Before the District Consumer Disputes Redressal Forum, Rohtak.

                                                                    Complaint No. : 159.

                                                                    Instituted on     : 17.04.2018.

                                                                    Decided on       :17.07.2020.

Fakir Chand Singla son of Shri Laxmi Narain Singla aged about 55 years, resident of 479/34, Hakikat Nagar, Janta Colony, Rohtak.

                                                                             ………..Complainant.

                                       Vs.

Oriental Insurance Company Ltd., through its Divisional Manager, Model Town, Rohtak.

……….Opposite party.

COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.

BEFORE:  DR. RENU CHAUDHARY, MEMBER.

                   MS. TRIPTI PANNU, MEMBER.

Present:       Sh.Deepak Jain, Advocate for the complainant.

                   Sh.R.K.Bhardwaj, Advocate for opposite parties.

                                      ORDER

TRIPTI PANNU, MEMBER:

1.                           Brief facts of the case are that the complainant obtained PNB-Oriental Royal Mediclaim policy from respondent company for covering the risk of health treatment of himself, her minor children and his wife. Since 2013-14, the complainant has regularly renewed and obtained the health policy covering the risk of Rs.500000/- for this mediclaim policy. At present the policy for the year 2017-18 is in existence and during the previous policy bearing no.261200/48/2018/1525 son of complainant namely Kunal Singla was having complaint of vomiting and he was taken to the hospital of Dr. Kedar Nath Garg on 17.08.2017 and after carrying investigation, it was found that Kunal was suffering from hepatitis and was treated there. Since there was no relief from illness, so complainant got the treatment of his son at Jaipur Golden Hospital on 15.12.2017 and on 23.12.2017 he was admitted in the said hospital and was got discharged on 26.12.2017. The respondent was timely informed by the complainant but opposite party declined cashless benefits to the complainant and asked to raise the bill after completion of treatment. The complainant filed the mediclaim of his son and submitted all the required documents with the opposite party and requested to pay the amount spent by him on the treatment of his son. The complainant submitted bills and treatment record to Raksha Health Insurance TPA Pvt. Ltd. as per forwarding letter dated 28.12.2017, as advised by respondent company. Thereafter the complainant requested the opposite party so many times to pay the insurance claim but the same has been declined by the opposite parties.  The complainant’s son had never taken treatment of obesity as mentioned by agent of the respondent company in its repudiation letter.  That the act of opposite party is illegal and there is deficiency in service on the part of opposite party. As such, it is prayed that opposite party may kindly be directed to pay amount of Rs.37000/- alongwith interest thereon @ 18% per annum and Rs.25,000/- as harassment and Rs.5500/- as litigation expenses to the complainant as explained in relief clause.

2.                          After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that it is wrong that the complainant was having complaint of vomiting and he was taken to Dr. Kedar Nath Garg on dated 17.08.2017. It is wrong that he was suffering from ‘Hepatities’ for which he was given treatment. It is wrong that the policy is cashless and the insurance company decline cashless benefits to the complainant and asked him to give bills after treatment. It is also wrong that the complainant filed the mediclaim of his son after treatment and executed all documents including bills. It is wrong that complainant requested to give Rs.37000/- and forwarded letters dated 28.12.2017 by which complainant submitted bills and treatment received to TPA Pvt. Ltd. There is a violation of terms and conditions of the policy specially condition No.4.16, therefore the claim is not payable and the complainant was informed well in time. It is denied that the son of complainant never obtained any treatment of obesity as mentioned by TPA in the repudiation letter. The repudiation letter is correct and is given according to the treatment taken by complainant’s son.  There is no deficiency in service on the part of opposite parties and dismissal of complaint has been sought.

3.                          Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C20 and has closed his evidence on dated 08.02.2019. Ld. counsel for the opposite party has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R4 and closed his evidence on 26.08.2019.

4.                          We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.

5.                          We have perused the discharge summary of the patient Kunal Singla, which is placed on record as Ex.C9 by the complainant in his evidence. As per the history of present illness at the time of admission in the Jaipur Golden Hospital, the patient was suffering from vomiting, breathlessness and loss of appetite and generalized weakness and in the column of chief complaints, it has been mentioned that complainant was suffering from vomiting, breathlessness and loss of appetite. The patient was admitted in the hospital on 23.12.2017 and was discharged on 26.12.2017. The claim of the complainant has been repudiated by the opposite party vide its letter dated 10.04.2018 placed on record as Ex.C20 on the ground that the patient was suffering from obesity and as per policy terms and condition clause No.4.16, treatment related to obesity is under exclusion. At the time of arguments, ld. Counsel for the opposite party has also placed on record a document “JN” which is PNB-Oriental Royal Mediclaim policy, and has relied upon the condition No.4.16, as per which, “Treatment of obesity or condition arising therefrom(including morbid obesity) and any other weight control programme, services or supplies etc.”. Opposite party has also placed on record documents Ex.R2 to Ex.R4.  As per Ex.R4, the weight loss + 4-5 kg. In this report, the weight of the patient has not been mentioned anywhere. Moreover, the respondents officials placed on record discharge summary as Ex.R2 and other inpatient history sheet and physical examination record of Jaipur Golden Hospital, which is placed on record as Ex.R4. Document Ex.R4 is having 18 pages, in which all indoor patient record and some other prescriptions issued by Dr. Kedar Nath Garg was also placed on record. We have perused all the relevant record and found that the patient was admitted in Jaipur Golden Hospital regarding vomiting, breathlessness and loss of appetite. In the whole record, it has not been mentioned anywhere that the patient was suffering from obesity or he was found overweight at any time by the treating doctor. In document Ex.R4, only in the column of Provisional diagnosis, it is mentioned as obesity. But the study of provisional diagnosis reveals that: “A provisional diagnosis means that the doctor is not 100% sure of a diagnosis because more information is needed”.  Meaning thereby,  the doctor himself was not sure that the patient was suffering from obesity or not. At the time of discharge, some medicines were prescribed by the treating doctor and he has not mentioned anywhere that the patient is overweight or suffering from obesity. As such the condition no.4.16 mentioned above cannot be considered as the patient had not suffered from obesity. Hence the repudiation of claim of the complainant on this ground is illegal and amounts to deficiency in service and the opposite party is liable to refund the amount of Rs.27671/- incurred by the complainant on the treatment of his son Kunal as shown in bill Ex.C13.

6.                          In view of the facts and circumstances of the case, complaint is allowed and we hereby direct the opposite party to refund the amount of Rs.27671/-(Rupees twenty seven thousand six hundred and seventy one only)  alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 17.04.2018 till its realization and Rs.3000/-(Rupees three thousand only) on account of deficiency in service and Rs.3000/-(Rupees three thousand only) as litigation expenses to the complainant within one month from the date of decision.

7.                          Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.

Announced in open court:

17.07.2020.

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                                                          Renu Chaudhary, Member.                               

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                                                          Tripti Pannu, Member.