DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 281/2013
Date of Institution : 01.10.2013
Date of Decision : 02.11.2015
Vikas Kumar Bansal, aged about 47 years, son of Shri Raj Kumar Bansal resident of # C-883, Street No. 2, Patel Nagar, Barnala.
…Complainant
Versus
1. Oriental Insurance Co. Ltd., Branch K.C. Road, Near OBC Bank, Barnala through its Branch Manager.
2. Oriental Insurance Co. Ltd., Branch Nabha Gate, Sangrur through its Branch Manager.
3. M/s Medi Assist India TPA Pvt. Ltd., # 61, 2nd Floor, Phase VII, Mohali (West), Punjab 160055 through its Area Manager.
4. Punjab National Bank, Main Branch, Shaheed Bhagat Singh Road, Barnala through its Senior Manager.
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. NK Singla counsel for the complainant with complainant.
Sh. Varinder Goel counsel for opposite parties No. 1 to 3
Sh. Vinod Goel counsel for opposite party No. 4.
Quorum.-
1. Shri S.K. Goel : President.
2. Sh. Karnail Singh : Member
3. Ms. Vandna Sidhu : Member
ORDER
(SHRI S.K. GOEL PRESIDENT):
Vikas Kumar Bansal son of Raj Kumar Bansal (hereinafter referred as complainant), has preferred the present complaint against the Oriental Insurance Company Limited and others (hereinafter referred as opposite parties) under Consumer Protection Act, 1986 (hereinafter referred as Act).
2. The facts emerging from the present complaint are that the complainant is having a Saving Account No. 0044000104213988 with the Punjab National Bank and he purchased a Cashless Health Insurance Policy No. 233599/48/2013/103 for the period 8.8.2012 to 7.8.2013 from opposite party No. 1 through opposite party No. 2 and an amount of Rs. 3,320/- was debited from the account of the complainant on 6.8.2012.
3. It is further averred that, the family members of the complainant i.e. Ms. Geeta Bansal, Ms. Palak Bansal and Mr. Anmol Bansal being spouse, daughter and minor son of the complainant respectively were also covered by the said policy. It is further averred that Health Card No. 5007760218, valid from 8.8.2012 in the name of the complainant alongwith health cards in the names of the family members of the complainant named above were issued by M/s Medi Assist India TPA Pvt Ltd. opposite party No. 3 which is a third party Administrator of the opposite parties No. 1 and 2.
4. It is further averred that, as per the terms and conditions of the said policy the insurer shall pay for hospitalization expenses for medical/surgical treatment at any nursing home/hospital in India as inpatient. It is alleged that during the validity of this insurance policy the complainant suddenly suffered from some heart problem on 27.3.2013 and as such he was admitted in Dr. Naresh Goel hospital situated at K.C. Road, Barnala from where he was referred to Hero Heart Dayanand Medical College and Hospital, Ludhiana on the same day i.e. 27.3.2013 where he remained admitted till 1.4.2013. During this period the complainant was operated upon for CAD with Single Vessel disease on 28.3.2013. It is alleged that at the time of admission of the complainant in the said hospital at Ludhiana, the complainant was advised to obtain the treatment as per his treating doctor's advice and to submit the full claim papers to the opposite party No. 3 for possible reimbursement. After discharge the complainant filled upon the claim form on 4.4.2013 and obtained medical certificate from Dr. Bishav Mohan of Hero Heart Dayanand Medical College and Hospital, Ludhiana who had treated the complainant on 8.4.2013 and submitted the said claim form, medical certificate, bills ( four in number) amounting to Rs. 2,21,898/-, discharge summary, copy of insurance and MAID card and copy of the pass book to opposite party No. 3 on 10.4.2013 through registered post. However the opposite party No. 2 sent a letter dated 10.5.2013 to opposite party No. 1 purporting to be addressed to the complainant that opposite party No. 3 informed that the claim of the complainant was not tenable and regretted their inability to admit their liability and repudiated the claim. The complainant submitted his representation/clarification vide letter dated 27.5.2013 to opposite party No. 1 that he never remained a diabetic patient at any point of time. Moreover the detailed summary in respect of the biochemistry in the discharge slip clearly proved that the complainant was never a diabetic patient at any point of time but the complainant did not receive any response to his representation dated 27.5.2013 and then the complainant sent a reminder dated 31.8.2013. Even the complainant moved an application dated 5.8.2013 to the Chief Cardiologist, Hero Heart Dayanand Medical College and Hospital, Ludhiana for issuance of certificate that the complainant is not diabetic and the same was issued to the complainant by Dr. Bishav Mohan. Despite this the opposite parties have not released the claim till today. Hence the present complaint is filed seeking the following reliefs.-
1) To pay an amount of Rs. 2,21,898/- alongwith interest at the rate of 18% per annum till realization.
2) To pay Rs. 2 lacs on account of mental agony, tension and harassment and Rs. 20,000/- on account of litigation expenses.
5. Upon notice, the opposite parties No. 1 and 2 filed a joint written version taking preliminary objections on the ground of maintainability, not coming to this Forum with clean hands, locus standi, jurisdiction, non joinder and mis joinder of necessary parties. On merits they have admitted that the complainant was insured for the period from 8.8.2012 to 7.8.2013. It is further submitted that the record of Hero DMC showed that the complainant has the history of diabetes. That third party administrator has given the opinion that the claim was not admissible. It is further submitted that the complainant obtained the certificate from the hospital contrary to the record of the hospital. There is no explanation as to why it was got recorded in the patient history that the patient was suffering from diabetes. They have denied the other allegations of the complainant and finally prayed for the dismissal of the complaint.
6. The opposite party No. 3 did not file written version despite availing many opportunities.
7. The opposite party No. 4 has also filed the separate written version admitting that the complainant got insurance policy of opposite party No. 1 through opposite party No. 4 and a demand draft of Rs. 3,320/- from the saving account of the complainant was sent by opposite party No. 4. However, they have denied any deficiency on their part and finally prayed for the dismissal of the complaint.
8. It is worth mentioning here that originally this complaint was decided by my predecessor vide order dated 12.11.2013 vide which the complaint was allowed for Rs. 2,00,000/- alongwith interest at the rate of 9% per annum against opposite parties No. 1 and 2 and Rs. 10,000/- was also ordered to be paid for harassment. The opposite parties have filed an appeal in the Hon'ble State Commission, Punjab, Chandigarh and vide order dated 6.5.2015 the Hon'ble State Commission admitted the appeal and remitted this case to this Forum for fresh decision in accordance with law.
9. In order to prove his case the complainant tendered into evidence his affidavit Ex.C-1, copy of pass book Ex.C-2, copy of insurance policy Ex.C-3, copy of health card Ex.C-4, copy of email dated 28.3.2013 Ex.C-5, copy of claim form Ex.C-6, copy of medical certificate Ex.C-7, copy of medical bills Ex.C-8 to Ex.C-11, copy of discharge summary Ex.C-12, copy of MAID card Ex.C-13, copy of letter dated 10.4.2013 Ex.C-14, copy of postal receipt Ex.C-15, copy of letter dated 10.5.2013 Ex.C-16, copy of registered envelope Ex.C-17, copy of clarification dated 27.5.2013 Ex.C-18, copy of reminder dated 31.8.2013 Ex.C-19, copy of postal receipt dated 4.9.2013 Ex.C-20, copy of application dated 5.8.2013 Ex.C-21, copy of certificate dated 6.9.2013 Ex.C-22, envelope containing ECG Ex.C-23, copy of prescription slip Ex.C-24 and Ex.C-25 and closed his evidence.
10. In order to rebut the evidence of the complainant the opposite parties No. 1 to 3 tendered in evidence affidavit of A.S. Dhingra Ex.OP-1.2.3/1 and closed their evidence vide order dated 21.10.2015. Whereas learned counsel for opposite party No. 4 made a statement on 5.10.2015 that he does not want to lead any evidence on behalf of opposite party No. 4.
11. We have heard the learned counsel for the parties and have carefully gone through the record on the file.
12. In order to prove his case, the complainant has placed on record his detailed affidavit Ex.C-1 reiterating his stand as taken in the complaint. Ex.C-2 is the copy of the saving account of the complainant in Punjab National Bank opposite party No. 4 showing his account No. 0044000104213988 and it further shows that the amount of Rs. 3,320/- was debited from his account on 6.8.2012. Ex.C-3 is the insurance policy issued by the opposite party No. 2 in favour of the complainant covering the period from 8.8.2012 to 7.8.2013. It further shows the deposit of Rs. 3,320/- as insurance premium. The second page of this policy also shows that apart from the complainant the other family members namely Geeta Bansal, Palak Bansal and Anmol Bansal were also covered and the sum assured is Rs. 2,00,000/-. Against the said evidence there is no rebuttal produced by the opposite parties. Therefore, the evidence qua the insurance policy of the complainant and other family members purchased from the insurance company is un-rebutted.
13. The next point is whether the complainant has undergone the treatment as stated by him and has incurred the expenses as alleged. To prove this, the complainant has placed on record bill No. 72093 dated 1.4.2013 Ex.C-8 of DMC and Hospital Unit Hero DMC Heart Institute, Ludhiana showing the expenses of Rs. 2,19,180/-. Ex.C-9 further shoes the payment of Rs. 375/- and Ex.C-10 shoes the payment of Rs. 1,500/- for Ambulance Service. This piece of evidence that he has incurred the above referred to expenses is not rebutted by the opposite parties and therefore this evidence is also un-rebutted.
14. Moreover the complainant has placed on record claim form Ex.C-6 to the third party administrator Medi Assist opposite party No. 3 indicating all the details of the insurance taken by him as well as the expenses incurred. However, vide letter Ex.C-16 the opposite party insurance company has rejected the claim of the complainant on the ground that the complainant was suffering from diabetes.
15. To face this situation the learned counsel for the complainant has contended that the complainant was not suffering from diabetes and there is no record with the opposite parties to prove that the complainant is a patient of diabetes. It is worth mentioning here that the opposite party has not placed on record any medical report to support this point that the complainant was suffering from diabetes.
16. On the other hand, the complainant has placed on record certificate Ex.C-22 of Hero DMC Heart Institute, Ludhiana from where he was treated, which reads as under.-
“This is to certify that patient Mr. Vikas Bansal 46 years old male S/o Sh. Raj Kumar R/o Patel Nagar, St. No. 1, Barnala was admitted in this institute on 27.3.2013 vide Adma. No. 72001, CR No. 167470 under Dr. Bishav Mohan as a case of CAD-Acute Anterior Wall MI, EF 38% (Thrombolysed with Metalyse on 27.3.2013), Single Vessel Disease. PTCA with stenting to LAD was done on 28.3.2013. As per records HBAic are with in normal levels of this. He was not given any Anti-diabetic drugs during the hospital stay. He was discharged on 1.4.2013 from the hospital in a stable condition.”
17. Moreover, the onus to prove that the complainant was having pre-existing disease i.e diabetes was upon the opposite parties. The opposite party has not produced any evidence to prove this point. Merely, mentioning that the complainant was suffering from diabetes in the rejection letter does not by stretch of any imagination outweigh the report of the doctor of Hero DMC Heart Institute, Ludhiana Ex.C-22.
18. As a result of our above discussion the evidence produced by the complainant is trustworthy and cogent and the opposite parties have not brought any evidence except the affidavit to rebut the medical evidence produced by the complainant.
19. In view of above discussion we allow the present complaint and order the opposite parties No. 1 and 2 jointly and severally to pay the amount of Rs. 2,00,000/- to the complainant alongwith interest at the rate of 8% per annum from the date of payment of expenses till realization. The opposite parties No. 1 and 2 further directed to pay Rs. 10,000/- to the complainant as compensation for harassment and Rs. 2,100/- as litigation expenses. This order shall be complied with within 45 days from the date of the receipt of this order. Copy of this order be supplied to the parties free of costs. The file be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
2nd Day of November 2015
(S.K. Goel)
President
(Karnail Singh)
Member
(Vandna Sidhu)
Member
