Jammu and Kashmir

Jammu

CC/332/2017

PANKAJ GANDOTRA - Complainant(s)

Versus

oriental insurance - Opp.Party(s)

VISHAL ABROL

23 Mar 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,JAMMU

(Constituted under J&K Consumer Protection Act,1987)

                                                          .

 Case File  No                237/DFJ           

 Date of  Institution     22-09-2015

 Date of Decision          27 - 02-2018

Pankaj Gandotra,

S/O Sh.Jagmohan Gandotra,

R/O 63 D/C Gandhi Nagar,Jammu.

                                                                                                                                  Complainant

                  V/S

1.The Oriental Insurance company Ltd.

   262100 OIC,DO1,Jammu Town Hall Building,

  Ist Floor Admin.Block,Jammu through its Manager.

2.V ipul Med Corp TPA Limited 515,Udhyog Vihar,

Phase 5 Gurgaon,Haryana.

                                                                                                                                  Opposite parties

CORAM

                  Khalil Choudhary            (Distt.& Sessions Judge)   President

                  Ms.Vijay Angral                                                                Member

                  Mr.Ghulam Sarwar Chouhan                                       Member

 

In the matter of  Complaint under section 10 of J&K Consumer

                              Protection Act 1987.

      

Mr.Vishal Abrol,Advocate for complainant, present

Mr.Rupinder Singh,Advocate for OP1,present.

 

                                                                     ORDER.

                Complainant approached this Forum on account of deficiency in service on the part of Ops,in not reimbursing the entire sum incurred on treatment of his wife, who was also insured under the said Medi Claim Policy. Relevant facts as are discernible from the complaint are that; the agent of OP Insurance Company approached him for obtaining the medi claim policy with features of covering the mediclaim of his family members too and complainant is paying the premium of the said policy for the last five years and the complainant was insured by the agent of OP after receiving the premium through cheque bearing No.2278998324 dated 05-03-2014 under the policy certificate No.262100/48/2014/2223 w.e.f.08-03-2014 to 07-03-2015,copy whereof is enclosed as Annexure-A.According to complainant as per said policy, the wife of complainant,namely,Smt.Monika Gandotra and children were also insured under the said mediclaim policy and in the month of Feb.2015 unfortunately his wife was suffering from severe ailment relating to her right eye i.e.CNVM Right Eye, immediately thereafter he approached Dr.Daljit Singh Eye Hospital Amritsar for providing best medical treatment to his wife and the doctors of the said hospital after thorough medical examination of the wife of complainant  advised her to undergo Anti VEGF Therapy Inj.Lucentis Right eye. Complainant further submitted that as per  advise the doctors of Dr.Daljit Singh Eye Hospital operated upon the eye of wife of complainant during hospitalization on,02-02-2015 and operated and discharged on,03-02-2015 and had spent approximately Rs.30,877/-on her treatment and other expenses, copies of all medical record is annexed as Annexure-B. Allegation of complainant is that he immediately informed Ops about the said ailment. as well as, treatment provided to his wife in Dr.Daljit Singh Eye Hospital, Amritsar and filled the claim form claiming the expenditure for the treatment and the Ops informed the complainant that his claim is not covered under the said policy, as the treatment is OPD in nature and the Op suggested to produce a certificate from the concerned hospital that the treatment is not OPD in nature ,copy of which is annexed as Annexure-C. Complainant further submits that on,03-03-2015 he again went to the hospital for further treatment of his wife where earlier treatment has been done and the wife of the complainant was operated on,03-03-2015 and discharged on,04-04-2015 wherein second Lucentis injection was given to his wife and total expenditure incurred by the complainant to the tune of Rs.29,500/-.Complainant further submitted that when he visited OP’s office he was asked to renew his policy which was going to be expired on,07-03-2015 immediately and only after that his case will be proceed further,though it is pertinent to mention that both the claims were within time of the policy under reference,but the complainant was not only compelled to renew the polcy before expiry date and on the said directions,complainant issued a cheque dated,04-03-2015 for the renewal of policy and requested them for reimbursement of the claim as soon as possible upon which the Insurance Company has directed him to submit relevant documents including claim form. Complainant further submitted that on,08-03-2015 he again visited OP office to submit requisite documents,i.e.claim form alongwith which he has also submitted the certificate given by doctor that procedure is not done as on OPD Procedure. It is performed in the operation theatre under strict aseptic precautions, thus making it clear that the treatment given to the complainant’s wife is not OPD,copy of bills, certificate issued by concerned doctor is annexed as Annexure D&E.Allegation of complainant is that despite of insurance cove rage not even a single penny was paid to him which he had spent on the treatment of her wife, which is duly covered under the insurance policy. Although complainant said to have approached OPs time and again for release of amount incurred on the treatment of her wife, but OPs did not release the same,therefore,this act of Ops constitutes deficiency in service and un fair trade practice. in the final analysis, complainant prays for reimbursement of sum of Rs.60,377/-alongwith interest and also prays for compensation and litigation expenses.

             On the other hand,OP1 filed objections and resisted the complaint on the ground that the complaint is not maintainable as the insured,namely,Smt.Monika Gandotra who allegedly suffered eye problem and took treatment and for whom claim has been filed is not a party complainant in the complaint and as such the complainant has no locus standii to file the present complaint. The OP1 further submitted that there is no deficiency in service on the part of answering OP in settling the case of complainant. The OP1 acting with great promptitude and reasonable seriousness after the claim was filed with it and immediately after the claim was lodged with the OP,the OP referred the matter to Vipul Medcorp,TPA Private Limited 515,Udyog Vihar,Phase 5,Gurgaon,Haryana for settlement of claim who are under a contract with the answering OP for the purpose of settlement of such like claims about which the complainant was fully aware. It is further submitted that OP2 processed the claim file No.15RB04OID0383 of the complainant in accordance with the terms and conditions, exclusion and limitation of Medi-claim Policy issued to the complainant,however,vide their letter dated 30-03-2015,the OP2 informed the complainant that the claim is not admissible and fails to meet the following criteria and is considered Non-admissible, Procedure not included in day care list so not payable as per Clause 2.3 of Policy. The Ops prayed for dismissal of complaint.

                       Complainant adduced evidence by way of duly sworn evidence affidavit and affidavit of Monika Gandotra.Complainant has placed on record copy of policy schedule, copies of medical record, copy of claim form, copy of bills, certificate, copy of discharge summary, copy of receipt of Rs.29,000/-

       We have perused case file and heard L/Cs for the parties at length.

              Briefly stated, case of complainant is that: the agent of OP Insurance Company approached him for obtaining the medi claim policy with features of covering the mediclaim of his family members too and complainant is paying the premium of the said policy for the last five years and the complainant was insured by the agent of OP after receiving the premium through cheque bearing No.2278998324 dated 05-03-2014 under the policy certificate No.262100/48/2014/2223 w.e.f.08-03-2014 to 07-03-2015 and as per said policy, the wife of complainant,namely,Smt.Monika Gandotra and children were also insured under the said mediclaim policy and in the month of Feb.2015 unfortunately his wife was suffering from severe ailment relating to her right eye i.e.CNVM Right Eye, immediately thereafter he approached Dr.Daljit Singh Eye Hospital Amritsar for providing best medical treatment to his wife and the doctors of the said hospital after thorough medical examination of the wife of complainant  advised her to undergo Anti VEGF Therapy Inj.Lucentis Right eye. Complainant further submitted that as per advise the doctors of Dr.Daljit Singh Eye Hospital operated upon the eye of wife of complainant during hospitalization on,02-02-2015 and discharged on,03-02-2015 and had spent approximately Rs.30,877/-on the treatment of his wife. Allegation of complainant is that he immediately informed Ops about the said ailment. as well as, treatment provided to his wife in Dr.Daljit Singh Eye Hospital, Amritsar and filled the claim form claiming the expenditure for the treatment and the Ops informed the complainant that his claim is not covered under the said policy, as the treatment is OPD in nature and the Op suggested to produce a certificate from the concerned hospital that the treatment is not OPD in. Complainant further submits that on,03-03-2015 he again went to the hospital for further treatment of his wife where earlier treatment has been done and the wife of the complainant was operated on,03-03-2015 and discharged on,04-04-2015 wherein second Lucentis injection was given to his wife and total expenditure incurred by the complainant to the tune of Rs.29,500/-. Complainant further submitted that when he visited OP’s office he was asked to renew his policy which was going to be expired on,07-03-2015 immediately and only after that his case will be proceed further, though it is pertinent to mention that both the claims were within time of the policy under reference, but the complainant was not only compelled to renew the policy before expiry date and on the said directions, complainant issued a cheque dated,04-03-2015 for the renewal of policy and requested them for reimbursement of the claim as soon as possible upon which the Insurance Company has directed him to submit relevant documents including claim form. Complainant further submitted that on,08-03-2015 he again visited OP office to submit requisite documents,i.e.claim form alongwith which he has also submitted the certificate given by doctor that procedure is not done as on OPD Procedure. It is performed in the operation theatre under strict aseptic precautions, thus making it clear that the treatment given to the complainant’s wife is not OPD.Allegation of complainant is that despite of insurance cove rage not even a single penny was paid to him which he had spent on the treatment of her wife, which is duly covered under the insurance policy. Although complainant said to have approached OPs time and again for release of amount incurred on the treatment of her wife, but OPs did not release the same

                 On the otherhand,defence of OP is that the complaint is not maintainable as the insured,namely,Smt.Monika Gandotra who allegedly suffered eye problem and took treatment and for whom claim has been filed is not a party complainant in the complaint and as such the complainant has no locus standii to file the present complaint. The OP1 further submitted that there is no deficiency in service on the part of answering OP in settling the case of complainant. The OP1 acting with great promptitude and reasonable seriousness after the claim was filed with it and immediately after the claim was lodged with the OP,the OP referred the matter to Vipul Medcorp,TPA Private Limited 515,Udyog Vihar,Phase 5,Gurgaon,Haryana for settlement of claim who are under a contract with the answering OP for the purpose of settlement of such like claims about which the complainant was fully aware. It is further submitted that OP2 processed the claim file No.15RB04OID0383 of the complainant in accordance with the terms and conditions, exclusion and limitation of Medi-claim Policy issued to the complainant,however,vide their letter dated 30-03-2015,the OP2 informed the complainant that the claim is not admissible as per clause 2.3 of policy.

                              In order to substantiate his allegations, complainant filed his own duly sworn evidence affidavit and affidavit of Smt.Monika Gandotra. Complainant and his witness reiterated the contents of complaint, therefore, same need no repetition. On the other hand, despite OP1 was granted numerous opportunities to support its version by leading evidence, but it failed to lead iota of evidence in support of its version,however,L/C for OP1 stated at bar that the written version filed by OP1 may be treated as evidence, to this effect signature of L/C for OP1 has been taken on the margin of this order sheet, hence the right of OP1 to lead evidence closed.Therefore,version of OP1 went unsubstantiated, unsupported and uncorroborated by cogent evidence, so much so, written version filed by Op1 is not supported by affidavit of OP1,therefore,same being bereft of  legal strength, hence, cannot be read in evidence.

          We have carefully perused the record. The incident for which the claim was preferred by the complainant occurred during the currency of policy,i.e.08-03-2014 to 07-03-2015 and the premium of Rs.11,304/-has been received by OP1 from the complainant. The claim of complainant is also strengthened by the Insurance policy issued by OP, wherein it is clearly mentioned the name of  complainant’s wife,namely, Smt.Monika Gandotra covered under the said policy.

             It is also to be noted that the case of the complainant is also strengthened by the Medical Certificate issued by the treating doctor, wherein it has been specifically mentioned as under

                 Procedure is not done as an OPD Procedure. It is performed in the Operation Theatre under strict aseptic precaution ,therefore,Ops are duty bound to indemnify the complainant, under the terms of policy

                       Ops are undoubtly performing their statutory duty in carrying out the business of insurance,therefore,is not expected to interpret the contractual clause to the prejudice of insured with a view to get benefit from the premium received for a particular period. Once terms and conditions of Mediclaim Policy, itself provides for renewal of policy, when for the first time cover incepts is obtained, in that event insurer cannot avoid benefit to the insured for the second term, when insurance policy is renewed after accepting premium, by treating same as new/fresh policy.

               It is admitted case of the parties that complainant underwent treatment at Dr,.Daljit Singh Eye Hospital,during currency of policy and according to complainant he incurred expenses to the tune of Rs.60,377/-.Complainant has placed on record bills/vouchers issued by Dr.Daljit Singh Eye Hospital, which are not disputed by OPs.

              

                Under these circumstances, we hold that the repudiation of claim for reimbursement by the insurer, is totally arbitrary, unreasonable and as a state agency, it has to set standards of model behaviour,to the contrary its attitude has displayed a contrary tendency.

                       L/C for complainant placed reliance on the judgment passed in case titled Sri Sajal Bhattacharyya V/S The Senior Divisional Manager & Ors.wherein it has been held as under

           Upon pleadings of both parties two points arose for determination

1. Is there any deficiency in service on the part of Ops?
2. Whether the complainant is entitled to get any relief as prayed for?

Both the points are taken up together for consideration. Admittedly the complainant has a valid medi claim policy. The complainant submitted his claim on,26-12-2012 and again the supplementary bill was submitted on,03-01-2012 as the claim was not settled within 2 months from the date of submission. The plea of repudiation that the injection (Injection Lucentis)is administered in case of age related muscular degeneration and as such is to be disallowed in cases of ARMD as the procedure involved is within OPD protocol only, appears to be too fragile to merit acceptance.Likewise,the plea of the Ops that 24 hours hospitalization is must for obtaining the reimbursement is also bogus in as much as the complainant had to incur the expenditure as claimed. It appears from the record that the patient was 61 years on the date of admission to the hospital for Lucentis Injection and was discharged on the same date,i.e.27-11-2012.The observation during repudiation cannot be treated as expert opinion. The point of minimum stay in the hospital was not mentioned in the prospectus of any of the four policies purchased by the complainant since 2011 till 2014.It is just an attempt on the part of the Ops to mislead the Forum and at the same time the conduct of the Ops is clear manifest that they adopted unfair trade practice to a bonafide policy holder. Hand book issued by the OP No.3 under the head line’Notice of claim’ only pinpoints-expenses on hospitalization for minimum period of 24 hours are admissible. This time limit is not applied to specific treatment.

                        After going through the whole case with the evidence on record what reveals here is the case of complainant is genuinely filed with speaking reasons and merit as being Consumer as per the purport of Section 2(d) of Consumer Protection Act and Ops are the service providers having failed in their statutory duty to provide adequate and effective services. The purport of legislation is well defined and statutorily takes care of consumer rights and cannot legally afford to a situation like the one confronted herewith in a manner where they are deprived of their rights as of consumer. The consumers have to come forth and seek for redressal of their grievance. The case of the complainant is also genuinely filed for seeking determination of his right by this Forum.

                              Under these circumstances, we hold that the rejection of claim for reimbursement by the insurer, is totally arbitrary, unreasonable and as a state agency, it has to set standards of model behaviour,to the contrary its attitude has displayed a contrary tendency.

                         Therefore, in view of the foregoing reasons the complaint filed by the complainant for redressal of his grievance is allowed and opposite parties are directed to pay to the complainant an amount of Rs.60,377/- alongwith interest @ 6% per annum w.e.f.22-09-2015(i..e.the date of filing of this complaint)till its payment. The complainant is entitled to compensation of Rs.10,000/-for causing mental agony and harassment. The complainant is also entitled to litigation charges of Rs.10,000/-.The opposite parties shall comply the order within one month from the date of receipt of this order. Copy of this order be provided to both the parties as per requirement of the Act. On deposit of the amount in this Forum, the same shall be paid to the complainant through payees account cheque.The complaint is accordingly disposed of and file be consigned to records after its due compilation.

Order per President                                   Khalil Choudhary

                                                                (Distt.& Sessions Judge)

Announced                                                   President

27 -02-2018                                        District Consumer Forum

Agreed by                                                     Jammu.                                                                                                                                  

                                                                      

Ms.Vijay Angral          

Member                                                                                                                                 

 

Mr.Ghulam Sarwar Chauhan

Member