Haryana

StateCommission

A/403/2015

NEW INDIA ASSURANCE CO. LTD. - Complainant(s)

Versus

PAWAN KUMARI AND OTHR. - Opp.Party(s)

NITIN GUPTA

12 Aug 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      403 of 2015

Date of Institution:      01.05.2015

Date of Decision :       12.08.2015

 

The New India Assurance Company Limited, Delhi-Rohtak Road, Bahadurgarh, District Jhajjar, through its Branch Manager, Now represented through the duly authorized signatory of Regional Office SCO No.36-37, Sector 17-A, Chandigarh.

                                      Appellant-Opposite Party No.1

Versus

 

1.      Smt. Pawan Kumari w/o Sh. Ranbir Singh, Resident of House No.13/343, Lambi Gali, near Jain Mandir, Bahadurgarh, District Jhajjar.

Respondent-Complainant

 

2.      Raksha TPA Private Limaited, 2^nd Floor, S.C.O. No.181, Sector 7-C, Chandigarh.

                                      Respondent-Opposite Party No.2

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member                                                                                                                                         

Present:               Shri Nitin Gupta, Advocate for appellant.

                             Shri S.D. Sharma, Advocate for respondent No.1.

                             Respondent No.2-performa.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

This appeal has been filed by The New India Assurance Company Limited-Opposite Party No.1, against the order dated March 24^th, 2015, passed by District Consumer Disputes Redressal Forum (for short ‘District Forum’), Jhajjar, whereby while Complaint No.252 of 2013 filed by Smt. Pawan Kumari-Complainant, following direction was issued:-

“….The respondent No.1 is, therefore, directed to pay a sum of Rs.3,71,746/- to the complainant along with an interest @ 9% p.a. from the date of admission of Ranbir Singh i.e. 23.9.2012 till realization of final payment to the complainant. The complainant is also entitled for a sum of Rs.2,000/- on account of litigation expenses for the present unwanted and unwarranted litigation only due to the deficiency in service on the part of the respondents. The complaint stands disposed of accordingly”.

2.         Pawan Kumar-Complainant (respondent No.1 herein) and her husband Ranbir Singh purchased a medi-claim insurance policy (Exhibit P-1) from The New India Assurance Company Limited (for short ‘the Insurance Company’)-Opposite Party No.1 (appellant herein) from September 12^th, 2011 to September 11^th, 2012. The sum assured was Rs.4,00,000/-. The complainant got the policy renewed from September 12^th, 2012 to September 11^th, 2013 and September 12^th, 2013 to September 11^th, 2014 vide Policies (Exhibit R-2) and (Exhibit R-3) respectively.

3.      Ranbir Singh-husband of the complainant fell ill. He was admitted in ‘Sir Ganga Ram Hospiita, New Delhi’ on September 23^rd, 2012. He was diagnosed for Abscess of liver, Amoebic Typhilities, Diabetes Mellitus, Benign prostatic hyperplasia and Cystoid maculr oedema. After treatment he was discharged on October 14^th, 2012. According to the complainant a sum of Rs.3,71,746/- on the treatment of her husband. Accordingly, the insured filed claim with the Insurance Company but the same was repudiated vide letter dated October 21^st, 2012 (Exhibit P-7). Aggrieved thereof, the complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 seeking direction to the Insurance Company to pay Rs.3,71,746/- on account of the expenses incurred by the insured on treatment and Rs.1,00,000/- for mental agony and harassment.

4.      Notice being issued, the Insurance Company contested the complaint by filing reply raising plea that the insured was admitted to Sir Ganga Ram Hospital, New Delhi on September 23^rd, 2012 with diagnoses of “Abscess of Liver with Amoebic Typhilitis with Diabetes Mellitus with Benign Prostatic Hyperplasia with Cystoid Macular Oedema”. He underwent TURP for BPH (prostate) and was given intra-vitreal injection Avastin during hospitalization. The policy being in the second year of its inception, the treatment of TURP fell under exclusion clause 4.3 of the insurance policy. Therefore, the Insurance Company rightly repudiated claim.  Thus, denying any kind of deficiency in service, it was prayed that complaint merited dismissal.

5.      After evaluating the evidence of the parties, the District Forum vide impugned order accepted complaint issuing direction to the Insurance Company, as detailed in paragraph No.1 of this order.

6.      While assailing the order of the District Forum, learned counsel for the appellant-Insurance Company has drawn the attention of this Commission to the terms and conditions of the policy and in particular clause 4.3 wherein waiting period has been prescribed for the diseases mentioned therein, as under:-

“4.3   Waiting period for specified diseases/ailments/conditions:

From the time of inception of the cover, the policy will not cover the following diseases/ailments/ conditions for the duration shown below. This exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with our Company without any break.

Sr.No.	Name of Disease/Ailment/ Surgery and covered for	Duration
1	xxx
2	xxx
3	xxx
4	Benign Prostate Hypertrophy	Two years
5	xxx
6	Diabetes melitus	Two years
7	xxx

 

7.      As per the discharge summary of Ranbir Singh-insured, under the heading of DIAGNOSIS ‘Benign prostatic hyperplasia’ was one of the diseases diagnosed. The ‘CLINICAL SUMMARY’ given in Exhibit P-5, reads as under:-

“Patient was admitted with complaints of high grade fever with chills since 10 days and pain abdomen. During his hospital stay he was clinically evaluated, and CT scan was discussed with Radiologist then pt. was referred to gastroenterologist. Colonoscopy biopsy was done on 25-9-12, which revealed large necrotic caecal ulcers with necrotic base suggesting amoebic typhilitis with caecal and colonic inflammatory mass with liver abscess. On 26/09/12 under USG guidance aspiration of liver abscess was done and pus sent for gram staining and culture & sensitivity which revealed no abnormality. During the hospital stay he was referred to the urology dept for his LUTS and he underwent TURP on 08.10.12, he was also referred to the ophthalmology dept. for his decreased vision and diagnosed as macular edema for which he undergone Intra vitreal injection of Avastin for his both eyes. At the time of discharge patient’s general condition was improved and he is discharge in a stable condition”.

8.      One of the procedures which the insured underwent is TURP which is used for Benign Prostate Hypertrophy, which was not covered for a period of two years from the commencement of the policy. The policy was in the second year. The first policy (Exhibit R/1) commenced with effect from 11.09.2011 to 11.09.2012. It was renewed from 12.09.2012 to 11.09.2013. The complainant has placed on the file the bills issued from ‘Sir Ganga Hospital, New Delhi’. It is not possible to exactly calculate the amount spent on the treatment of this disease. Though the total bills are for Rs.3,71,746/- which includes Rs.88,200/- as Room Rent Charges besides two payments for ‘Doctor’s Procedure Charges’ etcetera, medicines and other related expenses. This Commission feels that a lump sum amount of Rs.50,000/- is to be deducted out of the total bills.  Thus, the insurance company is liable to pay (Rs.3,71,746-50,000)= Rs. 3,21,746/- to the complainant and it is ordered accordingly. Rest of the order is maintained. 

9.      The impugned order is modified to the extent indicated above and the appeal stands disposed of.

10.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the respondent-complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced 12.08.2015

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL