Chandigarh

DF-II

CC/1173/2019

Ved Nanda - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

Nirmal Singh Jagdeva Adv.

26 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	1173 of 2019
Date  of  Institution	:	14.12.2019
Date   of   Decision	:	26.09.2023

 

 

 

 

 

Ved Nanda w/o Sh.J.L.Nanda, R/o H.No.1567, Sector 38-B, Chandigarh.

             …..Complainant

 

Versus

1]  Oriental Insurance Company Limited, through Regional Manager, R.O. 109-110-111, Sector 17-d, Chandigarh

2]  Raksha Health Insurance TPA Pvt. Ltd., SCO No.39, First Floor, Madhya Marg, Sector 26, Candigarh through its Manager.

   ….. Opposite Parties

 

 

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                MR.B.M.SHARMA                 MEMBER

 

Present:-  Sh.Nirmal Singh Jagdeva, Counsel for the complainant

Sh.Nikhil Sherawat, Adv. proxy for Sh.Satpal Dhamija, Counsel for Op No.1

            OP No.2 exparte

 

 

PER B. M. SHARMA, MEMBER

 

        Briefly stated, the complainant and her husband got themselves insured  under the PNB Oriental Royal Medical Policy of the OP No.1  which was valid from 01.10.2017 to 30.09.2018 (Annexure C-1) having membership ID 055617775638.  In June, 2018, the complainant faced a problem and the complainant consulted the local doctor who referred her to Fortis Hospital where a heart problem was diagnosed. On 10.06.2018, the complainant was admitted in the said hospital and underwent medical treatment and she applied for cashless treatment as per the policy(Annexure C-2), which was denied vide letter dated 14.06.2018 (Annexure C-3). The complainant was admitted in the hospital on 10.06.2018 and discharged on 14.06.2018 and incurred a sum of Rs.99,978/- on her treatment which was paid by the complainant from her own pocket. Besides this, the complainant also incurred a sum of Rs.4992/- on post treatment card. Subsequently, the complainant submitted the mediclaim along with requisite documents to the OP No.2 with reminder dated 20.09.2018. Finally, the OPs repudiated the claim vide letter dated 24.09.2019 (Annexure C-11) on the ground that the complainant has a history of DM,HTN and HTN is a pre-disposing factor of CAD.  The claim was also disallowed on one ground that the complainant submitted another claim for hospitalization from 15.03.2019 to 17.03.2019 and discharge summary of subsequent hospitalization was also used by the OP for rejecting the claim of 2018. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to reimburse the mediclaim of Rs.1,14,970/- along with interest, compensation for mental agony and physical harassment as well as litigation expenses.

 

2]       In its written version, the OP No.1 while admitting the factual matrix of the case has pleaded that the cashless benefit was denied vide Annexure C-3. It has further been sated that the OP No.2 i.e. authorized TPA of the OP has rightly denied the cashless benefit in view of terms and conditions of the insurance policy and during the pendency of the claim, the complainant filed the complaint which was disposed of being premature with a direction to decide the claim on merits. Accordingly after scrutinizing the documents, the claim was repudiated vide letter dated C-11. The complainant further lodged the claim under subsequent policy for the treatment from 14.03.2019 to 17.03.2019 and after receipt of the claim, the same was investigated and during investigation was found that the complainant had history of systemic hypertension x 40 yrs, diabetes mellitus x 40 yrs, hypothyroidism x 1 yr, bronchial asthma x 1 yr, CAD –July, 2018 and as such the claim was repudiated as per the terms and conditions of the policy.  It was further submitted that the terms and conditions of the policy were explained to the complainant at the time of proposing the policy and the same was served upon the complainant along with the policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on its part, the OP No.1 prayed for dismissal of the complaint.

         The OP No.2 did not turn up despite service of notice, hence the OP NO.2 was proceeded exparte vide order dated 11.10.2021.

3]       Replication has also been filed by the complainant controverting the assertions of the OP No.1 made in its reply.     

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have gone through the documents on record including written argument.

 

6]       The perusal of the file reveals that the insured complainant was treated for heart ailment at Fortis Hospital, Mohali on 10.6.2018 i.e. during policy period and discharged on 14.6.2018 and she incurred expense of Rs.1,09,978/- on the said treatment. However, the OP No.1 rejected her claim on the ground she has a history of DM, HTN and HTN is a pre-disposing factor of CAD.

 

7]      There is no evidence led by the OP No.1 to establish that the pre-­existing condition of Diabetes Mellitus­ or hypertension was the cause for the heart ailment/attack suffered by the complainant or that the complainant had any pre-existing heart related illness, disease or condition.  It is not the stand of the OP No.1 that the diabetes mellitus or hypertension cannot be controlled by medicines.  In this view of the matter, we are of the opinion that the OP Company has wrongly & illegally repudiated the genuine claim of the complainant, which amounts to deficiency in service and unfair trade practice on their part and it certainly has caused loss and harassment to her.    

 

8]       Reliance has also been placed on the latest decision of Hon’ble Apex Court in Civil Appeal No.8386/2015 – Manmohan Nanda Vs. United India Assurance Co. Ltd. & Anr., decided on 6.12.2021 wherein similar issue, as in present case, has been dealt with.

 

9]       Taking into consideration the discussion & findings aforesaid, we are of the opinion that the deficiency in service as well as unfair trade practice on the part of the OP No.1 has been proved. Therefore, the present complaint is allowed with direction to the Opposite Party No.1 to reimburse an amount of Rs.1,09,978/- to the complainant along with interest @10% p.a. from the date of discharge – 14.06.2018 till the date of its realization. The OP No.1 is also directed to pay compensation amount of Rs.25,000/ to the complainant for the harassment, mental agony and loss caused to him due to their deficient service coupled with unfair trade practice, along with litigation cost of Rs.15,000/-.

         This order shall be complied with by the OP within a period of 45 days from the date of receipt of copy of this order, failing which the OP No.1 shall be liable to pay additional cost of Rs.20,000/- apart from above relief.

 

10]      The complaint qua OP No.2 stands dismissed.

 

11]      Pending application(s), if any, stands disposed off.

         Certified copy of this order be sent to the parties, free of charge. After compliance, file be consigned to record room.

Announced

26.09.2023                             

Sd/-

 (AMRINDER SINGH SIDHU)

PRESIDENT

 

Sd/-

 (B.M.SHARMA)

MEMBER