Haryana

Ambala

CC/53/2012

JASBIR SINGH S/O SH NARAYAN SINGH - Complainant(s)

Versus

ORIENTAL INSURANCE COMPANY LTD - Opp.Party(s)

SUDHIR SEHGAL

22 Nov 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

            Complaint Case No.    : 53 of 2012

Date of Institution       : 10.02.2012

            Date of Decision         : 22.11.2016

 

1.         Jasbir Singh son of Shb. Narayan Singh R/o H.No.2029/1,Jaggi Garden,Phase-II, Ambala City.

2.         Amanpreet Singh S/o Jasbir Singh R/o H.No.2029/1, Jaggi Garden, Phase-II, Ambala City.

                                                                                               

                                                                                                                                 ……Complainants.

                                                                                                       Versus

1.         Oriental Insurance Company Ltd. Branch Office through its Manager, Near Vijay Cinema, LIC Building Ground Floor, Ambala City.

2.         Oriental Insurance Company Ltd. Regd. Office through its M.D.-cum-Chairman C/o Oriental House,P.B. No.7037, A-25/27,Asaf Ali Road, New Delhi.

3.         Vipul MedCorp TPA Pvt.Ltd. through its M.D., 515 Udhyog Vihar,Phase-V, Gurgaon.

4.         Vipul MedCorp TPA Pvt. Ltd. through its Incharge SCI No.98, First Floor, Industrial Area,Phase-2, Chandigarh.

                                                                                                ……Opposite Parties.

Complaint Under Section 12 of the Consumer Protection Act

 

BEFORE:       SH. D.N. ARORA,  PRESIDENT.

                        SH. PUSHPENDER KUMAR, MEMBER.

                       

Present:          Sh. Sudhir Sehgal, Adv. for complainants.

                        Sh. R.K. Jindal, Adv. counsel  for Ops.

 

ORDER.

 

                        In nutshell, brief facts of the complaint are that complainants purchased the Medi-Claim Policy ‘Happy Family Floater Policy’ from Op vide policy no.261101/48/2011/1457 dated 24.12.2010 wherein complainant no.1 was insured alongwith his wife Smt. Gurmeet Kaur and son Sh.Amanpreet Singh  with  Personal Accident cover of Rs.3.00 lacs and Basic Cover of Rs.2.00 lac. It has been submitted on 26.07.2011, complainant no.2 all of a sudden developed pain  in his stomach and he visited Kidney Centre Hospital at Chandigarh  where doctors  gave him medicines and advised to come after a week for further check-up.  Further, it has been submitted that on the intervening night of 27/28.07.2011, complainant no.2 felt severe pain in his stomach and he rushed to the Kidney Centre Hospital, Chandigarh where in emergency, complainant no.2 was gone under a surgery for removal of stone in his kidney. It has been submitted that complainant no.1 informed Ops No.1 & 2 qua surgery of complainant no.2 and their representative informed the Ops no.3 & 4.  Complainant no.2 was discharged from the hospital on 30.07.2011 with advise to take bed rest and taking of medicines.  Complainants contacted the OP No.1 and submitted claim papers including all relevant record of treatment on 19.08.2011.  It has been submitted that complainant was utter surprised that instead of releasing claim, the Ops started making query through letters initially dated 20.08.2011. Complainants contacted the OP No.1 regarding their letter  dated 08.11.2011 and inquired about the clause 4.3 of Medi-Claim Policy as no clauses are mentioned in the policy.  Moreover, at the time of purchasing of policy by complainant no.1, no such clause was ever disclosed by Ops whereas they repudiated the claim of complainant. Hence, the present complaint seeking relief as per prayer clause.

2.                     Upon notice, Ops No.1 & 2 tendered their reply raising preliminary objections qua maintainability of complaint & suppression of material facts. On merits, it has been submitted that  after receiving  the claim of complainant, matter was got investigated by the Ops  and as per terms & conditions  of the policy clause 4.3(xix), in case Calculus disease, the policy in question must have run for two years but in the present case, the policy did not complete two years, as such, the complainant  is not entitled  to get the medical expenses  allegedly incurred by him on the treatment of complainant no.2, as such, the OP insurance company has repudiated the claim of complainant vide letter dated 08.11.2011. So, there is no deficiency in service on their part and prayed for dismissal of complaint with costs.

                        Ops No.3 & 4 tendered their separate reply on the same lines as that of Ops No.1 & 2 and prayed for dismissal of complaint with costs.

3.                     To prove his version, counsel for complainant tendered affidavit of complainant Jasbir Singh as Annexure CX alongwith documents as Annexures C1 to C-13 and closed the evidence whereas on the other hand, counsel for Ops tendered affidavits Anenxures RX & RY alongwith documents as Annexures R-1  to R-5 and closed the evidence.

4.                     We have heard learned counsel for complainant and gone through the case file very carefully. The grievance of complainant is that the medi-claim submitted by complainant no.2 with the OP insurance company was repudiated by them vide their letter  Annexure R-1.  Perusal of document Annexure R-1 reveals that  claim of the complainant has been  repudiated on the ground that ‘this is  case of pyelonephritis with reneal policy being in the first year, the claim against conservative management for the same merits repudiation under clause 4.3 mediclaim exclusives of the policy’.  Counsel for complainant has drawn our attention towards   policy document (Annexure R-5) clause 4.3 (xix) which says the expenses on treatment of following ailment/diseases/surgeries for the specified period are not payable if contracted and/or manifest during  the currency of the policy:-

                                                CALCULUS DISEASE-                   2 years.

                        Perusal of policy document Annexure C-1 reveals that the policy was purchased by complainant for himself and his family member including complainant no.2 on 24.12.2010 and  as per document Discharge Summary (Annexure C-11), complainant no.2 was suffering from Lt. Renal Calculus and remained hospitalized at Kidney Centre Hospital, Chandigarh on 28.07.2011 and operated upon there and was discharged on 30.07.2011. Counsel for OP has placed reliance on case law delivered by  Hon’ble National Consumer Disputes Redressal Commission, New Delhi reported in  2016(4) CPR 179 titled as Dr. Bihari Lal Singhania Vs. Branch Manager, United India Insurance Company Limited & Ors.  wherein held that “Consumer Protection Act, 1986-Section 15,17,19 & 21-Insurance-Mediclaim Policy-General Surgery-Surgery for removal of Gall Bladder-exclusion Clause 4.3 of insurance policy makes it clear that if ‘Gall Bladder Stone removal’ is done during first  two years of operation of policy, expenses on such treatment are not payable-Based on reports stated above and documentary evidence, State Commission concluded  that claim was not admissible as during removal of gall bladder, stones were also extracted and exclusion clause was applicable-No any irregularity, infirmity or jurisdictional error in order  passed by State Commission-Revision Petition  dismissed.”

5.                     In view of the above discussion, it is admitted on record that complainant took the policy on 24.12.2010 for himself and his family member including his son Amanpreet Singh (complainant no.2) who due to his illness  of Lt. Renal Calculus was operated upon at Kidney Centre Hospital Chandigarh on 28.07.2011 and was discharged on 30.07.2011. As such, the disease/ailment occurred to the complainant within two years from the date of policy.  So, in view of the terms & conditions of the policy clause  4.3(xix),  expenses on treatment of calculus diseases are not payable, if it occurs within two years of currency of the policy, hence,  there is no deficiency in service on the part of the Ops and complainant is not entitled to get any claim from the Ops.  Accordingly, the compliant is devoid of merits and is dismissed with no order as to costs.  Copies of the order be sent to the parties concerned free of costs, as per rules. File after due compliance be consigned to record room.

                                                                                                   Sd/-

ANNOUNCED ON:  22.11.2016.                                            (D.N. ARORA)

                                 PRESIDENT                

                                                                                            

                                                                                            Sd/-

 

(PUSHPENDER KUMAR)

                                                                                                            MEMBER