we do not hesitate to conclude that OPs were not justified in repudiating the claim. Ops are thus liable to pay the expenses incurred on the treatment of the complainant No.1. From the Annexure C-22, it is evident that an amount of Rs.19,764/- was incurred on the treatment of the complainant No.1, therefore, the OPs are liable to pay the said amount to the complainants alongwith interest. OPs are also liable to compensate the complainants for the mental agony and physical harassment suffered by them.

8.                In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs, in the following manner:-

                   1)      To pay Rs.19,764/-, to the complainants alongwith interest @                               5% per annum, w.e.f 08.04.2019, when the claim was finally                               repudiated by the OPs.

                   2)     To pay Rs.3,000/- as compensation for the mental agony and                                physical harassment caused to the complainant.

 

                   The OPs are further directed to comply with the aforesaid directions within the period of 45 days from the date of receipt of the certified copy of this order. Certified copy of the order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.  

Announced on: 11.04.2022.

 

 

(Vinod Kumar Sharma)        (Ruby Sharma)                        (Neena Sandhu)

              Member                      Member                          President

 

 

 

 

 

 

 

 

Present:         Shri Navneet Gupta, Advocate, counsel for the complainants.

Shri R.K. Jindal, Advocate, counsel for the OPs.

         

 

Vide our separate detailed order of even date, the present complaint has been allowed. File be consigned to Record Room, after due compliance.

Announced on :11.04.2022

 

 

          (Vinod Kumar Sharma)  (Ruby Sharma)               (Neena Sandhu)

                  Member                      Member                        President

                                                                                      DCDRC, Ambala.