Jammu and Kashmir

Jammu

CC/105/2017

SUBASH CHANDER - Complainant(s)

Versus

oriental insurance - Opp.Party(s)

SAHIB AGARWAL

21 Nov 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,JAMMU

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

                                                          .

 Case File No.             :   375/DFJ                

 Date of  Institution   : 27-12-2016                   

 Date of Decision       :  15-11-2018

 

Subhash Chander,

S/O Lt.Sh.Roopchand Mahajan,

R/O Mohalla Dalpatian,Jammu.

                                                                                                                                                                Complainant

                   V/S

1.O.I.C.Through its Branch Manager,

Canal Road,Jammu.

2.Vipul Med Corp.TPA Private Ltd.

  S.C.I.No.98 First Floor Industrial Area Phase-II,

Chandigarh.

                                                                                                                                                                Opposite parties

 

     CORAM:-

                  Khalil Choudhary -             (Distt.& Sessions Judge) -  President

                  Ms.Vijay Angral                                                             -  Member

                  Mr.Ghulam Sarwar Chauhan                                     -  Member

 

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

                              Protection Act 1987.

 

Mr.Sahib Aggarwal,Advocate for complainant, present.

Mr.Virender Choudhary,Advocate for OPs,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 the treatment of  complainant. Relevant facts as are dicernible from the complaint are that; complainant said to have obtained Health Insurance Cover which is popularly known as Mediclaim Policy  bearing Policy No. 262101/48/2016/143  from OP1 w.e.f.27-05-2015 to 26-05-2016 for the year 2015-16(Copy of Insurance Policy is annexed as Annexure-A)That as per the terms and conditions envisaged in the Mediclaim Policy,OP2 was appointed as T.P.A.(Third Party Administrator) to manage the claims. That the complainant was admitted for his heart related treatment in Sir Gangaram Hospital, New Delhi on,14-07-2015 and was subsequently operated by Surgeon,namely,Dr.Ganesh Shivani for CABG(Coronary Artery Bye-Pass Grafting)and the complainant deposited certain amount of money while getting admission in the said hospital and thereafter informed concerned TPA Desk at Sir Gangaram Hospital, New Delhi about the cashless Mediclaim Policy availed by the complainant. Complainant further submits that initially his request for cashless medical facility was processed by the concerned T.P.A.and the amount was credited to the Hospital’s account by the concerned T.P.A.Thereafter,after getting surgery done and on the advice of concerned Dr.complainant was discharged from the Hospital on,20-07-2015,but only few hours after the discharge, he started suffering from high fever and breathlessness and was taken to the same hospital again and was referred to the doctors who supervised the complainant’s treatment. That on the advice of concerned doctor complainant was re-admitted in the hospital for proper medical examination and to stabilize the condition of the complainant following high fever alongwith breathlessness after surgery, complainant was redirected to remain under the supervision of doctors and therefore, the complainant had to be readmitted in Sir Gangaram Hospital, New Delhi(copy of prescription is annexed as Annexure-B)and the complainant was readmitted on,20-07-29015 itself following high fever and breathlessness post CABG and had to undergo various Medical examinations and was subsequently discharged on,24-07-2015 after some improvement and stabilization in patient’s deprecating health(copy of discharge summary is annexed as Annexure-C).According to complainant, while readmitted in the said hospital, he resubmitted an estimate form with OP2 verified by the concerned doctor who was treating the patient, but the concerned T.P.A.did not process the cashless hospitalization request of the insured on re-admission and while getting discharge from the concerned hospital, the patient had to clear whole bill incurred during re-admission till final discharge on,24-07-2015,complainant had to pay in toto an amount of Rs.53,840/-(copy of bill is annexed as Annexure-E)before taking the discharge from the hospital. Allegation of complainant is that the concerned TPA derelict in its duty to give cashless hospitalization to the complainant,whereas,inspite of their inability   to provide cashless hospitalization ,OP1&2 did not even reimburse the amount of Rs.53,840/-which was paid by him while taking discharge from the said hospital .Further allegation of complainant is that inspite of repeated requests to OPs,nothing yield any fruitful result. Hence the present complaint. In the final analysis, complainant prays for reimbursement of medical expenses of Rs.53,840/-alongwith interest @ 12% per annum from the date of discharge and also prays for compensation of Rs.6,30,000/-including litigation expenses.

                 On the other hand,OPs filed written version and resisted the complaint on the ground that the claim of complainant is rightly rejected by the answering OP by assigning valid reason after due application of mind. That there has been no deficiency of service on the part of OP Company in processing the claim of complainant, deficiency in service is a requirement sine-qua-non for invoking the jurisdiction of this Forum under C.P.Act.The claim of the complainant was duly processed and was found to be not payable.It is submitted that the complainant was discharged from the hospital on,20-07-2015 and all the hospitalization charges were borne by the OPs in terms of medi claim policy. As per the version of complainant, the complainant after discharge from the hospital was readmitted in the hospital and was subsequently discharged on,24-07-2015 and as per the version of the complainant, the complainant had to incur more expenditure. The answering  OP denies that any cashless hospital request of the insured on re-admission was denied.Moreover,as per own documents of the complainant, the complainant has incurred an amount of Rs.21,425/-on readmission and not Rs.53,840/-.That annexure-H of the present complaint clearly shows that complainant already received cashless facility of his Medi Claim Policy and Rs.2415/-adjusted out of earlier deposit and Rs.30,000/-also received by the hospital through cashless facility cash receipt dated 12-07-2015 clearly shows and only Rs.21,425/-balance amount deposited on,24-07-2015 by the complainant in the hospital .The answering OPs submits that neither the original bills nor the payment receipts received by the OPs,so that the claim of the complainant could be settled. The complainant despite request have not provided the original documents for the purpose of settlement of claim. Since complainant failed to provide requisite documents which are necessary for the settlement of the claim ultimately the claim of the complainant was rejected. Rest of the contents of complaint are denied by OPs.

                Complainant adduced evidence by way of duly sworn evidence affidavit and affidavit of Rakesh Kumar Shukla.Complainant has placed on record copy of Policy Schedule, copy of receipt ,copy of prescription, issued by Dharma Vira Heart Cent.Sir Ganga Ram Hospital New Delhi, copy of discharge summary, copy of insurance policy, copy of bill issued by Sir Ganga Ram Hospital for an amount of Rs.53,840/-,copy of receipt of Rs.30,000/- dated 12-07-2015 issued by Sir Ganga Ram Hospital New, copy of receipt of Rs.21,425/-as advance by cash issued by Sir Ganga Ram Hospital New Delhi and copy of letter issued by complainant to OPs.

                  On the other hand,Ops adduced evidence by way of duly sworn evidence affidavit of P.S.Thakur,Sr.Divisional Manager,The Oriental Insurance Company Ltd.

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

                   After hearing L/Cs for parties at length and perusing the case file, in our opinion, point for consideration is, as to whether or not Ops are justified in declining benefit of reimbursement of expenses incurred on the treatment of complainant.

                       In order to prove his contention, complainant adduced evidence in the shape of his own duly sworn affidavit and also filed evidence affidavit of Rakesh Kumar Shukla. The deposition of complainant and his witnesses are verbatim reproduction of averments of complainant,therefore,need not to be reiterated again.OPs have also lead evidence in the shape of affidavit of P.S.Thakur,Sr.Divisional Manager,The Oriental Insurance Company Ltd.

 the deposition of witness of Ops is also verbatim reproduction of defence raised by the Ops in its written version,therefore,same need no repetition.

                         According to complainant at the time of taking of Health Insurance Policy, he was made to believe that in the event of medical treatment, during currency of Insurance Policy, he would be fully reimbursed. We have no doubt in our mind that complainant has been induced to enter into a contract by the reason of suppression of material fact,otherwise,complainant might have not entered into contract if correct facts being made known to him. It is settled preposition of law that no one will be allowed to take advantage of his own wrong, especially while entering into a contract of insurance, which is of utmost good faith. Since the complainant has proved to the satisfaction of Forum that before entering into contract of insurance, he was made to believe that entire sum incurred on the treatment would be reimbursed,therefore,complainant entered into contract of insurance on the promise that entire sum shall be reimbursed, as such, at this stage insurer cannot taken refuge under the terms and conditions of policy, which were not  made known to complainant at the time of entering into the contract of insurance.

                     It is to be noted that the case of the complainant is also strengthened by the Policy Schedule, wherein it has been specifically mentioned we at Oriental continuously strive to ensure that you get the best possible treatment from our network hospitals. Please contact your TPA or any of the Oriental Officers for our preferred hospitals in your area before going for a treatment. This will help us serve you in the best possible manner

                       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.

               It is admitted case of the parties that complainant underwent treatment at Sir Gangaram Hospital New Delhi, during currency of policy and according to complainant he incurred expenses to the tune of Rs.53,840/-Complainant has placed on record copy of bill issued by Sir Ganga Ram Hospital, New Delhi , which are not disputed by OPs.

                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.

                       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 his grievance. The case of the complainant is also genuinely filed for seeking determination of his right by this Forum.

                   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.53,840/- alongwith interest @ 6% per annum w.e.f. 27-12-2016 (i.e. from the date of filing of this complaint)till its payment. The complainant is entitled to compensation of Rs.15000/-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

15 -11-2018                                        District Consumer Forum

Agreed by                                                     Jammu.                                                                                                                                  

                                                                      

Ms.Vijay Angral          

Member                                                                                                                                 

 

Mr.Ghulam Sarwar Chauhan

Member