Punjab

Ludhiana

CC/19/295

Bhupinder Singh - Complainant(s)

Versus

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

Kapil Katyal Adv.

22 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:295 dated 14.06.2019.                                                        Date of decision: 22.03.2023.

Bhupinder Singh Malhotra aged 31 years son of Sh. Harjeet Singh, resident of House No.273-Bm, Bhai Randhir Singh Nagar, Block-B, Ludhiana.   

..…Complainant

                                                Versus

1. Oriental Insurance Company Ltd., Regd. Office A-25/27, Asaf Ali Road, New Delhi-110002 through its Director/M.D.
2.  Oriental Insurance Company Ltd. Above Fine Furniture, Opp. Chhabra Hospital, Bus Stand Road, Ludhiana-141003 through its Branch Manager.
3. The Park Mediclaim TPA Pvt. Ltd., 702, Vikrant Tower, Rajendra Place, New Delhi-110008, through its Director/M.D.
4. The Park Mediclaim TPA Pvt. Ltd., B-XV-179/1, Sona complex, Room No.11, 2^nd Floor, G.T. Road, Miller Ganj, Ludhiana through its Branch Manager.                                 

.….Opposite parties.

Complaint Under Section 12 and 14 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. Kapil Katyal, Advocate. 

For OP1 and OP2          :         Sh. Rajeev Abhi, Advocate.

For OP3 and OP4          :         Complaint against OP3 and OP4 not admitted                                          vide order dated 28.06.2019.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Succinctly put, the facts of the case are that the complainant has been availing Happy Family Floater Policy 2015 mediclaim policies of the opposite parties since the year 2017 regularly and he availed the current policy No.233902/48/2019/5040 having card No.P-011931587 having validity from 02.01.2019 to 25.12.2019. The complainant availed earlier policy No.233902/48/2018/5461 valid from 26.12.2017 to 25.12.2018. The complainant submitted that during the continuation of the policy, unfortunately on 02.04.2018 he fell down in his washroom and suffered pain in the right leg and having difficulty in passing urine saddle anesthesia due to which he was having problem. He was suffering from genuine spine problem. On 05.04.2018, the complainant went to Dayanand Medical College and Hospital, Ludhiana and consulted Dr. Chaudhary in the Neuro Surgery Department of D.M.C. Ludhiana who advised him to get the MRI LS Spine done as there was danger to the spine of the complainant. Following the advise of the doctor, the complainant under compelling circumstances got MRI LS Spine done from D.M.C. Ludhiana on 27.04.2018 and after getting the report, he approached Dr. Chaudhary in his private clinic who advised the complainant to undergo Micro Discectomy L5-S1 surgery done under GA. On 29.04.2018, the complainant approached Dr. Damandeep Singh Makkar, Doctor of Orison Super Specialty Hospital, Infertility and Trauma Hospital, Ludhiana for taking second opinion who after seeing the MRI report advised the complainant for Micro Discectomy LL5-S1 surgery done under GA for which the complainant got admitted on 30.04.2018 at Orison Super Specialty Hospital, Ludhiana and on 01.05.2018 the complainant was operated for the said problem and spent Rs.80,000/- on his treatment excluding medicine bill borne by the complainant. The complainant further submitted that before admission in the hospital on 30.04.2018 and discharge on 04.05.2018 from the hospital, he sent intimation to the opposite parties which was duly received and acknowledged by them. The complainant submitted all the bills of treatment along with other relevant documents to the opposite parties on 13.06.2018 and also to opposite party No.4 followed by one letter dated 13.06.2018 for reimbursement of mediclaim of the complainant which was to be processed. In reply to the letter of opposite parties, the complainant furnished the entire details required by the opposite parties and again contacted the opposite party but no reply was given by the opposite parties. However, on 16.10.2018 claim No.0ICCHI/15183 was repudiated by the opposite parties for extraneous reasons unknown to the complainant which is totally illegal, arbitrary and unjust and the complainant is legally entitled to the claim amount as his problem is fully covered under the policy and it was occurred due to accident took place with the complainant at his house in the washroom. The act on the part of the opposite parties amounts to deficiency in service and unfair trade practice due to which the complainant suffered mental pain, agony, harassment, humiliation and anguish. In the end, the complainant prayed for issuing directions to the opposite parties to make the payment of claim amount of Rs.80,000/- along with compensation of Rs.50,000/- and litigation expenses of Rs.10,000/-.

2.                The complaint against opposite party No.3 and 4  was not admitted vide order dated 28.06.2019.

3.                Upon notice, opposite party No.1 and 2 appeared and filed joint written statement taking preliminary objections and assailed the complaint on the ground of maintainability; complaint barred under Section 26 of the Consumer Protection Act; complainant is estopped by his own act and conduct from filing the complaint and has concealed the material facts. The opposite parties alleged that immediately on the receipt of the claim, it was duly registered, entertained and processed. The complainant has obtained the Happy Family Floater policy from opposite party No.2 valid w.e.f. 02.01.2019 to 25.12.2019. The opposite parties further alleged that the insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy. It is one of the exclusion clause of the policy under the head Exclusions 4.3 point xx as under:-

Exclusion Clause 4.3 point xx

"The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:-

Xx Surgery for prolapsed inter vertebral disc unless arising from accident 2 years."

The complainant had lodged the claim for reimbursement of medical expenses incurred on his treatment at Orison Super Specialty Hospital - Infertility & Trauma Centre w.e.f. 30.04.2018 to 04.05.2018 with the diagnosis of PID (Prolapsed Intervertebral Disc) L5 S-1 with cauda equina for which Microdiscectomy L5 S-1 was done under GA on 01.05.2018 and immediately on the receipt of the claim and its related documents the same was referred to M/s. Park Mediclaim Insurance TPA Pvt. Ltd., a third party administrator-health services for its processing. After the receipt of the claim papers M/s. Park Mediclaim Insurance TPA Pvt. Ltd. vide its letter dated 28.04.2018 had called upon the complainant to submit the following documents for processing the claim:-

• Record of treatment for the last 26 days.
• All previous policy copies before 26.12.2017.
• Completely filled past history columns with duration.
• Provide number of days of stay with per day room rent.
• 10% co-payment applicable.

 

M/s. Park Mediclaim Insurance TPA Pvt. Ltd. vide its letter dated 25.05.2018 had called upon the complainant to provide the following information/ documents required for processing and finalizing the claim:-

• Please sign the enclosed consent letter addressed to the Medical Superintendent of the hospital requesting him/her to allow verification of your inpatient records by authorized representative of M/s Park Mediclaim Insurance TPA Pvt. Ltd. and return it back to us.
• Self-attested copy of your PAN card, photo ID proof issued by any Govt. Authority.
• Films and reports of MRI dated 27.04.2018.
• Films and reports of investigation dated 01.05.2018 and 30.04.2018.
• When were you diagnosed to have PID L5 S1 with Cauda Equina for the first time? Record of treatment taken in the past for the same after their first detection may support this information.
• A certificate from Orison Super Specialty Hospital, Infertility & Trauma Centre providing the registration status of the hospital with local authorities supported by a copy of registration certificate, if registered. If not, please provide the bed capacity and the type of facilities available at the hospital.
• Records of treatment taken before hospitalization.
• Cancelled bank cheque giving details of Bank Account number, email ID, IFSC code and MICR no., PAN no. with copy of PAN card (Mandatory) for our crediting the claim payment direct to your account promptly and correctly. Please ignore if already submitted.

M/s. Park Mediclaim Insurance TPA Pvt. Ltd. vide their letter dated 11.06.2018 also called upon the complainant to provide the pending documents as well as the additional documents/information as detailed below:-

• "Records of treatment taken before hospitalization…..”

The opposite parties further alleged that the other documents demanded vide letter dated 11.06.2018 are the same which were demanded vide letter dated 25.05.2018 upon which the complainant has sent certain documents vide letter dated 13.06.2018 and information vide letter dated 28.04.2018. M/s Park Mediclaim Insurance TPA Pvt. Ltd. vide its letter dated 01.08.2018 had again called upon the complainant to provide the following information and documents which are required for processing of the claim:-

• All the policy copies confirming coverage of the patient under Mediclaim Policy prior to 26.12.2017, if any.
• Cancelled bank cheque giving details of Bank account number, email ID, IFSC code and MICR no., PAN No. with copy of PAN card (mandatory) for our crediting the claim payment direct to your account promptly and correctly. Please ignore if already submitted.

The complainant received the said letter dated 01.08.2018 and sent the reply and information vide his letter dated 05.08.2018 received by M/s. Park Mediclaim Insurance TPA Pvt. Ltd. on 10.08.2018 by Ludhiana Office and 13.08.2018 by New Delhi office. After the receipt of documents and information and making due inspection of the record of the hospital and after perusal and scrutinizing the documents, placed in the claim file and after due application of mind by the officials/doctors of M/s Park Mediclaim Insurance TPA Pvt. Ltd. it was found that the claim of the complainant is not admissible and M/s Park Mediclaim Insurance TPA Pvt. Ltd. informed the Oriental Insurance Co. Ltd. vide their letter dated 25.08.2018 with the observations and recommendations to convey their decision to the insured in respect of claim of the complainant, which is reproduced as under:-

"Mr. Bhupinder Singh was hospitalized at Orison Super Specialty Hospital - Infertility & Trauma Centre, Ludhiana from 30.04.2018 to 04.05.2018 with diagnosis PID (Prolapsed Intervertebral Disc) L5 S1 with Cauda Equina for which Microdiscectomy L5 S1 was done under GA on 01.05.2018.

As per the available information, the claimant is covered under Happy Family Floater Policy since 26.12.2017 only.

Happy Family Floater Policy does not cover the surgical expenses on treatment of Prolapsed Intervertebral Disc for 2 years of inception of the policy vide exclusion clause 4.3. Hence, this claim is not admissible."

After the receipt of the claim file by Oriental Insurance Co. Ltd., opposite party no.2 and after scrutinizing the documents placed in the claim file as well as the observations and recommendations of M/s Park Mediclaim Insurance TPA Pvt. Ltd. and after due application of mind by the officials of the opposite party in terms of the insurance policy, the complainant was called upon to show cause vide letter dated 16.10.2018 as to why his claim should not be repudiated being not tenable on the following grounds:-

Clause 4.3 Happy Family Floater Policy does not cover the surgical expenses on treatment of Prolapsed Intervertebral disc for 2 years.

The opposite parties further alleged that the complainant has failed to send the reply to the show cause notice dated 16.10.2018 and as such his claim was repudiated vide letter dated 12.11.2018 on the grounds given in the letter dated 16.10.2018 and the same has rightly been repudiated and the grounds of repudiation are legal, valid, enforceable and are in accordance with terms and conditions of the policy. Opposite party No.1 and 2 denied any deficiency in service or negligence on their part. The opposite parties further alleged that since complicated question of law and facts is involved which required elaborate evidence both oral and documentary and it is only civil court of competent jurisdiction who can try and decide the present complaint. The complaint cannot be decided by the Hon’ble Forum in a summary manner.

                   On merits, opposite party No.1 and 2 reiterated the crux mentioned in the preliminary objections. Opposite party No.1 and 2 denied any deficiency in service on their part and in the end, a prayer for dismissal of the complaint has been made.

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. A1 is the copy of Happy Family Floater-2015 Policy Schedule w.e.f. 02.01.2019 to 25.12.2019, Ex. A2 is the copy of policy schedule w.e.f. 26.12.2017 to 25.12.2018, Ex. A3 is the copy of advise of Dr. Chaudhary , Ex. A4 is the copy of MRI report, Ex. A5 is the copy of MRI Lumber Spine, Ex. A6 is the copy of receipt/bill of Orison Hospital, Ex. A7 is the copy of discharge summary, Ex. A8 is the copy of letter of TPA, Ex. A9 is the copy of letter dated 13.06.2018 written by the complainant insurance company, Ex. A10 is the copy of invoice of Orison Hospital, Ex. A11 is the copy of terms and conditions of Happy Family Floater Policy-2015 and closed the evidence.

5.                On the other hand, the counsel for the opposite parties tendered affidavit Ex. RA of Sh. Sukhwinder Singh, Senior Divisional Manager, Original Insurance Co. Ltd., DO-II, Miller Ganj, Ludhiana as well as affidavit Ex. RB of  Dr. Ritesh Hiteshi, of M/s. Park Mediclaim Insurance TPA Pvt. Ltd., Sona Complex, Room No.11, 2^nd Floor, G.T. Road, Miller Ganj, Ludhiana along with documents Ex. R1 and Ex. R2 are the copies of letters dated 12.11.2018, 16.10.2018 written by the opposite parties to the complainant, Ex. R3 is the copy of letter dated 25.08.2018 written by TPA to the insurance company, Ex. R4 is the copy of report of TPA dated 25.08.2018, Ex. R5  is the copy of letter dated 05.08.2018 written by the complainant to the TPA, Ex. R6 is the copy of PAN card of the complainant, Ex. R7 is the copy of letter dated 01.08.2018 written by TPA to insurance company, Ex. R8 is the copy of email dated 08.02.2018, Ex. R9 is the copy of claim verification/investigation report, Ex. R10 is the copy of patient/attendant communication sheet of Orison Hospital, again Ex. R10 is the copy of Aadhar card of the complainant, Ex. R11 is the copy of discharge summary, Ex. R12 is the copy of literature downloaded from Wikipedia regarding Cauda equina, Ex. R13 is the copy of letter written by TPA to DMC Hospital, Ludhiana, Ex. R14 is the copy of letter dated 28.04.2018 written by the complainant to TPA, Ex. R15 is the copy of questionnaire, Ex. R16 is the copy of letter written by TPA to the complainant, Ex. R17 is the copy of letter dated 13.06.2018 written by complainant to insurance company, Ex. R18 is the copy of Radiodiagnosis report, Ex. R19 to Ex. R25 are the copies of test reports of the complainant, Ex. R26 is the copy of  is the copy of letter written by Orison Hospital to TPA, Ex. R27 is the copy of reminder/notice dated 11.06.2018 issued by TPA to the complainant, Ex. R28 is the copy of letter dated 25.05.2018 written by TPA to the complainant, Ex. R29 is the copy of letter written by complainant to Orison Hospital, Ex. R30 is the copy of email dated 28.05.2018, Ex. R31 is the copy of email dated 01.05.2018, Ex. R32 is the copy of discharge summary, Ex. R33 is the copy of OPD card of DMC Ludhiana, Ex. R34 is the copy of Claim Form-Part A, Ex. R35 is the copy of claim processing sheet of TPA, Ex. R36 is the copy of letter dated 14.05.2018 written by TPA to the complainant, Ex. R37 is the copy of postal receipt, Ex. R38 is the copy of proposal form, Ex. R39 is the copy of  insurance policy w.e.f. 26.12.2018 to 25.12.2019, Ex. R40 is the copy of insurance policy w.e.f. 26.12.2017 to 25.12.2018, Ex. R41 is the copy of terms and conditions of the policy and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply, affidavit and documents produced on record by both the parties.

7.                Perusal of Ex. A2 = Ex. R40 Happy Family Floater-2015 policy schedule shows that the policy was from 26.12.2017 to midnight of 25.12.2018. The cover note in this case was issued on 22.12.2017 and there was no previous policy with the complainant and this fact was also admitted by the complainant himself in the letter Ex. R5 addressed to the opposite parties. Admittedly, on 02.04.2018 i.e. during the subsistence of the policy, the complainant fell down in washroom and had to be admitted in Dayanand Medical College, Ludhiana on 05.04.2018. Ultimately, on 30.04.2018, he was admitted in Orison Super Specialty Hospital, Infertility and Trauma Hospital, Ludhiana where on 01.05.2018, he was operated. The complainant was diagnosed with PID (Prolapsed Intervertebral Disc) L5 S-1 with cauda equine. The complainant submitted claim for medical expenses incurred on his treatment. Opposite party No.3 and 4 vide their letter dated 25.08.2018 Ex. R4 recommended that the claim is not admissible as this policy in question does not cover surgical expenses of treatment of Prolapsed Inter-vertebral Disc unless arising from accident 2 years as per exclusion clause 4.3 point xx of the policy which is reproduced as under:-

Exclusion Clause 4.3 point xx

"The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:-

Xx Surgery for prolapsed inter vertebral disc unless arising from accident 2 years."

The opposite parties issued show case notice dated 16.10.2018 and 12.11.2018 to the complainant but the complainant failed to respond to represent his case. Thereafter, the opposite parties repudiated the claim as per recommendations.

8.                It can also be noticed that the complainant had obtained the policy for the first time in the year 2017 and subsequent renewal  of the policy had a gap of 7 days in between and the same was treated as a fresh policy. So the case is squarely covered under the exclusion clause 4.3 point xx of the policy terms and conditions and the opposite parties have rightly invoked the said clause. As such, there is no deficiency in service on the part of the opposite parties.

9.                As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:22.03.2023.

Gobind Ram.

Bhupinder Singh Vs Oriental Insurance Co. Ltd.          CC/19/295

Present:       Sh. Kapil Katyal, Advocate for the complainant.

                   Sh. Rajeev Abhi, Advocate for OP1 and OP2.

                   Complaint against OP3 and OP4 not admitted vide order dated                          28.06.2019.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:22.03.2023.

Gobind Ram.