Punjab

Fatehgarh Sahib

CC/34/2017

Rakesh Kumar - Complainant(s)

Versus

Oriental Insurance comp ltd - Opp.Party(s)

Sh Sumit Gupta

04 Sep 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                      Consumer Complaint No.34 of 2017

                                                                         Date of institution:  22.05.2017                         

                                                                        Date of decision  :   04.09.2018

 

Rakesh Kumar S/o Ram Kishore, House No.64, Sec-5B, New Shastri Nagar, Mandi Gobindgarh, Tehsil Amloh, District Fatehgarh Sahib.

 

……..Complainant

Versus

1. The Oriental Insurance Company Ltd., Loha Bazaar, Mandi Gobindgarh, Tehsil Amloh District Fatehgarh Sahib through its Branch Manager.
2. The Regional Manager, the Oriental Insurance Co. Ltd., Regional office, Surindera Building, S.C.O. 109-110-111, Sector 17-D, Chandigarh.
3. The Divisional Manager, the Oriental Insurance Company Limited, Calibre Market, Patiala Road, Rajpura Tehsil Rajpura District Patiala.
4. The General Manager, the Oriental Insurance Company Limited, Registered head office, A-25/27, Asaf Ali Road, New Delhi.
5. Vipul Medicorp TPA Private Limited, 515, Udyog Vihar, Phase-5, Gurgaon, Haryana.

…..Opposite Parties

Complaint under Sections 11 to 14  of the Consumer Protection Act 1986.

Quorum

         Sh. Ajit Pal Singh Rajput, President                               

        Sh. Inder Jit, Member

                                               

Present :        Pt. Narinder Kumar, Adv., counsel for complainant.

                      Sh. Amit Gupta, Adv.Cl. for OPs No.1 to 4.

                      Opposite Party No.5 exparte.

ORDER

By Inder Jit, Member

                      Complainant, Rakesh Kumar S/o Ram Kishore, House No.64, Sec-5B, New Shastri Nagar, Mandi Gobindgarh, Tehsil Amloh, District Fatehgarh Sahib, has filed this complaint against the Opposite parties (hereinafter referred to as “the OPs”) under Section 11 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.                   Complainant has taken a medical Insurance Policy from OPs vide No.233603/48/2012/809 dated 09.03.2012 for the period from 16.03.2012 to 15.03.2013 and paid Rs.5859/- as premium. The said policy was for two persons i.e. complainant and his wife Saroj Gupta.  The complainant continued the policy for next year i.e. from 16.03.2013 to 15.03.2014 and paid the premium of Rs.5969/-. In the year 2014, the complainant took Happy Family Floater Policy No.233603/48/2014/1219 for the period from 15.03.2014 to 15.03.2015 and paid the premium of Rs.7225/-. The said policy covers the whole family of the complainant i.e. complainant, his wife and two children. The complainant continued the said policy for the period from 16.03.2015 to 15.03.2016 and then from 16.03.2016 to 15.03.2017 and paid the premium of Rs.15,225/- and 15,515/- respectively.  On 21.04.2016, the complainant suffered from pain in Abdomen and went to Kaushal Nursing Home, Gole Market, Mandi Gobindgarh and took medicines from the concerned doctor.  Then on 24.05.2016, the complainant again suffered from pain in Abdomen and again visited Kaushal Nursing home and took treatment from the concerned doctor. Thereafter, the complainant went to Faridabad in connection with some urgent work,  where he again suffered from pain in Abdomen and for its treatment, he visited Sarvodaya Hospital and Research Centre Faridabad. The concerned doctor of the hospital conducted some tests and gave medicine to the complainant. Then on 30.05.2016, the complainant again suffered from pain in his Abdomen and was taken to SPS Hospital Ludhiana. The complainant got admitted in the said hospital on 31.05.2016 and was discharged on 03.06.2016 after taking treatment. The complainant applied for cashless medical treatment through     e-mail to the OPs but they denied the same. The complainant paid Rs.56,429/- to the said Hospital for his treatment during his stay in the hospital.  Thereafter, the complainant requested the OPs to sanction the medical claim of the complainant. The OPs demanded some documents, which were supplied by the complainant through letter dated 27.12.2016. But the OPs vide letter dated 01.02.2017, repudiated the claim of the complainant. The complainant has time and again requested the OPs to pay the claim amount but they have not paid any heed to the genuine requests of the complainant. The act and conduct of the OPs amounts to deficiency in service on their part. Hence, this complaint for giving directions to the OPs to sanction the claim amount of Rs.56,429/- in favour of the complainant and further to pay Rs.43,571/- as compensation for mental agony and harassment together with litigation charges.

3.                   Notice of the complaint was issued to the OPs but OP No.5 chose not to appear to contest this complaint. Hence, OP No.5 was proceeded against exparte.

4.                   The complaint is contested by OPs No.1 to 4, who filed joint written reply. In reply to the complaint, OP No.1 to 4 stated that the complainant obtained the said policies from the OPs subject to condition clauses, warranties and endorsements. The cashless facility is applicable only when the treatment is duly approved by the TPA before the treatment. On 10.06.2016, the complainant has lodged one claim with regard to his treatment in SPS Apollo Hospital, Ludhiana  from 31.05.2016 to 03.06.2016 under the policy No.233603/48/2016/1041.  On account of pain in abdomen and fever, complainant was having history of irritable bowel syndrome with fatty liver and type-2 diabetes mellitus and the claimant was treated conservatively. While processing the claim by the TPA, it was observed that:

                  " As per the submitted documents patient has been admitted for the complaints of pain in abdomen since last 1 month and was diagnosed as a case of irritable bowel  syndrome and fatty liver. As per the final bill patient has been managed only with oral tables and as per the reply attached in cashless scan documents, admission has been done for monitoring and evaluatory purpose. Thus, the case is not admissible as per clause 4.11 of the policy".

It is further stated that vide letter dated 10.08.2016, the TPA has conveyed the insurance company the inadmissibility of the claim of the complainant. The complainant has lodged one representation in response to letter dated 10.08.2016 of the TPA, which was sent by the Branch Office and same was duly considered but the claim of the complainant was found inadmissible and the same was duly conveyed to the complainant vide letter dated 01.02.2017. Hence, there is no deficiency in service on the part of the OPs No.1 to 4. After denying the other averments made in the complaint, the OPs prayed for dismissal of the complaint.

5.                   In order to prove his complaint, the complainant tendered in evidence affidavit of complainant Ex. C-1, true copies of documents i.e. cover note dated 11.03.2016 Ex. C-2, discharge summary Ex. C-3 to Ex. C-4, repudiation letter Ex. C-5, policies Ex. C-6 to Ex. C-9, OPD prescription of Kaushal nursing home Ex. C-10, OPD slip Ex. C-11, prescription slip of Sarvodaya Hospital and Research Centre Faridabad Ex. C-12, Lab report dated 26.05.2016 Ex. C-13, bill dated 26.05.2016 Ex. C-14, OPD receipt dt.26.05.2016 Ex. C-15, scan report dated 31.05.2016 Ex. C-16, colonoscopy report Ex. C-17, endoscopy report Ex. C-18, lab report Ex C-19 & C-20, microbiology report Ex. C-21, certificate issued by SPS Hospital Ex. C-22, lab report Ex. C-23, OPD slip Ex. C-24, city scan Ex. C-25, bill dated 03.06.2016 Ex. C-26, detailed bill dated 03.06.2016 Ex. C-27, detail of pharmacy bill Ex. C-28, advance receipts Ex. C-29 to C-31, receipt and bill dated 03.06.2016 Ex. C-32 & 33, letter to insurance company dt. 27.12.2016 Ex. C-34,emails Ex. C-35  & 36, certificate dated 17.12.2016 Ex. C-37, original repudiation letter Ex. C-38, bill Ex. C-39, OPD slip Ex. C-40 and closed the evidence. In rebuttal OPs No.1 to 4 tendered in evidence affidavit of Sh. S.K. Sharma, Divisional Manager Ex.OP1/1, affidavit of Ashwani Kumar R.M as Ex. OP1/2, copy of terms and conditions of the policy Ex.OP1/3(28 pages), copy of claim form Ex. OP1/4, discharge summary Ex. OP1/5, copies of letters Ex.OP1/6 to Ex. OP1/8 and closed the evidence.

6.                   Ld. counsel for the complainant argued that the complainant had taken the Health Insurance policy from the OPs. During the currency of the aforesaid policy, the complainant had pain in abdomen for which he took treatment from a local hospital and again from a hospital in Haryana State. When he could not recover from the aforesaid ailment, he was got admitted to SPS Hospital Ludhiana where, after investigation, he was treated and ultimately after recovery from the said ailment, he submitted his cashless medical claim of Rs.56,429/- with the OPs through e-mail which was declined by the OPs. Ld. counsel for the complainant further argued that the act and conduct of the OPs shows deficiency in service. Ld. counsel also showed copies of some documents placed on record in support of his claim. He emphasized the fact that the complainant was put to clinical tests to establish the cause of the pain/ailment and ultimately, on the basis of findings, the doctors at the SPS Hospital Ludhiana administered the required medicines/fluids/pills etc. He prayed for acceptance of complaint and sought that directions be issued to OPs to refund the expenditure incurred at the SPS Hospital Ludhiana besides ordering adequate compensation and litigation expenses in favour of the complainant. Ld. counsel for the complainant relied upon a judgment of Hon'ble National Commission in case titled as R.W.H. Ghyaz Ahmed Vs. New India Assurance Co. Ltd. and Ors. in Revision Petitioin No.2016 of 2012 decided on 05.12.2012.

7.                   Ld. counsel for the OPs argued that the Health Insurance claim of the complainant was repudiated by the OPs on the basis of terms and conditions of the insurance policy. He drew attention towards Ex. C-35 whereby pre-authorization for cashless treatment of the ailment of the complainant at SPS Hospital Ludhiana had been declined by the OPs as the     "patient was mainly admitted for evaluation of pain" cause and admission in Hospital for diagnostic purpose is not payable. However OPs advised the complainant to take treatment and submit bills which shall be processed as per terms and conditions of the policy. Ld. counsel further argued that the complainant was having " history of irritable bowel syndrome with fatty liver and type-2 diabetes mellitus" and the complainant was treated conservatively i.e. he was managed with oral tablets and IV fluids. Virtually admission of the complainant in hospital was done for monitoring and evaluation purpose and hence claim is not admissible "as 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 " clause 4.10 and 4.11 of terms and conditions of the policy which are read as under:-

"4.10 :  Expenses incurred at Hospital or Nursing Home primarily for evaluation/diagnostic purposes, which is not followed by active treatment for the ailment during the hospitalized period.

4.11 :        Expenses on vitamins and tonics etc unless forming part of treatment for injury or disease as certified by the attending physician".

            In view of aforesaid, the Ld. counsel for the OPs prayed for dismissal of the complaint.

8.                   We have gone through the written arguments, evidence placed on record and heard oral submissions of the Ld. counsel. We find force in the submissions of Ld. counsel for the OPs as it is evident from the evidence placed on record that the complainant was admitted to SPS Hospital Ludhiana for diagnostic purpose and was treated with oral pills and IV fluids, expenditure on which is not payable under the terms and conditions of the policy.  Ld. counsel for the complainant could not place on record any document showing any kind of active treatment given to the complainant during his stay in the hospital. The case law cited by the Ld. counsel for the complainant is not relevant to the case in hand. Hence we dismiss this complaint. Parties to bear their own costs.

9.                  The arguments on the complaint were heard on 28.08.2018 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated: 04.09.2018