Haryana

Kaithal

192/19

Preeti Ahuja - Complainant(s)

Versus

PNB Oriental Insurance Co. - Opp.Party(s)

Sh.Munish Sikri

16 May 2023

ORDER

               

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.

                                                     Complaint Case No.192/2019.

                                                     Date of institution: 08.07.2019.

                                                     Date of decision: 16.05.2023.

Preeti Ahuja age 29 years wife of Sh. Jitesh Ahuja, r/o H.No.414/8, Kirpal Cottage, Siwan Gate, Kaithal.

                                                                        …Complainant.

                        Versus

1. PNB Oriental Insurance Company Limited, Subarval Market, Railway Road, Kurukshetra through its Branch Manager.
2. Punjab National Bank, Ambala Road, Kaithal through its Branch Manager.
3. The Raksha Health Insurance TPA Pvt. Ltd., C/o Escort Corporate Centre, 15/5 Mathura Road, Faridabad, Haryana-121003, through its authorized person.

 

….Respondents.

        Complaint under Section 12 of the Consumer Protection Act

CORAM:     SMT. NEELAM KASHYAP, PRESIDENT.

                SMT. SUMAN RANA, MEMBER.

                SH. SUNIL MOHAN TRIKHA, MEMBER.

       

Present:     Sh. Munish Sikri, Advocate, for the complainant.   

                Sh. P.P.Kaushik, Advocate for the OP No.1.

                Sh. Dinesh Dhull, Adv. for the OP No.2.

                OP No.3 exparte.

               

ORDER

NEELAM KASHYAP, PRESIDENT

        Preeti Ahuja-Complainant has filed this complaint under Section 12 of Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the respondents.

2.             In nutshell, the facts of present case are that the OP No.1 had issued a medical health policy bearing No.261303/48/2016/581 dt. 06.07.2015 for an amount of Rs.2,00,000/- and complainant has renewed the same from time to time and now the OP No.1 has issued the family health policy No.261303/48/2019/674 dt. 11.07.2018 for a sum of Rs.5,00,000/-.  Due to some multiple joint pain of the upper and lower limb of the husband of complainant, the husband of complainant was admitted in Cygnus Hospital, Kaithal and the doctor has issued a bill of Rs.21,551/-.  The complainant lodged the claim with the OP No.1 and submitted all the necessary documents but the OP No.1 has repudiated the claim of complainant vide letter dt. 17.01.2019 on the ground that there is no active line of management.  The said repudiation of claim is stated to be wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of respondents and prayed for acceptance of complaint.     

3.          Upon notice, the OPs No.1 & 2 appeared before this Commission, whereas OP No.3 did not appear and opted to proceed against exparte vide order dt. 18.03.2021 passed by this Commission.  OPs No.1 & 2 contested the complaint by filing their written version separately.  OP No.1 filed the written statement raising preliminary objections with regard to locus-standi; maintainability; cause of action; that the complainant has concealed the true and material facts from this Commission.  In fact as per medical record provided by the complainant, the claim of complainant is not covered under the terms and conditions of insurance policy.  The claim of complainant was rightly repudiated by the competent authorities on the recommendation of Raksha Health Insurance TPA Pvt. Ltd. by observations that “CASE OF ACUTE LBA WITH LEFTRADICULOPATHY MANAGED CONSERVATIVELY.  THERE IS NO ACTIVE LINE OF MANAGEMENT.  ADMISSION ONLY FOR EVALUATION IS NOT PAYABLE AS PER POLICY TERMS AND CONDITIONS.  SO THE CLAIM IS RECOMMENDED TO BE NON PAYABLE AS PER CLAUSE 4.10.  There is no deficiency in service on the part of respondents.  On merits, the objections raised in the preliminary objections are rebutted and so, prayed for dismissal of complaint.

4.             OP No.2 filed the written statement raising preliminary objections with regard to maintainability; locus-standi; cause of action; that the answering OP has deducted the premium amount from the account of complainant for the benefit of the medical health and the OP No.2 has paid the premium amount to the OP No.1 under the scheme of Medical Health Policy.  The OP No.1 is bound to make the payment of the claim under the Medical Health Scheme of the Govt.  There is no deficiency in service on the part of respondents.  On merits, the objections raised in the preliminary objections are rebutted and so, prayed for dismissal of complaint.

5.             To prove his case, the complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C34 and thereafter, closed the evidence.

5.             On the other hand, the OP No.2 tendered into evidence affidavit Ex.RW2/A alongwith document Annexure-R1, OP No.1 tendered into evidence affidavit Ex.RW1/A alongwith documents Annexure-R2 to Annexure-R6 and thereafter, closed the evidence.

6.             We have heard the learned Counsel for both the parties and perused the record carefully.

7.             Ld. counsel for the complainant has argued that initially, the OP No.1 had issued a medical health policy bearing No.261303/48/2016/581 dt. 06.07.2015 for an amount of Rs.2,00,000/- and complainant has renewed the same from time to time and now the OP No.1 has issued the family health policy No.261303/48/2019/674 dt. 11.07.2018 for a sum of Rs.5,00,000/-.  It is further argued that due to some multiple joint pain of the upper and lower limb of the husband of complainant, the husband of complainant was admitted in Cygnus Hospital, Kaithal and the doctor has issued a bill of Rs.21,551/-.  The complainant lodged the claim with the OP No.1 and submitted all the necessary documents but the OP No.1 has repudiated the claim of complainant vide letter dt. 17.01.2019 on the ground that there is no active line of management.  The said repudiation of claim is stated to be wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of respondents.

8.             On the other hand, ld. counsel for the OP No.1 has argued that the claim of complainant was rightly repudiated by the competent authorities on the recommendation of Raksha Health Insurance TPA Pvt. Ltd. by observations that “CASE OF ACUTE LBA WITH LEFTRADICULOPATHY MANAGED CONSERVATIVELY.  THERE IS NO ACTIVE LINE OF MANAGEMENT.  ADMISSION ONLY FOR EVALUATION IS NOT PAYABLE AS PER POLICY TERMS AND CONDITIONS.  SO THE CLAIM IS RECOMMENDED TO BE NON PAYABLE AS PER CLAUSE 4.10.

9.             Ld. counsel for the OP No.2 has argued that OP No.2-bank has deducted the premium amount from the account of complainant for the benefit of the medical health and the OP No.2 has paid the premium amount to the OP No.1-insurance company under the scheme of Medical Health Policy.  It is further argued that the OP No.1 is bound to make the payment of the claim under the Medical Health Scheme of the Govt.

10.            We have considered the rival contentions of both the parties.  The OP No.1 has taken the objection that the husband of complainant had taken treatment in Cygnus Hospital, Kaithal and there was no disease diagnose, so, the OP No.1 is not liable to pay any hospitalization expenses incurred by the husband of complainant.  He has further argued that the claim of complainant was rightly repudiated vide letter dt. 17.01.2019 as per Annexure-R3 on the ground that THERE IS NO ACTIVE LINE OF MANAGEMENT.  ADMISSION ONLY FOR EVALUATION IS NOT PAYABLE AS PER POLICY TERMS AND CONDITIONS.  SO THE CLAIM IS RECOMMENDED TO BE NON PAYABLE AS PER CLAUSE 4.10.  To rebut the said contention of ld. counsel for the OP No.1, ld. counsel for the complainant has drawn our attention towards the policy Annexure-C30, relevant portion of which is mentioned as under:-

“The policy shall pay for hospitalization expenses for medical/surgical treatment at any Nursing Home/Hospital in India as an in-patient defined in the policy. 

In the event of a claim under the policy exceeding Rs.1 lac or a claim for refund of premium exceeding Rs.1 lac, the insured will comply with the provisions of the AML policy of the Company.  The AML policy is available in all our operating offices as well as Company’s website.”

11.            As per treatment record Annexure-R7, it is clear that the husband of complainant namely Jitesh Ahuja was admitted in Cygnus Super Speciality Hospital, Kaithal on 12.09.2018 and was discharged on 15.09.2018, the abstract of which is mentioned as under:-

        “Chief Complaint:        Polyarthralgia

        History of present illness: PATIENT WAS ADMITTED DIFFUSE POLCYARTHRALGIA, BOTH UPPER AND LOWER LIMBS FROM LAST 03 WEEKS WITH C/O ACUTE LBA WITH LEFT RADICULOPATHY.”

                So, from the aforesaid treatment record, it is clear that the husband of complainant had taken treatment as indoor patient in Cygnus Hospital, Kaithal regarding joint pain in upper and lower limb.  Hence, we are of the considered view that the OP No.1 has wrongly repudiated the claim of complainant.  In the present case, the complainant has claimed the bills amounting to Rs.21,551/-.  Out of bills placed on file by the complainant, some bills are placed on file by the complainant prior to admission for the period 12.09.2018 to 15.09.2018 in Cygnus Hospital, Kaithal.  The said bills are dt. 22.08.2018 amounting to Rs.673/- as per Annexure-C20, bill dt. 17.08.2018 amounting to Rs.235/- as per Annexure-C21, the bill dt. 17.08.2018 amounting to Rs.2850/- as per Annexure-C22 and bill dt. 25.08.2018 amounting to Rs.1750/- as per Annexure-C23 and total amounting to Rs.5508/-.  So, the complainant is not entitled for reimbursement of said bills amounting to Rs.5508/- and she is entitled for the amount of Rs.16,043/- (Rs.21,551/- minus Rs.5508/- as per bills Annexure-C20 to Annexure-C23 mentioned above).

12.            Thus, as a sequel of aforesaid discussion, we direct the OP No.1-insurance company to pay the amount of amount of Rs.16,043/- to the complainant within 45 days from today and further to pay Rs.5,000/- as compensation on account of physical harassment and mental agony as-well-as Rs.5,000/- as litigation charges to the complainant.  It is also made clear that if OP No.1-insurance company is failed to pay the aforesaid awarded amount of Rs.16,043/- to the complainant within stipulated period, then they shall be liable to pay interest @ 7% p.a. from the date of this order till its realization.  Hence, the present complaint is accepted according against OP No.1-insurance company and dismissed against Ops No.2 & 3.                          

13.            In default of compliance of this order, proceedings against respondent-OP No.1 shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both.  A copy of this order be sent to both the parties free of cost.  File be consigned to the record room after due compliance.     

Announced in open court:

Dt.:16.05.2023.

                                                                (Neelam Kashyap)

                                                                President.

(Sunil Mohan Trikha),           (Suman Rana),          

Member.                            Member.

 

Typed by: Sanjay Kumar, S.G.