Chandigarh

DF-I

CC/243/2015

Roseleen Sidhu - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

In person

26 Nov 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/243/2015
Date of Institution	:	20/04/2015
Date of Decision	:	26/11/2015

 

Roseleen Sidhu wife of Sh. Navreet Singh Hundal, aged 38 years, resident of House No.4540, Darshan Vihar, Sector 68, Mohali.

…..Complainant

V E R S U S

1.      Oriental Insurance Company Limited, through its Regional Head, Regional Office, SCO 109-111, Sector 17D, Chandigarh.

2.      Oriental Insurance Company Limited, through its Chairman/Managing Director, Regd. & Head Office
A-25/27, Asaf Ali Road, New Delhi 110002.

……Opposite Parties

 

QUORUM:	P.L.AHUJA	PRESIDENT
	SURESH KUMAR SARDANA	MEMBER

                                                                               

                       

ARGUED BY	:	Complainant in person
		Sh. Pardeep Kumar, Counsel for OPs

                       

                 

PER P.L.AHUJA, PRESIDENT

1.         Mrs.  Roseleen Sidhu, complainant has filed this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against Oriental Insurance Company Limited and another, Opposite Parties (hereinafter called the OPs), alleging that in the year 2005 she had taken a medical insurance policy and thereafter regularly paid the yearly premiums. 

                According to the complainant, in the year 2002, people in India started suffering from a particular ailment which on treatment was found as Hepatitis C. The patient of this treatment was used to be treated as indoor patient which remained in operation till the year 2006-07. In October 2012, the complainant suffered from an ailment which could be treated by injections on weekly basis.  On approach made to the expert doctors with Post Graduate Institute of Medical Education and Research (PGI), Chandigarh, the complainant received injection ‘interferon a 2b 80 mcg per week’ commencing from October 2012 till December 2013 on regular basis.  Accordingly, 60 injections costing Rs.11,500/- each, were administered to the complainant and the total cost of the treatment came at Rs.6,90,000/-. The complainant submitted her claim with the OPs, but, they did not entertain the same.  Faced with this situation, the complainant made a claim to Insurance Ombudsman, Chandigarh, but, the same was rejected vide order dated 4.8.2014 on the reasoning of a day care treatment without mandatory indoor hospitalization for 24 hours and treatment not falling in the approved ‘day care’ procedures. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the OPs, the complainant has filed the instant complaint.  

2.         In their joint written statement, OPs have taken a number of preliminary objections including that this Forum does not have the territorial jurisdiction. It has been averred that the complainant was insured under Mediclaim Insurance Policy for a sum of Rs.2.00 lacs only that too upto 6.8.2013.  It has been contended that the claim of the complainant was denied by the OPs as the same was not payable as per terms and conditions of the subject Mediclaim Insurance Policy. It has been submitted that the order dated 4.8.2014 of the Insurance Ombudsman, Chandigarh is well reasoned. Pleading that there is no deficiency in service or unfair trade practice on their part, OPs have prayed for dismissal of the complaint. 
3.         In her rejoinder, the complainant has controverted the stand of the OPs and reiterated her own.
4.         The parties led evidence in support of their contentions.
5.         We have gone through the entire evidence, written arguments submitted by both sides and heard the arguments addressed by the complainant in person and learned counsel for the OPs. 
6.         The first material point for determination in this case is whether this Forum has territorial jurisdiction to entertain and try this complaint or not? The learned counsel for the OPs has drawn our attention to the copies of the insurance policies at Annexure C-1 and has contended that the complainant has been obtaining the mediclaim insurance cover policies w.e.f. 9.11.2005 to 6.8.2013 from branch/divisional office of the OPs at Mohali, who is the issuing office of these policies. He has also contended that even when the complainant filed a complaint (Annexure C-4) before the Insurance Ombudsman, she alleged that Mr. Jaswal, the representative of the Oriental Insurance Co., said that she would not be able to get the reimbursement from the company in any case. The learned counsel for the OPs has contended that Mr. Jaswal is an official of the OPs posted at its D.O. Mohali. The learned counsel for the OPs has further contended that the complainant had been in contact with the officials of D.O. Mohali for reimbursement of the alleged treatment cost which was declined. He has further submitted that the mere fact that the complainant took treatment at Chandigarh does not confer territorial jurisdiction on this Forum.  The learned counsel for the OPs has vehemently argued that since no cause of action, wholly or in part, arose within the territorial jurisdiction of this Forum, therefore, this Forum has no jurisdiction to try and entertain the present complaint. 
7.         We have given our thoughtful consideration to the above arguments of the learned counsel for the OPs. It is true that the issuing office of the mediclaim policies obtained by the complainant is the branch/divisional office Mohali. However, it is pertinent to note that the complainant has been serving in Tranzcanz Overseas SVS Pvt. Ltd., SCO No.61-63, First Floor, Sector 9D, Chandigarh.  According to the complainant, the official of the OP company since beginning had approached her at her office at Chandigarh and on his allurement that on having any medical expenses, the claim would be reimbursed, she kept on taking the medical policies on yearly basis starting from the year 2005.  It is also worth noting that the amount of premium was paid from the bank account of the complainant maintained with the HDFC Bank, Sector 9, Chandigarh. In this context, the complainant has also produced the copies of statements of account (Annexure
   C-7) alongwith the entries in her passbook. The documentary evidence in the shape of statements of account  and entries in the passbook of the complainant with HDFC Bank, Sector 9, Chandigarh show that she has all along been paying the insurance premiums to the OPs from her bank account maintained with the said bank.  It is also significant to note that the complaint filed by the complainant against the OPs seeking reimbursement of treatment expenses with Insurance Ombudsman, Chandigarh was dismissed on 4.8.2014 at Chandigarh.  Thus, a part of the cause of action arose to the complainant at Chandigarh. Hence, we are of the considered opinion that this Forum has jurisdiction to try and entertain the present complaint.
8.         It is the admitted case of the OPs that the complainant had taken individual mediclaim policy from the OPs in the year 2005 and she has been paying the regular premiums on yearly basis and the last policy was for the period from 7.8.2012 to 6.8.2013 for a sum insured of Rs.2.00 lakhs. According to the complainant, she was suffering from chronic hepatitis C and she took treatment from PGI, Chandigarh. 60 injections were administered on her to treat the ailment.  The cost of one injection was Rs.11,500/-. According to the complainant, she submitted her claim with the OPs for an amount of Rs.6,90,000/- towards the cost of 60 injections administered to her for the period w.e.f. October 2012 to December 2013. The complainant has also produced the copies of out patient cards (at Annexure C-2) and the copies of the receipts (at Annexure C-3) in respect of the amount spent by her. 
9.         The next point for determination in this case is whether the complainant is entitled to the reimbursement of the amount spent towards the cost of injections administered to her? 
10.         The learned counsel for the OPs has contended that the claim of the complainant falls within the purview of exception clause 2.3 (c) of the policy (Annexure R-1), the relevant portion of which is extracted as below :-

“(C) This condition of minimum 24 hours Hospitalisation will also not apply provided, medical treatment, and/or surgical procedure is:

i.      undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hours because of technological advancement, and

ii.     which would have otherwise required a hospitalization of more than 24 hours.”

The learned counsel for the OPs has contended that the complainant got the injections administered as an OPD patient at PGI, Chandigarh. Further, the injections administered to her never required any general or local anesthesia in hospital, therefore, the Insurance Ombudsman rightly observed in his order (Annexure C-5) that the insurance company’s decision to reject the claim on the ground of ‘day care’ treatment without mandatory indoor hospitalization for 24 hours and treatment does not fall in the approved ‘day care’ procedure.  The learned counsel for the OPs has strenuously argued that the order passed by the Insurance Ombudsman is a well-reasoned order and after considering all the contentions/submissions of the complainant, her claim was rightly rejected by the OPs and the Insurance Ombudsman.

11.         We have given our careful consideration to the above arguments.  At the outset, it is important to note that the exception clause mentioned in the terms and conditions (Annexure R-1) and reproduced in the written statement of the OPs pertains to mediclaim insurance policy (group) whereas the complainant is an individual and she has produced the correct copy of the mediclaim insurance policy (individuals) alongwith her rejoinder.  According to the correct terms and conditions, clause 2.3 (c) i.e. the exception clause reads as under :-

“(c)   This condition of minimum 24 hours Hospitalisation will also not apply provided

                I)      The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available only in hospitals.

BUT

                II)     Due to technological advances hospitalization is required for less than 24 hours.

AND/OR

III)    Surgical procedure involved has to be done under General Anaesthesia.”

We are of the view that the OPs have not come with clean hands in the matter and have rejected the claim on the basis of the terms and conditions of the mediclaim insurance policy (group) which are not applicable to the complainant.

12.         The complainant has specifically pleaded in para 4 of the complaint as under :-

                “xxx                          xxx                           xxx

                It is important to state here that in the year 2002, people in India started suffering from a particular ailment, which on treatment was found as Hepatitis C. The patient of this treatment was used to be treated as indoor patient, which practice remain in operation till the year 2006-2007. As the medical science progressed and advanced, there was technological advancement in respect to this treatment and the indoor treatment was converted to outdoor treatment.”

Significantly, the above said plea of the complainant has not been specifically denied by the OPs in their written reply.  Thus, it is established that earlier patients like complainant were used to be treated by injecting hepatitis C as indoor patient.  However, due to advancement in the technology and further research, now the patient is administered such injections as an out door patient and the patient need not to remain admitted even for 24 hours.  The certificate dated 19.1.2015 (Annexure C-6) of Dr. R.K. Dhiman of Department of Hepatology, PGI, Chandigarh shows that the complainant has been cured from chronic hepatitis C.  She received peg interferon  2b 80 mcg per week + ribavirin (800-1000 mg/day) for the 60 weeks w.e.f. October 2012 to December 2013. At PGI, Chandigarh giving IFN injection is an OPD procedure and patient need not be admitted as hospitals are overflowing with more serious patients. Today due to technological advancement, it is an OPD treatment. 

13.         Evidently, the complainant has been visiting the PGI, Chandigarh for getting administered the above said injections and due to technological advances, hospitalization is required for less than 24 hours. The objection raised by the learned counsel for the OPs that the complainant never required any general or local anesthesia in hospital is devoid of any force because as per the exception clause mentioned above, the condition of minimum 24 hours hospitalization does not apply where the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available only in the hospitals, but, due to technological advances, hospitalization is required for less than 24 hours.  The words “and/or” mentioned in the condition relating to surgical procedure are quite significant and show that surgical procedure under general anesthesia is not mandatory under the exception clause.  In our opinion, had the word been “and” only, then the surgical procedure under general anesthesia would have been necessary.  Consequently, the complainant is entitled to the reimbursement of the amount spent on injections which were administered to her as an outdoor patient in PGI, Chandigarh.
14.         The last point that survives for determination is as to how much amount is to be reimbursed to the complainant. According to the complainant, she spent an amount of Rs.6,90,000/- on the injections so administered w.e.f. October 2012 to December 2013.  The last mediclaim policy was obtained by the complainant for the period from 7.8.2012 to 6.8.2013, therefore, the complainant is entitled to the reimbursement for the period from 7.8.2012 to 6.8.2013 only and not for the period from 7.8.2013 to December 2013. The copies of the out patient cards (Annexure C-2) show that the treatment of the complainant was started at PGI, Chandigarh on 1.10.2012. Thus, the complainant is entitled to the reimbursement in respect of the amount spent from 1.10.2012 to 6.8.2013. The complainant has submitted a chart for injections which shows that for the period w.e.f. 26.10.2012 to 2.8.2013, 41 injections at a cost of Rs.4,71,500/- were administered to her.  The OPs have not filed any such chart in rebuttal nor have taken any such specific plea that the complainant did not spend the amount of Rs.6,90,000/- on the administration of the injections.  Thus, there is no reason to disbelieve that the complainant spent an amount of Rs.4,71,500/- on the injections administered to her w.e.f. 26.10.2012 to 2.8.2013. Since the complainant was having a policy for the period from 7.8.2012 to 6.8.2013 for the sum insured of Rs.2.00 lakhs only, therefore, she cannot be reimbursed more than Rs.2.00 lakhs.  We are of the view that the rejection of the claim of the complainant in toto is quite unjustified and amounts to unfair trade practice as well as deficiency in service on the part of the OPs.  The complainant ought to have been paid Rs.2.00 lakhs spent by her for getting administered injections in PGI, Chandigarh when her policy from 7.8.2012 to 6.8.2013 was subsisting.
15.         For the reasons recorded above, we find merit in the complaint and the same is partly allowed.  The OPs are directed :-

(i)     To make payment of an amount of Rs.2.00 lakhs to the complainant alongwith interest @ 9% per annum from the date of filing of the claim till realization.

(ii)    To also make payment of an amount of Rs.11,000/- to the complainant towards litigation expenses. 

16.         This order be complied with by OPs within one month from the date of receipt of its certified copy, failing which they shall make the payment of the amount mentioned at Sr.No.(i) above, with interest @ 12% per annum from the date of filing of the present complaint till realization, apart from compliance of direction at Sr.No.(ii) above.
17.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-		Sd/-
26.11.2015	[Suresh Kumar Sardana]		[P. L. Ahuja]
hg	Member		President