DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.
Consumer Complaint No.133 of 2014
Date of institution: 07/10/2014
Date of decision : 21.09.2015
Gurpal Malhotra son of Sh. Karam Chand resident of Mohalla Quilla, Bassi Pathana, District Fatehgarh Sahib.
……..Complainant
Versus
- Punjab National Bank, Jail Road, Bassi Pathana District Fatehgarh Sahib through its Branch Manager.
- Oriental Insurance Company Ltd. Oriental House, P.B. No.7037, A-25/27, Asaf Ali Road, New Delhi-110002 through its Authorized Signatory.
…..Opposite Parties
Complaint Under Section 12 of the Consumer Protection Act
Quorum
Sh. Ajit Pal Singh Rajput, President Sh. Amar Bhushan Aggarwal, Member
Present : Sh.Naveen Behl Adv. Cl. for the complainant Sh. Sanjeev Chopra, Adv. Cl. for OP No.1 Sh. D.P.S.Anand, Adv.Cl. for OP No.2.
ORDER
By Sh. Ajit Pal Singh Rajput, President.
Complainant, Gurpal Malhotra son of Sh. Karam Chand resident of Mohalla Quilla, Bassi Pathana, District Fatehgarh Sahib, has filed this complaint against the Opposite parties (hereinafter referred to as “the OPs”) under Section 12 of the Consumer Protection Act. The brief facts of the complaint are as under:
2. The complainant is having bank account No.1217000100290470 with opposite party No.1 and in the month of April 2014 OP No.1 approached the complainant to buy one mediclaim insurance policy. OP No.1 also disclosed that it has tie up with OP No.2 and it sells the insurance policy under the name PNB Oriental Royal Mediclaim Policy. OP No.1 assured the complainant that in case of any health problem to the policy holder, the entire cost of treatment from starting of treatment including tests or admission to discharge in the empanelled hospital will be paid by the opposite parties on cashless basis and it was also told that if the treatment is taken from non-empanelled hospitals of the opposite parties, then the treatment expenses will be reimbursed within 30 days. Under the impression of OP No.1 the complainant bought said Mediclaim Policy for the sum of Rs.4 lakh, for which he paid Rs. 5780/- to the OPs vide demand draft. Thereafter the complainant suffered heart problem, due to which he got his primary treatment from ACE HEART & VASCULAR INSTITUTE, Sector 69, Mohali and applied for cashless Mediclaim with OP No.1. But the OPs denied the cashless claim and suggested him to obtain treatment as per his/her doctor’s advice and to submit the claim papers for reimbursement. Thereafter, the complainant was got admitted in the MAX Super Specialty Hospital, Phase-6, Mohali and was treated there. The complainant also applied for the claim with the opposite parties in the said hospital under cashless claim number 10161097. The complainant remained admitted in the said hospital from 07.07.2014 to 15.07.2014 and during this period, the OPs had paid nothing despite repeated requests of the complainant. The complainant paid a total amount of Rs.2,54,389.93 to the Max Hospital and Ace Heart Institute. After discharge the complainant approached OP No.1 regarding non-giving the cashless benefit and OP No.1 assured the complainant that entire cost of treatment will be reimbursed very soon and OP No.1 got filled the claim form and relevant documents were also taken from the complainant. Thereafter, OP No.2 denied the insurance claim of complainant vide its message dated 05.09.2014 without any reason, which amounts to unfair trade practice and deficiency in service on the part of the OPs. Hence, this complaint for giving directions to the OPs to pay the claim amount of Rs. 2,54,389.93/- along with interest and to pay Rs.2,25,000/- as compensation on account of causing mental pain, harassment and undue litigation.
3. The complaint is contested by the opposite parties. In reply to the complaint the OP No.1 stated that it never approached the complainant to buy Medi-Claim insurance policy from it, rather the complainant has approached it and voluntarily came to its branch and got opened his joint account along with his wife and the bank by opening his account gave the insurance policy after disclosing all the terms and condition to the complainant. It is further stated that all the correspondence with regard to denial as alleged by complainant is with OP No.2, who is to pay the amount, if any, to the complainant as alleged by him. There is no unfair trade practice and deficiency in service on its part. OP No.1 has only acted on behalf of OP No.2 as it has tied up with OP No.1 only for the purpose of selling/disclosing the terms and conditions of the policy and further it depends upon the customer to purchase it or not. There is no liability on the part of OP No.1 to pay any amount as alleged by the complainant. After denying all the other averments made in the complaint, it prayed for dismissal of the complaint.
4. In reply to the complaint OP No.2 stated that the cashless request of the complainant was rejected and he was directed to submit the claim papers for reimbursement after the discharge from the hospital. It is further stated that on receipt of claim papers the claim of the complainant was referred to Medi Assist, who are Third Party Administrator under the policy, which consist of highly qualified professional doctors. The claim lodged with OP No.2 was sent to Medi Assist along with complete treatment papers, bills and discharge summary, who after complete examination of the said claim had came to the conclusion that the claim was not payable under exclusion clause 4.1 and 4.2 of the policy as the claimant was treated by the way of surgery for the heart ailment in the year 2002 prior to the inception of the policy which amounts to pre-existing disease and is not covered under the terms and conditions of the policy. It is further stated that the complainant was admitted at Max Health Care Hospital for the treatment of CAD, Hypertension with Diabetes on 07.07.2014 and was discharged on 15.07.2014. As per terms and conditions of the policy the expenses on treatment of ailment/diseases/surgeries for Hypertension and Diabetes disease for specified period of two years are not payable if contracted and/or manifested during the currency of the policy. Hence, the claim of the complainant was rightly repudiated as per terms and conditions of the policy. After denying the other averments made in the complaint, it prayed for dismissal of the complaint.
5. In order to prove the case, the complainant tendered his affidavit Ex.C-1, copy of premium Chart Ex. C-2, copy of account statement Ex. C-3, copy of proposal form Ex. C-4, copy of claim form Ex. C-7, copy of mobile message dt.05.09.2014 Ex. C-8, copy of email dated 04.07.2014 Ex. C-9, copy of test reports Ex. C-10 and Ex. C-11, copy of letter dated 08.07.2014 Ex. C-12, copy of receipt dated 15.07.2014 Ex. C-13, copy of bill dated 15.07.2014 Ex. C-14 and closed the evidence. In rebuttal the OP No.1 tendered affidavit of Sh. C.S.Mal, Sr. Mananger Ex. OP1/1 and closed the evidence. OP No.2 tendered affidavit of Sh. A.K. Sehgal Ex. OP2/1, affidavit of Dr. Satyakam Bhairma Ex. OP2/2, copy of discharge summary Ex. OP-4, copy of insurance policy with conditions Ex. OP-5, attested copy of repudiation letter Ex. OP-6 and closed the evidence.
6. The ld. counsel for the complainant has submitted that OP No.2 had rejected the medical claim of the complainant not in a bona fide manner but on the arbitrary ground, which is not sustainable in the eye of law. The ld. counsel submitted that the OPs had rejected the claim on the basis that the complainant had undergone a Heart Surgery in the year 2002 and concealment of pre-existing disease amounts to violation of terms and conditions. The ld. counsel pleaded that even if the complainant had undergone a Heart Surgery the said ailment is not connected with the treatment taken of CAD, Hypertension with Diabetes. The ld. counsel argued that it is evident from discharge summary i.e Ex.C-6 that the procedure done on the complainant was “Left internal mammary artery anastomosed to LAD. Individual reversed saphenous vein anastomosed to D1 and OM1.” He further stated that the aforesaid procedure is not at all related with the Heart and nor the same is related to Diabetes and Hypertension. The ld. counsel stated that Ex.OP-4 was required to be proved by examining the witnesses and doctors by the OPs which they have failed, hence, the reason for repudiation of the claim cannot be accepted. He made a submission that the present complaint be accepted and OPs be directed to make the payment for the treatment, as deficiency of services on the part of the OPs stands proved.
7. On the other hand, the ld.counsel for the OP No.1 submitted that complainant opened his joint account alongwith his wife and the OP bank while opening his account gave the insurance policy after disclosing all the terms and condition to the complainant. He further stated that all the correspondence with regard to denial as alleged by complainant is with OP No.2, who is responsible for payment, if any, to the complainant as alleged by him. The ld. counsel pleaded that the present complaint be dismissed qua OP No.1 as no deficiency of service had been proved against it.
8. On the other hand, the ld. counsels for the OP No.2 has stated that the medi-claim could not be paid as per the exclusion clause 4.1 and 4.2 of the policy as the complainant was treated by way of surgery for the heart in the year 2002, prior to the inception of the policy, which amounts to pre-existing disease and is not covered under the terms and conditions of the policy. He submitted that the treatment undergone by the complainant is connected with the Heart. The ld.counsel further stated that it is well established from discharge summary (colly) i.e Ex. OP-4 that complainant was suffering from Diabetes and Hypertension, the concealment of this fact means breach of the contract of insurance.
9. After hearing the Ld. Counsel for the parties and going through the pleadings and evidence produced by them and oral as well as written submissions, we are of the opinion that submission of ld. counsel for the complainant that Ex-OP 4 alongwith the treatment record was required to be proved by examining the witnesses and doctors by the OPs, cannot be accepted as this Forum only adjudicates upon the cases in a summary manner. The Hon’ble State Commission,Punjab in a case Savitri Devi Vs Guru Ram Dass Jee International Airport,2015(3) CLT 415(PB) has observed that “ where the matter cannot be adjudicated without recording elaborate evidence involving cross-examination of witnesses, the complainant be directed to approach competent civil court to seek redressal of her grievance”.
10. Accordingly in view of the aforementioned discussion and the judgment, in our view, we feel that in the present case also elaborate evidence involving cross-examination of witnesses is required for proper adjudication of the case. Thus, we would not like to go into the merits of the case. Hence, the present complaint is disposed of with liberty to the complainant to approach the appropriate Court of law, in case he wishes to prove or lead voluminous evidence and may be entitled to the benefit of the observations of the Supreme Court in Laxmi Engineering Works Vs. P.S.G. Industrial Institute II(1995) CPJ 1 (SC) for the purpose of exclusion of time spent before this Forum. Parties to bear their own cost.
11. The arguments on the complaint were heard on 09.09.2015 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.
Pronounced Dated:21.09.2015
(A.P.S.Rajput)
President
(A. B. Aggarwal)
Member
