DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 65 of 22.2.2018

                                      Decided on: 3.9.2021

Kiran aged 61 years wife of Sh.Parmod Kumar r/o House No.311, Thatherian Street, Nabha, District Patiala.

                                                                   …………...Complainant

                                      Versus

1. Oriental Insurance Co. Ltd. Sai Market, Lower Mall,Patiala through its Divisional manager.
2. Punjab National Bank Main Nabha through its Branch Manager.

                                                                   …………Opposite Parties

Complaint under the Consumer Protection Act

QUORUM

                                      Sh. Jasjit Singh Bhinder, President

                                      Dr.Harman Shergill Sullar,  Member         

ARGUED BY              

                                      Sh.O.P.Chopra,counsel for complainant.

                                      Sh.B.L.Bhardwaj,counsel for OP No.1.

                                      Sh.Vaibhav Mangla, counsel for OP No.2.                   

 ORDER

                                      JASJIT SINGH BHINDER,PRESIDENT

1. This is the complaint filed by Kiran (hereinafter referred to as the complainant) against Oriental Insurance Co. and another (hereinafter referred to as the OP/s).
2. The brief facts of the case are that the complainant is having saving bank account with PNB Nabha, jointly operated with her husband Sh.Parmod Kumar. It is averred that through this bank she purchased policy No.233500/48/2017/4475 valid from 11.3.2017 to 10.3.2018 from OP No.1 under PNB-Oriental Royal Mediclaim Policy schedule vide which her husband was also insured and the complainant is paying the premium of policy regularly.
3. It is averred that from 16.11.2017 to 18.11.2017 Parmod Kumar was treated in Columbia Hospital, Patiala due to dengue fever and Rs.22,448/- was incurred on his treatment. The complainant applied for claim but same was repudiated by OP No.1 on 27.12.2017 on the ground that “Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 3 years of this policy being in force continuously arising from pre-existing ailments/diseases/injuries.”
4. It is further averred that as per medical science dengue has no relation with the diseases mentioned in the letter dated 27.12.2017 and the complainant is entitled to the claim of Rs.22,448/- and compensation of Rs.50,000/- and Rs.5000/-as litigation expenses.. The repudiation of the claim by the OP No.1 is unjustified and amounts to deficiency of service on its part which caused mental agony, pain and harassment to the complainant. Hence this complaint with the prayer to accept the same by giving direction to the OPs to pay Rs.77,448/- alongwith interest @24% per annum from 18.11.2017 till realization.
5. Upon notice OPs appeared through their respective counsels and contested the complaint by filing written reply.
6. In the written reply filed by OP No.1 it is admitted that the complainant and her husband Parmod Kumar were insured for a sum of Rs.5Lakh under the PNB-Oriental Royal Mediclaim Policy schedule for the period from 11.3.2017 to 10.3.2018. It is averred that Parmod Kumar got admitted on 16.11.2017 in Columbia Asia Hospital and as per discharge summary he was kco Hypertensive/Diabetes mellitus Type-2, Coronary Artery disease post PTCA stent to RCA 2005 BEP Grade 1 with unstable Angina, PTCA stent to LAD PLV, 11POBA to Diagonal(Nov 2013) with dengue fever and discharge diagnosis with DM, HTN, cad-post ptca, bph, dengue hemorrhagic fever, bleeding p/r anal fissure. It is further averred that claim of Rs.22,448/-was received and the same was processed by Raksha Health Insurance TPA Pvt. Ltd. and it was found that patient was suffering  from CAD, HTN & T2DM, As per the records it is found that patient has the history of CAD since 2005 before the inception of policy. Policy is in 3^rd year of inception. Therefore, this claim is non payable. As such the claim was rightly repudiated vide letter dated 11.12.2017. There is no deficiency of service on the part of the OP. After denying all other averments, the OP has prayed for the dismissal of the complaint.
7. In the written reply filed by OP No.2, it is pleaded that the complainant does not fall within the ambit of the Act. It is admitted that the complainant is having saving bank account with OP No.2 jointly with her husband and she has purchased the policy. It is pleaded that OP No.2 has just acted as a facilitator agent between the complainant and OP No.1 and has got no role to pay in the present complaint and has prayed to dismiss the complaint.
8. In support of the complaint, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C3 and closed the evidence.
9. The ld. counsel for OP No.1 has tendered in evidence Ex.OPB affidavit of Mukesh Malhotra, Divisional Manager alongwith documents Exs.OP1 to OP4 and closed the evidence.
10. The ld. counsel for OP No.2 has tendered in evidence Ex.OPA affidavit of Rajesh Garg, Sr.Manager and closed the evidence.
11. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
12. The ld.counsel for the complainant has argued that the complainant was having saving account with PNB, Nabha alongwith her husband and she purchased medical policy from OP No.1 effective from 11.3.2017 to 10.3.2018.The ld. counsel further argued that on 16.11.2017 Sh.Parmod Kumar fell ill and he was admitted to Columbia Asia Hospital, Patiala and Rs.22,448/- was spent on his treatment. The ld. counsel argued that the claim was lodged with OP No.1 but it was wrongly repudiated. So complaint be allowed.
13. The ld. counsel for OP No.1 has argued that dengue is not covered under the medical policy and the claim was rightly repudiated. The ld. counsel further argued that the previous illness of Parmod Kumar has been concealed. So the complaint be dismissed.
14. To prove this case, complainant has tendered her affidavit,Ex.CA and she has deposed as per the averments. Ex.C1 is the insurance policy of PNB-Oriental Royal Mediclam policy Schedule. It was valid from 11.3.2017 to 10.3.2018.Ex.C2 is letter written by Oriental Insurance Co. to the complainant. It is mentioned that Parmod Kumar was patient of heart disease.Ex.C3 is record of Columbia Asia Hospital in which it is mentioned that patient was suffering from hypertension, diabetes and coronary artery disease.
15. No doubt Sh.Parmod Kumar was suffering from hypertension, diabetes and coronary artery disease but the present complaint pertains to the admission due to dengue fever and he was not admitted in the hospital due to hypertension, diabetes or coronary artery disease or any other disease. This dengue disease has no concern with hypertension, diabetes and coronary artery disease. From this document, it is clear that he was suffering from dengue fever.Ex.C3 is accompanied by total bill of Rs.22,448/- which was spent on the treatment of Sh.Parmod Kumar.
16. On the other hand Sh.Mukesh Malhotra has tendered in evidence his affidavit, Ex.OPA on behalf of OP No.1 and he has deposed as per the written statement.Ex.OP1 is the letter written by OP No.1 to the complainant Kiran. It is mentioned that patient was suffering from heart disease since 2005 so claim is not payable. Ex.OP2 is document of Raksha Health Insurance TPA Pvt. Ltd. As per this letter Sh.Parmod Kumar was suffering from heart disease so claim was not payable.
17. As already discussed above, no doubt Sh.Parmod Kumar was patient of hypertension, diabetes and coronary artery disease but the present bill pertains to dengue fever for which he was admitted to Columbia Asia Hospital. As per medical jurisprudence, this dengue has got no concern with the above mentioned diseases of hypertension, diabetes and coronary artery disease. Had the patient suffering from these diseases then the insurance company could have valid defence that these diseases were not mentioned by the complainant and her husband, when they took the insurance policy. So as dengue fever has got no concern, the OP cannot reject the claim and the OP has wrongly repudiated the claim and is liable to pay the same alongwith interest.
18. So due to our above discussion, the complaint is allowed and OP No.1 is directed to pay the claim amount of Rs.22,448/- to the complainant alongwith interest @6% per annum from the date of repudiation  till its payment. The OP No.1 is also directed to pay Rs.10,000/- as compensation and costs of Rs.10,000/- to the complainant  within a period of 45 days from the date of the receipt of the certified copy of this order.

ANNOUNCED

DATED:3.9.2021             

                                        Dr.Harman Shergill Sullar   Jasjit Singh Bhinder

                                                      Member                                        President