Delhi

New Delhi

CC/487/2015

P.D Khurana - Complainant(s)

Versus

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

12 Feb 2019

ORDER

 

 

                               CONSUMER DISPUTES REDRESSAL FORUM-VI

                                    (DISTT. NEW DELHI),

                              ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                                    NEW DELHI-110001

 

Case No.C.C.487/2015                                           Dated:

         In the matter of:

P.D. Khurana,

S/o  Late Sh. Isher Dass Khurana,

H-7, Sai Apartment, Sec.13,

Rohini,  Delhi-110085.

                  ……..Complainant.

VERSUS

The Oriental Insurance Co. Ltd.

88, Janpath, Ground Floor,

              New Delhi-01.

………Opposite Party.

                

     NIPUR CHANDNA, MEMBER

ORDER

       

The complainant has filed the present complaint against the OP under section 12 of Consumer Protection Act, 1986.  The gist of the complaint is that the complainant is a senior citizen, retired officer and was  policy holder bearing No.272900/2011/10077, Policy No.272900/48/2012/10804 and policy No.272900/48/2013/16799 for the years 2011, 2012 and 2013 respectively of OP.  The complainant has lastly purchased a Mediclaim policy No.72900/48/2014 on 22/03/2014 from the OP. The complainant has also  renewed the said policy for the year 2015. That on 14.08.2013, the complainant was admitted in the Aster Eye Care for eye’s treatment.  The  complainant was again treated  twenty times on different dates at the Aster Eye Care and Centre for Sight Hospital.  The complainant lodged the  claim with OP for reimbursement of totaling amount of Rs.92678/- and Rs.280480/- incurred by him.  The complainant has also sent all the original bills/copies and discharge certificate.   But the OP repudiated his claim on flimsily grounds.  The complainant has also sent a legal notice  dated 09/06/2015 but till date nothing has been done by the OP to settle his genuine claim.  Complainant, therefore, approached this Forum for redressal of his grievance.

2.     Complaint has been contested by OP.  In its written statement,  OP stated  that as per medical records of Center, the complainant was suffering from diabetes mellitus for the last 20 years and hyper tension for the last 24 years.  As per clause 2.3, 4.1 and 4.2 of mediclaim  policy  any pre-existing disease when the cover incepts for the first time are excluded  for such insured person upto three years of this policy.  The complainant has concealed the material facts from the OP.  Moreover, during the course of treatment of eye complications , the complainant deliberately withheld the material information from the OP which is a violation of terms and condition of the policy.  It is stated that the Insurance policy is a contract between the parties and the terms and conditions to be followed strictly by both the parties and any violation in  respect thereof  deserves the complaint to be dismissed. OP denies any deficiency in service on its part.  In view of violation of terms and conditions of the mediclaim policy, the claim was rightly repudiated.  

3.     Both the parties have filed their evidences  by way of affidavit,

4.     We have heard argument advance at the Bar and have perused the record.

5.     It is argued by the counsel for complainant that the claim was repudiated by the OP on false and frivolous ground of non-admission in the hospital for 24 hours, whereas the treatment taken by him does not require 24 hours hospitalization and is day care treatment in which the injections were administered in the OT only.  In support of his contention he has drawn our attention toward the certificate issued by the treating doctor, the contents of which are reproduced as under:

“This is to certify that Mr. P.D. Khurana OPD No.CPS-SAFD/176508 is being treated  for diabetic macular edema.  Intra vitreal  injection of lucentis is being administered as required as a sight salvaging procedure.  The procedure is ALWAYS administered in the OT and the consensus among viteroretinal surgeons in the country is that this procedure needs to be administered in the OT only.”

He further argued that the reliefs claim be granted in his favour.

6.     It is argued on behalf of OP that the claim of the complainant was  repudiated by the OP Insurance Co. only after taking the opinion of empanelled doctor A.R. Rakesh.  Since the complainant failed to fulfill clause No.2.1 of the policy, the repudiation was justified.  

7.     We have gone through the medical opinion report given by Dr. AR. Rakesh, empanelled doctor of OP.  Bare perusal of the report makes it clear that the Intra vitreal  injection of lucentis  can be given in any sterile room that means the aforesaid injections cannot be given in OPD or at home.  The perusal of certificate issued by the treating doctor clarified that  the Intra vitreal  injection of lucentis is being administered as required as a sight salvaging procedure.  The procedure is ALWAYS administered in the OT and the consensus among viteroretinal surgeons in the country is that this procedure needs to be administered in the OT only.

8.     Bare perusal of the certificates issued by the treating doctor and empanelled doctor of OP clearly indicates that the salvaging procedure involves the admission and discharge of the patient for undergoing the procedure. In this procedure, surgeon requires local anesthesia before any injection can be injected in the eye . The copies of the discharge card issued by Centre for Sight Hospital stated that the complainant admitted in the hospital and later on discharged, it might not be 24 hours hospitalization. Moreover, the perusal of clause 2.5 which is reproduced as under:

2.5 DAY CARE TREATMENT :- Day care treatment refer to medical treatment and or surgical procedure which is :

1. undertaken under General / local Anesthesia in a hospital / day care centre in less than 24 hrs because of technological advancement and

2. which would have otherwise required a hospitalization of more than 24 hours.  This clause Clearly shows that the case of the complainant is squarely covered under clause 2.5 of the policy terms and condition and is payable. The objection taken by the OP regarding the preexisting disease is not at all acceptable as the OP insurance co. had not repudiated the claim of the complainant on the ground of pre –existing  rather it was repudiated  under clause 2.3 , i.e treatment taken on OPD basis and necessary 24 hours hospitalization are not completed .

9.     In view of above discussion, we are of the considered view that the repudiation of the claim by OP under clause 2.3 of the policy terms and conditions is unjustified, and arbitrary, which amounts to deficiency in services on the part of OP. We therefore hold, OP guilty of deficiency in services and direct it as under:-

1. Pay to the complainant sum of Rs.3,80,640/- along with 9% interest from the date of filing of complaint i.e. 28.07.2015 till realization.

 

2.  Pay to the complainant a sum of Rs.20,000/- towards  compensation which will also include the cost  of litigation.

 

The order shall be complied within 30 days of the receipt of the copy of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post.

Announced in open Forum on 12/02/2019. 

 

   (ARUN KUMAR ARYA)

                                                 PRESIDENT

 

(NIPUR CHANDNA)                                          (HM VYAS)

       MEMBER                                                       MEMBER