Chandigarh

DF-I

CC/439/2016

Promola Bhalla - Complainant(s)

Versus

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

Vikram singh

28 May 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

                               

Consumer Complaint No.	:	CC/439/2016
Date of Institution	:	15/06/2016
Date of Decision	:	28/05/2018

 

Promila Bhalla w/o late Sh. Baldev Bhalla r/o B/12, 748, Vishwakarma Colony, Pinjore, Panchkula, Haryana.

… Complainant

V E R S U S

1.     Oriental Insurance Company Limited office at SCO 109/111, Sector 17-D, Chandigarh through its General Manager.

2.     TPA-M/s Medi Assist India through its Manager Office at Shilpa Vidya, 3^rd Floor, 49,First Main Road, Sarakki, Industrial Layout, III Stage, J.P. Nagar, Bangalore.

3.     Indus Super Speciality Hospitals (A unit of Indus Health Care) Address :- Opposite DC Office, Phase-1, Mohali, Punjab 160055 through its Administrator/Managing Director.

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

                                                                     

ARGUED BY	:	Sh. Vikram Singh, Counsel for complainant
	:	Sh. J.P. Nahar, Counsel for OPs 1 & 2
	:	OP-3 ex-parte.

Per Rattan Singh Thakur, President

1.         Allegations in brief are, complainant is the wife of late Sh. Baldev Bhalla and insurance policy No.231290/48/2014/749 was purchased from OP-1 in the year 2013. The complainant was the nominee. Complainant is regular client of OP-1 and had obtained successive policies from them. Averred, husband of the complainant remained generally in good health but he suffered some ailment and was admitted with OP-3 and ultimately due to cardiac arrest had died on 29.11.2013 under treatment of   OP-3.  Maintained, after some time, complainant filed claim to OP-1 on 11.12.2013. In the course of investigation, complainant was asked to deposit some documents regarding first diagnosis of chronic kidney disease and treatment of complainant at Sector 32 hospital, Chandigarh for finalization of claim. The claim was repudiated and consumer complaint No.390 of 2016 was filed before the Consumer Forum-II, UT, Chandigarh which was withdrawn on 9.6.2016 due to technical defect with permission to file afresh. Hence the present consumer complaint praying for award of the amount of bill alongwith compensation for mental pain and agony and litigation expenses.
2.         OP-1 contested the consumer complaint and filed reply inter alia raised preliminary objections complainant has not approached this Forum with clean hands and the claim of the complainant was closed as the requisite documents were not submitted. Specific details of the hospitals were not given and only sketchy papers OPD card of 24.11.2013 submitted which reflects of CBC, RFT, LFT and chest x-ray were advised and her husband was diagnosed to be having CKD (Chronic Kidney Disease) with Pyxia of unknown origin. Further documents qua kidney disease were asked to be submitted but the same were not supplied. On these lines, the cause is sought to be defended.
3.         OP-2 adopted the written reply of OP-1.
4.         OP-3 did not appear despite due service, therefore, vide order dated 9.8.2016 it was proceeded ex-parte.
5.         Parties led evidence by way of affidavits and documents.
6.         The complainant has moved an application for condonation of delay of 108 days. The grounds of condonation are correspondence was made as the claim was submitted and consumer complaint No.390 of 2016 was also filed which was withdrawn on 9.6.2016 due to technical defect.  The said averments are supported by way of affidavit of the complainant, a widow, aged about 68 years, in the evening of life.  There seems to be sufficient grounds for condonation of delay and the application is accordingly allowed.
7.         We have heard the learned counsels for the contesting parties and gone through the record of the case.  After appraisal of record, our findings are as under:-
8.         Per pleadings of the parties and the documents produced i.e. Annexure R-1, own document of OP-1 shows complainant, Mrs. Promila Bhalla had taken mediclaim policy and the period of insurance was 3.9.2013 to midnight of 2.9.2014.  Annexure R-1 which consists of two leaves shows the particulars of the persons covered were Ms. Ritika Bhalla, dependent child; Mrs. Promila Bhalla, complainant herself and Mr. Baldev Kumar Bhalla, spouse aged 69 year. Total sum insured was Rs. Five lakhs only and the premium paid was Rs.6,830/-. The date of death of Sh. Baldev Kumar Bhalla is 29.11.2013.  He was also one of the persons insured under the mediclaim policy which was issued in the name of the complainant and statedly she happened to be the nominee. There is no controversy with regard to these facts.
9.         Per pleadings and the documents annexed shows Mr. Baldev Kumar Bhalla, husband of the complainant, had died in the hospital of OP-3.  Documents and record shows his hospitalization and domiciliary hospitalization benefit policy claim form (Annexure C-2).  Per diagnosis, deceased Sh. Baldev Kumar Bhalla had suffered from pneumonia with septicemia, anemia and acute renal failure.  His date of admission was 27.11.2013 and date of discharge was 29.11.2013 on which date he had died.  The cause of death has been reflected in the death summary which shows cardiac arrest. He was the person insured under the policy taken by the complainant herself for her husband as well as girl child. 
10.         A perusal of the record further shows total amount spent in the treatment was Rs.80,046/- .  It is so made out from Annexure C-3. This was the amount charged by OP-3 for the treatment. It is further made out, OP had suspected he was suffering from kidney disease at the time when the policy was taken and he had made concealment of this material fact in the application form. The complainant, on being demanded, had not supplied the treatment chart of previous hospitals, therefore, the claim was repudiated.  This was the sole ground for the repudiation of the claim. 
11.         Per complainant, which fact she had sworn in by way of affidavit, she had supplied all the papers of the medical treatment of her deceased husband and except that there was no other medical record.  OPs had not produced any record i.e. the form which was filled up by the complainant that her husband Sh. Baldev Kumar Bhalla had suffered from kidney disease on the date of being applied for and this fact was concealed. The policy was taken by the complainant on behalf of her husband Sh. Baldev Kumar Bhalla also and in this situation it has to be attributed that the complainant was aware of his renal disease which her husband had suffered on the date when the policy was applied for. 
12.         We have perused Annexure C-1 which shows complainant had taken the PNB Oriental Royal Mediclaim Policy operative from 3.9.2012 to 2.9.2013. This shows, complainant had been buying the mediclaim policy for herself and her husband.  Therefore, there is no concrete material on record to suggest this policy was taken just to make out a claim when her husband was near the termination of his life.  It was a sort of renewal and even at the stage of renewal, necessary enquiries were made regarding any serious ailment suffered by the insured.  OPs happily had accepted the premium of Rs.6,830/- on 6.9.2013 and date of death of deceased Sh. Baldev Kumar Bhalla is 29.11.2013, therefore, the reasons assigned for compelling the complainant to disclose the previous treatment taken by the deceased are not tenable and the complainant being widow of deceased Sh. Baldev Kumar Bhalla was entitled to receive this amount which he or she had spent for the treatment, copy of which is Annexure C-3.  Thus, we are of the firm opinion that there has been deficiency in service on the part of OPs 1 & 2.
13.         In view of the above discussion, the present consumer complaint deserves to succeed and the same is accordingly partly allowed qua OPs 1 & 2. OPs 1 & 2 are directed as under:-

1. To immediately pay to the complainant billed amount of Rs.80,046/- alongwith interest @ 9% per annum from the date of repudiation i.e. 28.2.2014 till realization.
2. To pay Rs.20,000/- to the complainant as compensation for deficiency in service and mental agony and harassment caused to her;
3. To pay to the complainant Rs.10,000/- as costs of litigation.

14.         This order be complied with by OPs 1 & 2 within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
15.         The consumer complaint qua OP-3 stands dismissed with no order as to costs.
16.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
28/05/2018	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	President