Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 225.
Instituted on : 25.05.2018
Decided on : 14.10.2024.
- Smt. Padma Gulati age 69 years, wd/o Late Sh. Chuni Lal.
- Subhash Gulati age 53 years, s/o Late Sh. Chuni Lal.
- Smt. Asha Arora age 55 years, d/o Late Sh. Chuni Lal.
- Smt. NeeruDureja age 37 years, s/o Late Sh. Chuni Lal.
- Smt. RinkiSachdeva age 44 years, d/o Late Sh. Chuni Lal
All residents of H.No.955/19, Arya Nagar, Rohtak.
………..Complainants.
Vs.
Oriental Insurance Co. Ltd. Through its Divisional Manager, Model Town, Delhi Road,Rohtak.
….….Respondent/opposite party.
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
Present: Sh.Manjeet Yadav, Advocate for the complainants.
Dr.Deepak Bhardwaj, Advocate for the opposite party.
ORDER
NAGENDER SINGH KADIAN PRESIDENT:
1. Brief facts of the case, as per the complainants are that Chuni Lal had taken the mediclaim policy from the respondent vide policy no.261200/48/2018/1256 and member ID No.055618762628 for the sum assured Rs.500000/-. The said Chuni Lal had suffered from viral/Dengue and he was got admitted in Apex Plus Super Specialty Hospital Rohtak on 24.10.2017 but due to deterioration of his health on account of Viral/Dengue, he expired on 29.10.2017 The complainants being legal heirs of Late Sh. Chuni Lal filed the claim before the respondent and furnished all the documents as required by the respondent. But the respondent avoided the matter on one pretext or the other on the ground that the said Chuni Lal was a patient of heart problem. Said Chuni Lal died not due to heart problem but his death was due to suffering from Viral/Dengue and as such respondent is liable to pay the amount of claim as per policy. But despite repeated requests of the complainants, the claim amount has not been paid to them. The act and conduct of the opposite party is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite party may kindly be directed to make the payment of Rs.500000/- on account ofmediclaim policy issued by the respondent in favour of Chuni Lal and Rs.50000/- on account of mental agony and harassment suffered by the complainantsalongwith interest @ 24% p.a. from the date of death of Chuni Lal i.e. 29.10.2017 till the actual realisation of whole amount and also to pay litigation expenses to the complainants.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that immediately after receiving the intimation from the complainant the opposite party took immediate action for processing the claim file and also send letters to the complainant by the Raksha TPA Ltd. as well as respondent but neither any proper reply was given nor the other required documents were submitted by the complainant. After perusal of the documents present in the claim file, the competent authority of the opposite party repudiated the claim vide repudiation letter dated 10.04.2018 with the contents: “In regard to above claim, it has been observed, patient admitted with altered Sensorium, fever, respiratory distress with K/C/O/HTN/IHD/CVA/DM-2/encephalopathy. Declared dead on 29.10.2017 at 6:00 AM. As patient is having fresh policy, clause on death is due to pre-existing disease. As per policy terms and conditions clause no.4.1, Ped covered after 3 years. Therefore the competent authority has repudiated the claim and closed the file as ‘No Claim”. Now the claim of the complainant is not covered under the insurance policy and there is a violation of terms and conditions of the policy contract and the claim is not maintainable. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. Counsel for the complainants in his evidence has tendered affidavit Ex.Ex.CW1/A, documents to Ex.C1 to Ex.C14 and has closed his evidence on dated 04.03.2024. Ld. counsel for the opposite party tendered affidavit Ex.RW1/A, document Ex.R1 to Ex.R3 and closed his evidence on dated 07.02.2020.
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 documents placed on record by both the parties.As per the written statement and affidavit Ex.RW1/A, the claim of the complainants has been repudiated by the opposite party vide letter dated 10.04.2018 and main contents of the letter Ex.RW1/A is as under:
“In regard to above claim, it has been observed, patient admitted with altered Sensorium, fever, respiratory distress with K/C/O/HTN/IHD/CVA/DM-2/encephalopathy. Declared dead on 29.10.2017 at 6:00 AM. As patient is having fresh policy, clause on death is due to pre-existing disease. As per policy terms and conditions clause no.4.1, Ped covered after 3 years. Therefore the competent authority has repudiated the claim and close the file as ‘No Claim’. This is four your information please”. We have perused the documents placed on record by both the parties. As per referral summary Ex.C4 dated 23.10.2017 the patient was admitted in Holy Heart Hospital on dated 23.10.2017 and was discharged on 24.10.2017. It has been mentioned in the referral summary that the patient Chuni Lal was suffering from fever for 5 days, headache& drowsiness and on that dayhe was complaining of mod-high grade fever, a/w vomiting since 5 days and was in drowsy condition. As per the past/surgical history mentioned in this document, patient have a past history of K/C/O. HTN, T2DM, CAD, Old ACS(16 years back) BPH. Meaning thereby the deceased had developed disease ACS(acute Coronary Syndrome) 16 years back and thereafter he was admitted in Apex Plus Super Speciality hospital on 24.10.2017 and died on 29.10.2017 during the treatment. As per the doctor of theApex Super Speciality hospital(Ex.C5), patient was not maintaining vital saturation and continue having respiratory distress even on ventilator and developed cardiac arrest and expired on 29.10.2017. After perusal of above mentioned both treatment history, we came to the conclusion that patient was not suffering from any pre-existing disease at the time of his death. The complainants also placed on record a certificate Ex.C9 issued by Dr. Saurabh Arora regarding the admission and discharge of the complainant. Perusal of this certificate itself shows that policyholder had no active cardiac complaint at the time of admission in Holy Heart Hospital. Hence the doctors of Holy HeartHospital shifted the patient to neurologist for further management and from where the deceased took treatment. Hence it has not been proved that deceased was having pre-existing disease at the time of admission in the hospital on 24.10.2017. Hence there is deficiency in service on the part of opposite party and opposite party is liable to pay the amount spent by the complainants on the treatment of deceased Sh. Chunni Lal, to the complainants. As per the bills placed on record by the complainantsas Ex.C14 the total amount of expenditure comes toRs.103506/-. As such the complainants are entitled for the alleged amount.
6. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite party to pay the claim amount of Rs.103506/-(Rupees one lac three thousand five hundred and six only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e.25.05.2018 till its realisation and also to pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service aswell as Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainants in equal share within one month from the date of decision.
7. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
8. 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:
14.10.2024.
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Nagender Singh Kadian, President
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TriptiPannu, Member.
