Haryana

Yamunanagar

CC/102/2013

Anil Kumar S/o Ram Krishan - Complainant(s)

Versus

Oriental Insurance Company Ltd. - Opp.Party(s)

Atul Jaiswal

12 May 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                             Complaint No..102  of 2013.

                                                                             Date of institution: 11.02.2013.

                                                                             Date of decision: 12.05.2017.

    Sh. Anil Kumar aged about 40 years son of Sh. Ram Krishan 249-250, Model Town, Yamuna Nagar, Tehsil Jagadhri, District Yamuna Nagar.

                                                                                                                     …Complainant.

                                    Versus

 

1. The Oriental Insurance Company Ltd. Opp. Madhu Hotel, Jagadhri Road, Yamuna Nagar 135001.
2.  Vipul Medcorp TPA Private Limited, SCO No. 98, First Floor, Industrial Area, Phase-2, Chandigarh.                                                                                                                                                                       

                                                                                                                     …Respondents 

BEFORE:       SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

                        SMT. VEENA RANI SHEOKAND, MEMBER.

 

Present:  Sh. Atul Jaiswal, Advocate, counsel for complainant.  

                Smt. Aruna Sharma, Advocate, counsel for respondent No.1.  

                Respondent No.2 ex-parte.                            

 

ORDER

 

1.                     Complainant Anil Kumar filed the present complaint under section 12 of the Consumer Protection Act praying therein that respondents (hereinafter referred as OPs) be directed to pay a sum of Rs. 64,262/- on account of medical expenses incurred by the complainant and also to pay Rs. 50,000/- as compensation and litigation expenses.

2.                     Brief facts of the present case, as alleged by the complainant,  are that  complainant has been obtaining medi claim policy from OP No.1 for the last 5-6 years regularly and last policy obtained from OP No.1 bearing policy No. 261700/48/2012/1465 which was valid from 30.9.2011 to 29.9.2012 for a sum of Rs. 4,00,000/-. The complainant fell ill and was suffering from Budd Chiari Syndrome, and got treatment from Sir Ganga Ram Hospital, New Delhi in the year 2006 and for which he was reimbursed the expenses incurred there upon by the OPs. Again on 18.03.2012 the complainant was admitted to Medanta Medicity Gurgaon from 18.03.2012 to 22.03.2012 where right hepatic vein ballooning was done and the hospital charged Rs. 64,262.56 from the complainant. The complainant so many times requested the OP No.1 as well as Op No.2 to release the amount of medical expenses but the OPs put off the matter on one pretext or the other. Ultimately, the OP No.2 vide their letter dated 01.05.2012 demanded the quarry “ since when insured is suffering from Budd Chairi Syndrome, possible underlying cause of disease with genetic association if certified by treating doctor” which the complainant had sent the previous discharge summary to the OPs but the OPs again demanded the same and the complainant sent all the documents alongwith certificate given by the concerned doctor who treated the complainant in 2006 and who cleared the inquiry demanded by the OP No.2 but till today, the OPs have not cleared the genuine claim of the complainant and is harassing him day by day. Ultimately, the complainant served a legal notice dated 27.08.2012 to OPs but again OPs demanded the same enquiry from the complainant as the OPs had not cleared the genuine claim of the complainant in the same way. The complainant again served a legal notice dated 09.11.2012 to the Ops and requested them to pay the genuine claim of the complainant but they did not do so. As such, there is a deficiency in service on the part of OPs. Hence this complaint. 

3.                     Upon notice, OP No1 appeared and filed its written statement whereas Op No.2 failed to appear despite service through registered post dated 17.05.2013, hence he was proceeded ex-parte vide order dated 08.7.2013. OP No.1 filed its written statement by taking some preliminary objections such as complaint is not maintainable, no locus standi to file the present complaint, no cause of action, estopped by his own act and conduct, not approached this Forum with clean hands and has concealed the true facts and on merit it has been admitted that complainant has taken mediclaim policy bearing No. 261700/48/2012/1465 w.e.f. 30.9.2011 to 29.9.2012 for a total sum insured of Rs. 2,00,000/- from the OPs Insurance Company.  The true facts are that the OP No.2 TPA and Op No.1 Insurance Company issued letter dated 13.04.2012 to the complainant in which some quarries were raised and some documents were required as mentioned in the latter i.e. “Kindly send us since when insured is suffering from Budd Chiari Syndrome possible underlying  cause of disease with genetic association if any certified by treating doctor. Kindly provide Dr. Prescription dated 03.01.2011 in original. Kindly provide all past policy copy before 2010. Kindly provide all original receipts payment made to the hospital.” Rest contents of the complaint were denied for want of knowledge. Lastly prayed that as there is no deficiency in service or unfair trade practice on the part of Ops and prayed for dismissal of complaint.

4.                     To prove the case, counsel for complainant tendered into evidence affidavit of complainant as Annexure CW/A and documents such as Photo copy of Insurance Cover Note as Annexure C-1, Photo copy of discharge summary of Medanta Hospital as Annexure C-2, Photo copy of Hematology result reports as Annexure C-3, Photo copy of Biochemistry result reports as Annexure C-4, Photo copy of Medanta Hospital bill dated 22.03.2012 amounting to Rs. 64,262.56 as Annexure C-5. Photo copy of intimation letter dated 28.03.2012 regarding health as Annexure C-6, Photo copy of discharge letter dated 07.01.2011 of previous treatment as Annexure C-7, Photo copy of certificate issued by Dr. Rajesh puri, Medanta Hospital dated 20.6.2011 as Annexure C-8, Photo copy of legal notice dated 22.09.2012 as Annexure C-9, Photo copies of receipt of courier service Annexure C-10 and C-11, Photo copy of legal notice dated 9.11.2012 as Annexure C-12, Photo copy of Hospital bill dated 23.12.2013 as annexure C-13 and closed the evidence on behalf of complainant. 

5.                     On the other hand, counsel for the OP No.1 tendered into evidence Affidavit of Sh. Gurmej Singh Deputy Manager OIC as Annexure RA and documents such as Photo copy of enquiry letter dated 13.04.2012 as Annexure R-1, Photo copy of medi-claim policy as Annexure R-2 and closed the evidence on behalf of OP No.1. 

6.                     We have heard the counsels of both the parties and have gone through the pleadings as well as documents placed on the file very carefully and minutely.

7.                     It is not disputed that the complainant was having a medi claim policy bearing No. 261700/48/2012/1465 which was valid from 30.9.2011 to 29.9.2012 for a sum of Rs. 2,00,000/-. It is also not disputed that complainant has not lodged the claim with the OPs and requested for reimbursement of the amount of Rs. 64,262.56 as not denied by the OP No.1 in its written statement.

8.                     The only plea of the OP No.1 insurance company is that OP insurance company issued a letter on 13.04.2012 (Annexure R-1) seeking quarry “ since when insured is suffering from Budd Chairi Syndrome, possible underlying cause of disease with the genetic association with certified by treating doctor” But the complainant failed to reply the same, hence, the claim of the complainant has rightly been rejected. Hence, there is no deficiency in service on the part of OPs and prayed for dismissal of complaint.

9.                     On the other hand, learned counsel for the complainant draw our attention towards letter/certificate dated 20.6.2011 (Annexure C-8) issued by Dr. Rajesh Puri Associated Director Medanta Medicity Hospital Gurgaon in which it has been certified that “ patient Mr. Anil Kumar aged 45 years old male HUID-57070 was admitted in City Hospital from 18^th to 26^th July 2006 and diagnosed to have Budd Chairi Syndrome ( Right Hepatic Vein Dilated and Stented) Possible underlying cause of disease. Available blood investigations show no genetic association. However, in the available blood test, genetic test was not done because sometimes when the patient is put on heparin these tests are generally not done. Patient has no family history of Hypercoagulablestate”. Learned counsel for the complainant further argued that earlier claim for the period from 3.1.2011 to 7.1.2011 where right genetic vein ballooning was done and the hospital charged Rs. 32452/- from the complainant had already been paid by the Insurance Company on the same cause of disease and even after this claim complainant was again admitted on 20.12.2013 in Medanta Hospital and discharged on 23.12.2013 for that period the OPs had already paid the amount of hospital bills through Vipul Medicorp TPA Pvt. Ltd. and lastly prayed that the complainant has duly replied and submitted the certificate of doctors, hence the genuine claim of the complainant has been wrongly repudiated by the OPs.

10.                   After hearing both the parties, we are of the considered view that the claim of the complainant has been wrongly withheld by the OPs Insurance Company as from the perusal of letter issued by Dr. Rajesh Puri on dated 20.6.2011 (Annexure C-8) and clarification letter/certificate issued on 13.04.2012 (Annexure R-1) it is clear that complainant has duly replied the quarries put by the OPs and even the doctor has given his opinion in his certificate that Budd Chairi Syndrome, ( right hepatic vein dilated and stented) Possible underlying cause of disease, no genetic association. Learned counsel for the OP No.1 failed to convince this forum that the alleged disease Bud Chairi Syndrome was not covered under the policy in question. Even, the OPs not bothered to file any terms and conditions and failed to point out any violation of terms and conditions and in the absence of any cogent reason, we are unable to held that the Ops has rightly repudiated the claim of the complainant. It is also pertinent to mention here that an earlier complaint bearing No. 1090 of 2011 decided on 22.03.2016 on the same cause of action was also decided by this Forum and the OPs Insurance Company had already satisfied the awarded amount  

11.                   After going through the above noted circumstances, we are of the view that the Ops Insurance Company has wrongly withheld the claim of the complainant without any cogent reason which constitute a deficiency in service on the part of OPs. Hence, we have no option except to partly allow the complaint of complainant.

12.                   Resultantly, we partly allow the complaint of complainant and direct the Ops to pay a sum of Rs. 64,262/- on account of medical expenses to the complainant alongwith interest at the rate of 7% per annum from the date of filing of complaint till its actual realization and further to pay a sum of Rs. 2000/- as compensation for mental agony, harassment as well as litigation expenses. Order be complied within 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court:12.05.2017

                                                                                    (ASHOK KUMAR GARG)

                                                                                    PRESIDENT

                                                                                    DCDRF,YAMUNANAGAR

 

 

 

                      (VEENA  RANI SHEOKAND)         (S.C.SHARMA)

                       MEMBER                                            MEMBER