Haryana

Panchkula

CC/120/2017

MRS. INDU GARG - Complainant(s)

Versus

ORIENTAL INSURANCE COMPANY LTD. - Opp.Party(s)

VISHAL SAHNI

27 Apr 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,  PANCHKULA.        

                                                       

Consumer Complaint No	:	120 of 2017
Date of Institution	:	13.6.2017
Date of Decision	:	27.04.2018

Mrs. Indu Grg w/o Sh. Jiwan Kumar, R/o H.No.1593, Sector 21, Panchkula.

 

                                                                           ….Complainant

Versus

1. The Oriental Insurance Company Limited, Branch Office SCO 325, IInd Floor, Sector 9, Panchkula, 134109, through its Branch Manager.

 

2. The Oriental Insurance Company Limited, Division Office No.II, SCO 48-49, Sector 17-A, Chandigarh, 160017, through its Branch Manager.

 

3. The Oriental Insurance Company Limited, Regd & head Office A-25/27, Asaf Ali Road, New Delhi 110002, through its M.D/Chairman/Authorized.

 

4. Dayanand Medical Collage & Hospital, Unit-Hero DMC, Heard Institute, Ludhiana, through its MD/Manager.

 

5. M/s Raksha TPA Pvt. Ltd., through Director/Manager/Authorized person at 15/5, Mathura Road, Faridabad, Haryana, 121003.

 

6. M/s Raksha TPA Pvt. Ltd, through Director/Manager/Authorized person at SCO 359-360, Ist Floor, Sector 44-D, Chandigarh, 160047.

 

….Opposite Parties

 

COMPLAINT UNDER SEC. 12 OF THE CONSUMER PROTECTION ACT, 1986.

Before:              Mr.Dharam Pal, President.

Mr.Jagmohan Singh, Member.

 

For the Parties:   Mr. Suraj Parkash, Advocate for complainant. 

                        Mr. J.P.Nahar, Advocate for OPs No.1 to 3, 5 and 6.

                        None for OP No.4.

ORDER

(Dharam Pal, President)

1.     This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by Indu Garg, complainant against Oriental Insurance Company Limited and Others, the opposite parties.

2.     It is stated in the complaint that complainant purchased a medical policy under Happy Family Floater Policy (Silver Plan 10% Co-pay) for the year 2014-2015 vide Policy No.231200/48/2015/732 and again purchased/renewed and got insured her entire family members i.e. herself (Indu Garg), her husband Jiwan Kumar and her son Keshav Garg vide policy No.231200/48/2016/858 cover noted dated 2.10.2015 and policy dated 6.10.2015 (previous policy No.231200/48/2015/732) and has taken cover of Silver Plan 10% Co-pay policy of your company covering the risk period from midnight 3.10.2015 to midnight 2.10.2016 through the authorized agent of the OPs No.1 to 3 in the total sum of Rs.5.00 lacs against the premium of Rs.13,420/- excluding NCB Rs.1,342/- and assured her and her entire family. On 11.9.2016, the husband of the complainant suffering from pain in left arm, so he admitted in Dayanand Medical Collage & Hospital (OP No.4) vide admission No.104112 and after diagnosed to have hypothyroidism and he underwent coronary artery bypass grafting on 20.9.2016 and was discharged on 26.9.2016. While admitting her husband complainant requested for cashless facility, which was denied by OPs No.1 to 3 through their TPA (OP No.5), but advised to send the claim of complainant for reimbursement. The total expenditure made on the treatment, which was covered under the policy as Rs.2,44,036/-. Vide letter dated 27.9.2016, the complainant requested the OPs No.1 to 3, 5 and 6 for the reimbursement of medical bills after submitting all the necessary documents as per insurance policy vide letter dated 16.10.2016. At last, the OPs No.1 to 3, 5 and 6 had denied to settle the claim or to reimbursement of any medical bills of her husband assigning baseless reasons. The OP No.5 and 6 vide their letter dated 9.11.2016, had declined the claim of the complainant. Thereafter, complainant made several requests, but to no effect and OPs No.1 to 3, 5 and 6 decline all her requests and submissions. The OPs No.1 to 3, 5 and 6 had misinterpreted the clauses of the policy and totally denied the claim. Hence, this complaint.

3.     Upon notice, OPs appeared and contested the complaint by filing their separate written statement taking preliminary objections that the present complaint is not maintainable; the complainant has not come before the Forum with clean hands and has suppressed the material facts from this Forum.

4.     In their written version, the OPs No.1 to 3 have stated that the policy for the period 3.10.2015 to 2.10.2016 with the terms and conditions and with 10% Co-pay in Silver Plan. The Condition No.4.23 of the policy provides for “Compulsory Co-Payment: under the Silver the insured has to bear 10% of admissible claim amount in each and every claim”. The hospitalization was in the second year of the policy and expenses incurred for treatment of any disease related to hypertension are not payable for two years. The OPs had repudiated the claim as per terms and conditions of the policy. The policy was a second year policy and the complainant had underwent surgery for CABG which has been caused by the hypertension which is excluded for two years. The certificate issued by the doctor only is of no consequence as it confirms only that the patient had no past history of coronary artery disease but the exclusion provides that expenses for treatment of hypertension were not payable two years and therefore the expenses for treatment were not payable.  It is mentioned in the discharge summary that there is history of “Angina and Hypothyroidism” issued by the OP No.4. The reason given for repudiation are lawful and as per the terms and conditions of the policy. It is wrong that there were different interpretations of the policy and which was favourable one to the complainant should be accepted. The policy is very clear and brooks no doubt and is clear that the expenses incurred for hypertension and to relate diseases were not payable.

5.     Thus there is no deficiency in service on the part of answering OPs No.1 to 3 and as such, the complaint of the complainant is liable to be dismissed with costs. OPs No.5 and 6 had not filed any written statement and adopted the same, filed by OPs No.1 to 3).

6.     In his written version, the OP No. 4 has stated that there is no specific allegation of any deficiency in rendering the medical treatment/services on the part of the OP No.4 and even no relief has been claimed by the complainant against the OP No.4. OP No.4 is having its hospital at Ludhiana and treated the husband of the complainant at Ludhiana.  So there is no jurisdiction of this Forum to try and entertain the present complaint. The OP No.4 has no role in the reimbursement of any treatment bill to the complainant.  OP No.4 has no concern with the insurance of the complainant or the payment of the cost of treatment to the complainant under any insurance policy.  It is admitted that patient Jiwan Kumar came to Hero DMC Heart Institute with complaints of pain in left arm after eating meal since 4-5 months. After proper investigation, patient final diagnosed was hypothyroidism, CAD with Acute Coronary Syndrome, triple vessel disease, normal LV systolic function and after proper treatment patient was ambulatory and pain free and discharged on 25.9.2016 in stable condition. At the time of admission of the complainant’s husband with the OP No.4, pre-authorization letter along with documents i.e driving licence, policy of oriental insurance company and letter of corporate cell of OP No.4 for providing cashless facility was forwarded to OP No.6 through fax. In response to the said letter the Raksha TPA demanded two documents from OP No.4 i.e. complete medical history and initial evaluation sheet. At once the corporate cell of the OP No.4, reply of this letter and sent the documents i.e. complete medical history, prescription slip of Dr. Sarju Rahlan of DMC Heart Centre and coronary angiography report of Pancham Hospital, Ludhiana. OP No.6 refused to provide the cashless facility to the patient.  Thus there is no  deficiency in service on the part of answering OP No.4 and as such, the complaint of the complainant is liable to be dismissed with costs.

7.     The learned counsel for complainant placed on record the affidavit as Annexure C-A along with documents Annexure C-1 to C-29 and thereafter closed the evidence. On the other hand, the learned counsel for OPs No.1 to 3, 5 and 6 has placed on record the affidavit as Annexure R-1/A along with documents Annexure R-1/1 to R-1/3 and has closed the evidence. On the other hand, the OP No.4 has not tendered any evidence after availing many opportunities including last opportunity. Therefore, evidence of OP No.4 had been closed by court order on 13.3.2018. 

8.     We have heard the learned counsel for both the parties and have also perused the record.

9.     After hearing both the counsels for the parties and going through the record available on the case file, we are of the considered opinion that this Forum has got no territorial jurisdiction to entertain and decide the matter in question as the complainant purchased the policy from Op No.2 at Chandigarh and took the treatment from DMC Hospital at Ludhiana. The complainant applied for reimbursement at the office of Ops at Chandigarh (Annexure C-19) and thereafter the complainant sent the requisite documents demanded by Ops also at Chandigarh (Annexure C-20). The Op No.1 has been impleaded as a party in the array of parties being the Branch office of Op No.2 as mentioned by the complainant in para 1 of the complaint that OP No.1 is local branch office of Op No.2 and 3 and OP No.2 is the Division office who issued the policy in question and Op No.3 is Head office of Ops No.1 and 2. But no correspondence had been dealt with Op No.1, therefore, Op No.1 is not a necessary or proper party. Therefore, the counsel for the complainant failed to produce any evidence to prove that this Forum has the territorial jurisdiction. It has been provided in Section 11 of the Consumer Protection Act that

11(2)      A complaint shall be instituted in a District Forum within the local limits of whose jurisdiction-

(a)        the opposite party or each of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides or carries on business or has a branch office or personally works for gain, or

(b)        any of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides, or carries on business or has a branch office, or personally works for gain, provided that in such case either the permission of the District Forum is given, or the opposite parties who do not reside, or carry on business or have a branch office, or personally work for gain as the case may be, acquiesce in such institution; or (c)     the cause of action wholly or in part, arises.

10.                In the instant case, no cause of action or part thereof has arisen within the territorial jurisdiction of this Forum. This issue has also been decided by the Hon’ble National Commission, New Delhi in case titled as Alok Sinha vs. Mahindra and Mahindra Ltd. & Ors. in F.A. No.1367 of 2017 decided on 26.07.2017, wherein it has been categorically held that:-

“4.    We do not find merit in the contention of learned counsel for the appellant. On perusal of impugned order, we find that order of the State Commission is based upon the law laid down by Hon’ble Supreme Court in the matter of Sonic Surgical Vs. National Insurance Company Ltd. (supra). In the said judgment, while dealing with the issue of interpretation of Section 17 (2) of the Consumer Protection Act, Hon’ble Supreme Court has observed as under:

“Moreover, even if it had application, in our opinion, that will not help the case of the appellant. Learned counsel for the appellant submitted that the respondent-insurance company has a branch office at Chandigarh and hence under the amended Section 17(2) the complaint could have been filed in Chandigarh. We regret, we cannot agree with the learned counsel for the appellant. In our opinion, an interpretation has to be given to the amended Section 17(2) (b) of the Act, which does not lead to an absurd consequence. If the contention of the learned counsel for the appellant is accepted, it will mean that even if a cause of action has arisen in Ambala, then too the complainant can file a claim petition even in Tamil Nadu or Gauhati or anywhere in India where a branch office of the insurance company is situated. We cannot agree with this contention. It will lead to absurd consequences and lead to bench hunting. In our opinion, the expression ‘branch office’ in the amended Section 17(2) would mean the branch office where the cause of action has arisen. No doubt this would be departing from the plain and literal words of Section 17(2) (b) of the Act but such departure is sometimes necessary (as it is in this case) to avoid absurdity. [vide G.P.Singh’s Principles of Statutory Interpretation, Ninth Edition, 2004 P. 79] in the present case, since the cause of action arose at Ambala, the State Consumer Redressal Commission, Haryana alone will have jurisdiction to entertain the complaint.

For the reasons stated hereinabove, we do not see any reason to interfere with the impugned order of the NCDRC. Accordingly, this appeal is dismissed. No order as to the costs.”

5.     Admittedly, the Op No.1 has its Head Office at Mumbai and subject car was purchased at Noida i.e. beyond territorial limits of State Commission, Delhi. Merely because opposite party has branch office at Delhi, in view of the above noted judgment of the Supreme Court, it cannot be said that State Commission Delhi has jurisdiction to entertain this complaint. Thus, we do not find fault with the order of the State Commission. Appeal is accordingly dismissed.”

11.        Resultantly, in view of the foregoings and entirety of the case, we are of the opinion that the present complaint is not maintainable. So, the same is hereby dismissed, with no order as to costs.

12.        However, the complainant is at liberty to approach to appropriate Court/Forum if he so advised and in that eventuality, the period of litigation before this Forum shall not be counted towards the period of limitation for approaching appropriate Court/Forum. Exemption of time spent before this Forum is granted in terms of the judgment of the Hon’ble Supreme Court of India in the case titled “Laxmi Engineering Works versus PSG Industrial Institue (1995) 3 SCC page 583.

13.        A copy of this order be sent to the complainant free of costs and file be consigned to the record room after due compliance.

 

Announced

27.04.2018                 JAGMOHAN SINGH                DHARAM PAL

                                MEMBER                                     PRESIDENT

Note: Each and every page of this order has been duly signed by me.

                                                                                                DHARAM PAL

                                                        PRESIDENT