DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Consumer Complaint No.227 of 26.6.2018

                                      Decided on: 3.5.2018

Anand Puri aged 60 years son of Late Sh.Devi Dayal, resident of H.No.20-A,Sewak Colony, Patiala ( Aadhar No.7672 3918 4278, Mobile No.098159-32245)

                                                                   …………...Complainant

                                      Versus

1.       Oriental Insurance Company Limited, Sai Market, Lower Mall, Patiala, through its Divisional Officer, PIN 147 001.

2.       Raksha TPA Private Limited, SCO 359-360, Sector 44-D, Chandigarh-160047, through its Authorized Representative/Signatory.

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Sh. M.P.Singh Pahwa, President

                                      Smt. Inderjeet Kaur, Member

                                      Sh.B.S.Dhaliwal, Member      

ARGUED BY

                                       Sh.Anand Puri, complainant in person.

                                      Sh.D.P.S.Anand, counsel for OP No.1.

                                      OP No.2 ex-parte.

 ORDER

                                    SH. M.P.SINGH PAHWA,PRESIDENT

1. This is the complaint filed by Anand Puri (hereinafter referred to as the complainant) against  Oriental Insurance Co. Ltd. and anr. (hereinafter referred to as the OP/s).
2. Briefly the case of the complainant is that  he purchased OBC- Oriental Royal Mediclaim Policy No.233500/48/2017/4241 vide cover note No.CHD-C170529 dated 27.2.2017. Besides the complainant, his family members are also covered. Policy was valid from 28.2.2017 to midnight of 27.2.2018. It was got renewed from 29.2.2018 to 28.2.2019 vide policy No.233500/48/2018/4845.The policy is continuing till date.
3. On 18.11.2017, complainant suddenly suffered nose bleeding. He was  admitted in Sadhbhavna Medical and Heart Institute, Patiala vide CR No.48259 dated 18.11.2017. He was discharged on 20.11.2017. On 21.11.2018, after discharge from the hospital, son of the complainant namely Varun Puri informed OP No.2 through e-mail to settle the claim. The complainant and the hospital authority informed OP No.2 for payment as the policy was cashless but OP No.2 requested the hospital authority to collect the expenses from the patient  and also requested the complainant to submit the hospitalization papers for reimbursement. Complainant paid Rs.17468/- as hospitalization charges to Sadhbhavna Medical & Heart Institute, Patiala. Thereafter he lodged the claim of this amount with OP No.2. He submitted the  claim documents alongwith bills on 24.11.2017.When the complainant  had not received any information from the OPs, he filed  an application dated 26.12.2017 under RTI Act. Thereafter the OP rejected the claim on 27.12.2017, which shows malafide act on the part of the OPs.
4. It is alleged that the claim has been wrongly rejected vide letter dated 27.12.2017.At the time of purchasing/taking the policy, the complainant was not having any problem. He had not past history of hypertension. He suddenly got the treatment of bleeding from his nose. He  suffered from Dengu attack in the same month i.e. November,2017. The problem can be due to this reason also. The cause of Epistaxis  is not related to HTN and  there can be other reasons.
5. The complainant also got issued legal notice dated 7.6.2018 but to no response. Hence this complaint whereby the complainant has claimed Rs.10,000/- as damages on account of mental tension, agony, physical harassment, unfair trade practice etc. Rs.22000/-as  litigation expenses and reimbursement of Rs.17468/-.
6. Upon notice none appeared on behalf of OP No.2.As such OP No.2 was proceeded against exparte. OP No.1 contested the complaint and filed the written reply through its counsel. In reply the OP raised preliminary objections that the complaint is not maintainable as the claim of the complainant suffered from Epstaxis and hypertension. Hypertension is the cause of epstaxis. Its treatment is excluded from the scope of the policy for 24 months of policy inception.The policy was in the first year, the claim was not payable  as per clause 4.2 of the policy.The insured has been informed accordingly vide letter dated  27.12.2017. The insurance is a contract of indemnity. It has to be viewed as a normal contract as per the Indian Contract Act. Any violation of the insurance contract by the parties to the contract of insurance, the contract becomes void and in that event the insurance company will not be liable to answer the claim. That the complainant does not qualify ingredients of a valid complaint as envisaged in Section 2(1)(c) of the Consumer Protection Act; that complicated question of law and facts are involved and civil court is only competent to decide the dispute.
7. On merits, purchase of the policy is admitted. All other averments of the complainant are denied. In the end, the OPs prayed for the dismissal of the complaint.
8. Parties were afforded opportunity to produce their evidence.
9. In  support of his complaint, the complainant tendered into evidence his affidavit,Ex.CA, copies of policies,Exs.C1,C2, copy of ID card, Ex.C4,copy of  discharge card,Ex.C5, copy of e-mail,Ex.C6, claim form, Ex.C7 postal receipt,Ex.C8,copy of  bill,Ex.C9, copy of indoor receipt, copies of medicines bills, Exs.C10 to C13, & Ex.C13/A copy of RTI application ,Ex.C14, copy of postal receipt, Ex.C15, copy of repudiation letter dated 27.12.2017, Ex.C16. copies of reports, Exs.C17 & C18, copy of legal notice, Ex.C19, copies of postal receipts, Exs.C20& C21.
10. The ld. counsel for the OPs tendered into evidence affidavit of Mukesh Malhotra, Ex.OPA, copy of policy, Ex.OP1, copy of repudiation letter, Ex.OP2, copy of discharge summary, Ex.OP3 and closed the evidence.
11. We have heard the complainant and the ld. counsel for the OPs and also gone through the record of the case file.
12. The complainant and the ld. counsel for the OPs have reiterated the stand as taken in their respective pleadings.
13. The ld. counsel for the complainant has submitted that the OP has repudiated the claim vide letter dated 27.12.2017 on the ground that “the patient suffered from EPSTAXIS & Hypertension. HTN is the case of EPISTAXIS. Treatment of HTN is excluded from the scope of the policy for first 24 months of policy inception. Since the policy is in the first year, the claim is not payable as peer clause 4.2 of the policy”, but the documentary evidence does not support the version of the OP. Copy of the discharge summary is Ex.C4, which shows that the complainant  approached the hospital in connection with nose bleedings since morning. Of course  it is mentioned that nose bleedings is the cause of HTN/Epistaxis but the problem was for nose bleeding and not for hypertension. Therefore, the given clause is not applicable in this case. As such the repudiation is not sustainable, which amounts to deficiency in service. To support this submission the complainant has also  cited 2016(4)CLT 372 SBI General Insurance Company Limited Versus Balwinder Singh Jolly.
14. On the other hand, the ld. counsel for the OPs has submitted that the contract of insurance is like other contracts. Parties are bound by the terms and conditions mentioned in the policy documents. The OP has brought on record, copy of the policy document Ex.OP1. As per clause 4.1, any ailment/disease, which are pre existing are excluded up to three completed years of the policy and clause 4.2 contains details of the treatment of the ailment/diseases, which are not payable for a period mentioned against the disease. Treatment of hypertension is not payable for a period  mentioned against the disease. Treatment for hypertension is not payable for a period of two years. Admittedly policy was within the period of two years. Complainant himself has placed on record copy of discharge summary Ex.C4, which find mention that patient is suffering from nose bleeding and this disease is only due to hypertension. Therefore, the exclusion clause is applicable .As such the repudiation is justified. To support this submission, the ld. counsel for the OPs has cited 2017(4)CPJ 54 Sunita Goyal Vs. Bajaj Allianz Life Insurance Co. Ltd.
15. We have carefully gone through the rival submission and case law cited by the parties.
16. The admitted facts are that the complainant has availed mediclaim policy of the OPs since 28.2.2017.The complainant took treatment on 18.11.2017.The OP has repudiated the claim vide letter dated 27.12.2017,Ex.C16 on the ground that as per clause 4.2 of the policy terms and conditions, the treatment is excluded.Therefore, the main point for determination is whether the treatment availed by the complainant is excluded?
17. Of course clause 4.2 of the policy document, Ex.OP1, contains the names of the treatments/diseases for which expenses are excluded for a particular period and as per this clause treatment for hyper tension is excluded for a period of two years. The point is whether the complainant took treatment for hypertension or any other disease?
18. The discharge summary will be helpful to find answer to this question. From the perusal of the discharge summary Ex.C4, the following points are noted:

Presenting complaints            Pt. presented with c/c/o nose bleeding since morning.

Past history                            K/C/O HTN

Hospital Course                 Patient managed accordingly. Now being discharged.

19. These facts show that patient was suffering from nose bleeding and he took treatment for nose bleeding. The treatment was not for hypertension. Therefore, in these circumstances, the exclusion clause is not applicable. Resultantly the repudiation of the claims is not justified.
20. In view of the aforesaid reasons, the complaint is accepted with costs of Rs.5000/-. The OP No.1 is directed to pay  Rs.17.468/- and the costs of Rs.5000/-to the complainant . Compliance of the order be made by the  OP No.1 within a period of 45 days from the date of the receipt of the certified copy of this order.
21. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter, file be indexed and consigned to the Record Room.

ANNOUNCED

DATED:3.5.2019         

 B.S.Dhaliwal                         Inderjeet Kaur              M. P. Singh Pahwa

       Member                                 Member                                      President