DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

(CENTRAL)   ISBT KASHMERE GATE DELHI

CC/286/2017

No. DF/ Central/

P.C. Gupta

69-B, Pocket –A,

Sukhdev Vihar,

New Delhi – 110 025

…..COMPLAINANT

 VERSUS

1.  Park Mediclaim TPA Pvt. Ltd.,

702, Vikrant Tower, Rajendra Place,

New Delhi - 110008

13, Community Center, New Friends Colony,

New Delhi – 110 025

      …..OPPOSITE PARTIES

Coram:       Ms. Rekha Rani, President

                   Ms. Manju Bala Sharma, Member

                     Sh. R.C. Meena, Member

ORDER

Mr. R.C. Meena, Member

1.     Instant complaint has been filed by Shri P.C. Gupta in short the complainant u/s 12 of the Consumer Protection Act pleading therein that he was medically insured in the company in which he was associated from 1990 to 2006 thereafter from 2007 the complainant is medically insured with the OP No. 2 for Rs. 3 Lac for medi-claim.

2.    On 15^th Feb. 2017 complainant had a medical problem of brain haemorrhage and was admitted to Holy Family Hospital near his residence and

on his request he was discharged from the Hospital on 17^th Feb. 2017 under the

specific advice of the doctors to keep in touch with the hospital in case of any inclination of discomfort and also advised to follow up of the ailment.

3.     The complainant initially submitted a bill to OP 1 on 27^th Feb. 2017 for Rs. 29750/- whicn was approved and paid to the complainant.  Copy of first claim is placed at Annexure C – 2.

4.     The complainant was again admitted to the Hospital on 11^th April 2017 due to drowsness/ sleeply and urology problem and was discharged on 12^th April 2017.   On the advice of the Doctor the complainant purchased CPAC Machine and started using the same so that the oxygen reaches to the brain to overcome the present ailment and submitted bills of Rs. 84,487/- to OP No. 1 for reimbursement.  OP 1 raised query for years of medical coverage with OP No. 2 and also authorization letter for it for inspection of the hospital records. 

Complainant had furnished the same to OP No. 1.  After enquiry OP 1 informed

the complainant that the claim has been sent to OP No. 2 for their consideration. 

OP No. 1 get 6.5% amount which is paid by OP No. 2 out of the insurance premium received by the insured.  OP No. 1 did not either settled the claim or

Rejected the same but only intimated about the rejection of claim of the complainant to OP No. 2 vide their letter dated : 17^th October 2017 which come under the exclusion clause 4.13 of the policy. 

     It is also alleged by the complainant that OP No. 2 has acted against the Govt. Policy for Public Service.  The complainant also sent legal notice dated

04^th November 2017.  It is also alleged by the complainant that OP No. 1 and

OP 2 both are deficient in service and also used unfair trade practice and prays for direction to OP to Order for Rs. 84,487/- with interest @ 18% w.e.f. 1^st May 2017 till payment, Rs. 25,000/- on account of mental harassment along with cost of legal expenses.

5.     OP 2 in its reply contested the claim of the complainant.  It is submitted by the OP that this complaint is outside the purview of the contract.  As per the exclusion clause 4.13 of ‘PARIVAR MEDICLAIM POLICY’ expenses incurred for diagnostic and laboratory examination are excluded.  The expenses incurred on the treatment of the complainant are not payable as the same are comes under the exclusion clause.  Insurance is a contract between the insurer and insured and conditions are sacrosanct and must be adhered to by both the parties and no party is allowed to go beyond the terms and conditions of the policy.

      OP 2 has submitted that there is no deficiency of service on their part and the claim of the complainant has rightly been repudiated as per the terms and conditions of the policy.

     OP 2 has further submitted that purchase of CPAP machine is not payable as per exclusion clause 4.13 of Parivar Mediclaim Policy.

‘‘‘‘Expenses incurred at hospital primarily for diagnostic, x-ray or laboratory examinations or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital are not payable’’’’.

    OP also submitted that reply to the legal notice dated 04/11/2017 was sent to the complainant which has not been deliberately annexed with the complaint.

     There is no deficiency in service and unfair trade practice on the part of OP and therefore the complaint is liable to be dismissed.

6.     We have heard Shri PC Gupta Complainant in person and Shri S.K. Tyagi Counsel for OP No. 2.  We have gone through the case file and perused the record. 

      The complainant was admitted in Hospital on 11.04.2017 for sleep study test and discharged on 12.04.2017.  Complainant was diagnosed Mild obstructive sleep and noctual CPAP of 9 cm to 20 was recommended.

    The complainant has prayed to order for Rs. 84,487/- including current bill with 18% interest from 01.05.2017 till payment and Rs. 25000/- as award on account of mental harassment.  The complainant has annexed Parivar Medicliam Policy – National Mediclaim Policy.  Complaint has stated that the OP 2 is heavily relying in his written submission and as well as rejection of claim Clause 4.13 which is as per above policy :    

‘‘4.13 Vaccination or inoculation’’

Respondent has submitted Parivar Mediclaim for family Policy wherein in clause 4.13 it is mentioned that :

 ‘‘‘‘Expenses incurred at hospital primarily for diagnostic, x-ray or laboratory examinations or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital are not payable’’’’.

7.       After perusal of both the policy submitted by Complainant and Respondent, CPAP has excluded in both the Policies.  Relevant portion of claimant policy are as below :
Clause 4 : Exclusions : 

The company shall not be liable to make any payment under the policy in respect of any expenses incurred in connection with or in respect of  :

4.24 :  Equipments

External/durable medical /non-medical equipments/instruments of any kind used for diagnosis/treatment including CPAP, CAPD, infusion pump, ambulatory devices like walker, crutches, belts, collars, caps, splints, slings, braces, stockings, diabetic foot-wear, glucometer, thermometer, similar related

items (as listed in Appendix II) and any medical equipment which could be used at home subsequently.  

8.    The complaint has claimed reimbursement Bills of Rs. 84,487/- for sleep study test and CPAP Machine.  As per above exclusion 4.24 clause any equipment/instruments used for diagnosis/ Treatment are excluded.

     The Complainant has undergone sleep study test which show obstructive sleep and Doctor advised CPAP machine.  The sleep study test is used for diagnosis and CPAP Machine is medical equipment which is used at home for treatment.  The sleep study test and CPAP Machine are covered under above exclusion clause of equipment/instrument used for diagnosis/treatment.        

9.     In view of the material placed on record and discussion as above.    The complainant is not entitled for reimbursement of claim. The complaint accordingly dismissed.   File be consigned record room. 

 Announced on this 13^th Day of November 2019.