DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 45 of 13.2.2017
Decided on: 14.5.2018
Jagjit Singh aged about 60 years, resident of House No.82, Ranjit Vihar, Sirhind Road, Patiala.
…………...Complainant
Versus
- Oriental Insurance Co. Ltd. Regd.& Head Office: A-25/27, Asaf Ali Road, New Delhi-110002 through its Managing Director.
- Oriental Insurance Co. Ltd.Divisonal office: Sai Market, Lower Mall, Patiala through its Manager.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.Jagjit Singh,Advocate, counsel for complainant.
Sh.D.P.S.Anand,Advocate, counsel for opposite parties.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Sh.Jagjit Singh, complainanthas 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 the O.Ps.)
2. In brief, the facts of the complaint are that the complainant got himself and his wife Narinder Kaur insured with the OPs under ‘Oriental Bank Mediclaim Policy’for the period from 24.2.2016 to 23.2.2017, vide policy No.233500/48/2016/3746 and paid Rs.6960/- as premium, for the sum assured of Rs.5,00,000/-. It is stated that during the subsistence of the policy, his wife Smt.Narinder Kaur, suffered from acute chest pain and she was got admitted in Columbia Asia Hospital, Patiala for medical treatment, where she remained admitted from 15.7.2016 to 17.7.2016 and Rs.3,09,978/- were incurred on the treatment of his wife. The complainant gave intimation in this regard to the OPs and submitted all the necessary documents with them. The OPs appointed M/s Medi Assist India TPA Private Limited for verification but it repudiated the claim on e-mail without any sufficient cause and reason, though the doctor had issued the certificate that there was no past history of any coronary artery disease/hypertension or diabetes. The complainant also got served the OPs with the legal notice dated 24.1.2017 but to no effect. The act and conduct of the OPs amounted to deficiency in service which caused mental agony and physical harassment to the complainant. Hence this complaint with the prayer for giving directions to the OPs to pay Rs.3,09,978/- alongwith interest @18% per annum w.e.f. the date of discharge of wife of the complainant from the hospital till realization; to pay rs.1,00,000/- as compensation for causing mental agony and physical harassment; to pay Rs.25000/-as litigation expenses. Any other relief which this Forum may deem fit may also be granted.
3. On being put to notice, the OPs appeared and filed their written version taking preliminary objections that the complaint is not maintainable; that complicated questions of law and facts are involved in the present case and the civil court is competent to try the present dispute and the same is liable to dismissed. The OPs are ready to settle the claim subject to production of the original passport or its complete photo copy duly attested by the complainant. On merits, it is stated that the OPs had issued Oriental Bank Mediclaim policy, in favour of the complainant for the period from 24.2.2016 to 23.2.2017, covering the risk of the complainant and his wife Smt.Narinder Kaur and the total sum assured was Rs.5lacs.The policy has been issued in black and white and with detail terms and conditions mentioned therein, which has been signed and accepted voluntarily by the parties and both the parties are bound with the contract. It is stated that on receipt of intimation of loss and documents, the same were sent to M/s Medi Assist India TPA Private Limited, who after examination and verifying all the documents found that the claim was not payable as the expenses on treatment of hyper tension for specified period of two years are not payable if contracted and /or manifest during the currency of the policy. The present policy was running in the first year and the insured was accordingly informed on 8.3.2017. The claim has been rightly repudiated by the OPs. There is no deficiency of service on their part. After denouncing all other averments made in the complaint, it was prayed to dismiss the complaint.
4. On being called to do so, the ld. counsel for the complainant has tendered in evidence Ex.CA,affidavit of the complainant alongwith documents Exs.C1 to C8 and closed the evidence of the complainant.
The ld. counsel for the OPs has tendered in evidence Ex.OPA, affidavit of Sh.Rajwant Rai, Sr.Divn.Manager, Ex.OPB, affidavit of Dr.Sunder Parthasarthy alongwith documents Exs.OP1 to OP3 and closed the evidence of the OPs.
5. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
6. Admittedly, the complainant got himself and his wife Smt.Narinder Kaur, insured with the OPs, vide policy document Ex.C1 for the period from 24.2.2016 to 23.2.2017.As per the complainant, during the subsistence of the policy, his wife had chest pain and remained admitted in Columbia Asia Hospital, for the period from 15.7.2016 to 17.7.2016 and spent Rs.3,09,978/-. He lodged the claim with the OPs but they repudiated the same vide letter dated 8.3.2017,Ex.OP2, on the ground that the claim did not fall within the purview of policy terms and conditions.
The ld. counsel for the OPs has vehemently argued that the claim had rightly been repudiated because from the discharge summary Ex.C3, issued by Columbia Asia Hospital, it is apparent that the complainant was suffering from hyper tension and as per terms and conditions of the policy, the claim was not payable.
8. It may be stated here that the parties are bound by the terms and conditions of the policy. In term No.4.2 of the policy terms and conditions, it is mentioned that, “The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable if contracted and/ or manifested during currency of policy.” The disease ‘Hypertension’ has been found mentioned at Sr.no.17 of the list of the diseases mentioned in the policy document, itself. The period of two years has been found mentioned, for the disease ‘Hypertension’ in the said list, meaning thereby if, the insured suffers from hypertension within two years from the date of inception of the insurance policy, then as per clause 4.2, the insurer is not liable to reimburse the amount, incurred on the treatment by the insured.
No doubt the doctor concerned of Columbia Asia Hospital, had given the certificate,Ex.C4, to the effect that the wife of the complainant had no past history of coronary artery disease/hypertension or diabetes but from the said certificate, it is not clear that after the admission of the wife of the complainant, her blood pressure remained normal. Since this fact, that wife of the complainant was suffering from hypertension, was detected on 15.7.2016 during the period when she was got admitted in the Columbia Asia hospital i.e. within the period of about five months, from the date of the inception of the policy in question, therefore, as per clause 4.2 of the policy term, the OPs are not liable to pay the amount incurred by the complainant on the treatment of his wife.
9. In view of our aforesaid discussion, we do not find any merit in the complaint. Consequently, we dismiss the same without any order as to costs. 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:- 14.5.2018
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
