DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA

 

Consumer Complaint No. : CC/39/2019

Date of Institution : 22.04.2019

Date of Decision :  23.07.2019

 

Gurmel Singh Sandhu, aged about 65 years, son of Balwant Singh, resident of B-XIII/1574/2, Adarsh Nagar, Court Road, Lakhi Colony, Barnala 14801. 

... Complainant

Versus

1. Punjab National Bank, Handiya Bazar Branch, Barnala through its Branch Manager.

2. The PNB-Oriental Royal Insurance Co. Ltd., Regd. & Head Office at A-25/27, Asif Ali Road, New Delhi 110002 through its General Manager.

3. The PNB-Oriental Insurance Co. Ltd. Divisional Office at 4501, Bank Street, Bathinda 151005 through its Divisional Manager.

4. Raksha Health Insurance TPA Ltd., having its Head Officer at 15/5, Mathura Road, Faridabad 121003 through its General Manager.

5. Raksha Health Insurance TPA Ltd, SCO No. 39, First Floor, Sector 26, Madhya Marg, Above Barbeque Nation, Chandigarh 160019 through its Authorized Signatory. 

…Opposite parties

(Complaint U/s 12 of the Consumer Protection Act, 1986)

QUORUM:

SH.KULJIT SINGH, PRESIDENT

SH. TEJINDER SINGH BHANGU, MEMBER 

COUNSEL FOR THE PARTIES:

 

For complainant : Sh. GS Gill Advocate. 

For OP-1        : Sh. AK Jindal Advocate.

For Ops-2 & 3    : Sh. NK Garg Advocate

For Ops-4 & 5    : Exparte 

Per KULJIT SINGH, PRESIDENT 

1. The present complaint has filed under Section 12 of the Consumer Protection Act, 1986 against OPs on the averments that he purchased PNB-Oriental Royal Mediclaim Insurance Policy No. 233200/ 48/2018/3975 from OP No. 2 on 21.2.2018. First policy was purchased on 09.02.2016, which has continuously been purchased for the consecutive years till date and further upto February 2020. As per said policy the complainant and his wife namely Gurpreet Kaur Sandhu, two daughters namely Yashpritpal Kaur and Isherjyoti Kaur were to receive cashless treatment in case of any ailment suffered by them. He further submitted that previous treatment was given from 06.11.2018 to 10.12.2018 to the complainant by Dr. Dinesh Garg of Advanced Centre for Eyes, Ludhiana and complainant was advised to visit for subsequent treatment after two week for which complainant reported to the said hospital on 1.1.2019 who admitted the complainant in the said hospital on 1.1.2019 and his left eye was operated and he was discharged on 2.1.2019 and charged an amount of Rs. 12,100/- i.e. Rs. 500/- vide receipt dated 1.1.2019 and Rs. 11,200/- vide receipt dated 2.1.2019. The above said policy was shown to Dr. Dinesh Garg of Advanced Centre for Eyes, Ludhiana who told that the complainant could get the reimbursement for his TPA. The complainant lodged his claim No. 55651819382052 with OP No.5 for Rs. 12,100/- along with all original documents and bills but OP no.3 repudiated his claim vide letter dated 27.02.2019 on fake ground. He made repeated requests to OPs for reimbursement the amount spent by him on his treatment. But OPs refused to settle his claim. Therefore, he has filed the present complaint and prayed that OPs be directed to refund the amount of Rs.12,100/- spent on his treatment, besides Rs.1,80,000/- on account of metal agony and harassment suffered by him and Rs.50,000/- as litigation expenses.

2. Upon notice, OP no.1 appeared and filed written reply and contested the complaint of the complainant by raising preliminary objections that the complainant has got no locus standi or cause of action to file the complaint. OP no.1 is not in business of insurance nor under law it carries on the business of insurance. Therefore, OP no.1 is not liable to pay any amount. This Forum has no jurisdiction to entertain and adjudicate upon the dispute involved in the complaint. The dispute raised by the complainant in the complaint is manifestly outside the purview of the said Act. On merits, it was averred that OP has no concern whatsoever with the alleged insurance claim of the complainant. OP no.1 stated that it is only a facilitator/corporate agent merely introducing the parties only. OP no.1 denied all averments of the complainant and it prayed for dismissal of the complaint.

3. OPs no.2 and 3 filed separate written reply and contested the complaint of the complainant by raising preliminary objections that complainant has got no locus standi or cause of action to file the complaint. The complaint is not maintainable. The complaint in question is misconceived, malafide and not maintainable. On merits, it was averred that the complainant was not admitted in the hospital more than 24 hours, which is clear cut violation of the policy clause 2.5. The complainant is not entitled to any relief as claimed and OPs No. 2 and 3 prayed for dismissal of the complaint. 

4. OPs no.4 and 5 not appeared despite service, as such they are proceeded against exparte, vide order dated 09.07.2019 passed by this Forum.

5. The complainant has tendered in evidence his affidavit Ex.C-1 along with copies of documents Ex.C-2 to Ex.C-17 and closed the evidence. As against it; OPs no.2 and 3 tendered in evidence copy of terms and conditions as Ex.OP-2.3/1 and closed the evidence. The opposite party No. 1 has not tendered any evidence on record. 

6. We have heard learned counsel for the parties and have also examined the record of the case. 

7. The complainant averred that he has purchased the PNB-Oriental Royal Mediclaim Insurance Policy from OP no. 2, vide policy no. 233200/48/2018/3975 on 21.02.2018. The first policy was purchased on 09.02.2016, which will be continuing till February 2020. As per the said policy, the whole family of the complainant was entitled to receive cashless treatment in case of any ailment suffered by them. He further deposed in his affidavit Ex.C-1 that complainant reported to the said hospital on 1.1.2019 who admitted the complainant in the said hospital on 1.1.2019 and his left eye was operated and he was discharged on 2.1.2019 and charged an amount of Rs. 12,100/- i.e. Rs. 500/- vide receipt dated 1.1.2019 and Rs. 11,200/- vide receipt dated 2.1.2019. The above said policy was shown to Dr. Dinesh Garg of Advanced Centre for Eyes, Ludhiana who told that the complainant could get the reimbursement for his TPA. The complainant lodged his claim No. 55651819382052 with OP No.5 for Rs. 12,100/- but OP no.3 repudiated his claim vide letter dated 27.02.2019. On the other hand, OPs repudiated the claim of the complainant on the ground that he was not admitted in the hospital more than 24 hours, which is clear cut violation of the policy clause 2.5.

8. We have considered the affidavit of the complainant Ex.C-1 along with copies of documents Ex.C-2 to Ex.C-17. To refute this evidence of the complainant, OPs no.2 and 3 tendered terms and conditions of the policy. The complainant reported the matter to Dr. Dinesh Garg of Advanced Centre for Eyes Ludhiana, who admitted him and operated upon the left eye and discharged on 02.1.2019. The hospital charged Rs.12,100/- for this purpose from him. The complainant purchased policy on 09.02.2016, which was up to February 2020. So, it was clear that the treatment of left eye of complainant was operated within the currency period of the policy. 

9. As per exclusion clause 2.5 of the insurance policy terms and conditions Ex.OP-2.3/1 the patient have required hospitalization of more than 24 months. Treatment normally taken on an outpatient basis is not included in the scope of this definition.

“Clause 2.5 DAY CARE TREATMENT:- Day care treatment refers to medical treatment and or/surgical procedure which is 

i) undertaken under General or Local Anesthesia in a hospital/day care centre is less than 24 hrs because of technological advancement and,

ii) which would have otherwise required a hospitalization of more than 24 hours. 

Treatment normally taken on an outpatient basis is not included in the scope of this definition.

10. From Ex.C-12 it is clear that complainant received treatment from 01.1.2019 to 02.01.2019 and amount of Rs.12,100/- has been charged from complainant for this treatment. As per document Ex.C-14 AMRD drug like avastin or lucentis or macugen and other related drugs is given as intravetral injection, which is not payable on OPD basis neither in hospitalization. But in the present case, the complainant reported to Dr. Dinesh Garg of Advanced Centre for eyes Ludhiana and operated upon left eye of the complainant on 1.1.2019 and discharged from the hospital on 02.1.2019. But OP wrongly repudiated the claim of the complainant. As per Ex.C-8 Dr. Dinesh Garg (MD) of Advanced Centre for Eye prescribed the below noted prescriptions :-

· Do note rub the eye

· Do not bend below the waist.

· Do not wash face for two days.

· Control your blood sugar if you are diabetic.

· Inform in case of any pain, redness, diminision of vision or swelling of the eyes etc.

· Review after 7 days /SOS/as advised.

Ex.C-10 is discharge summary, from this document it is clear that the complainant admitted in the hospital on 01.01.2019 and discharged on 02.01.2019. From this document, it is clear that complainant was admitted in the above said hospital for one day. But OP no.2 and 3 submitted in para no.3(b) of the written statement that complainant was not admitted in the hospital more than 24 hours, which is clear violation of the policy clause 2.5. In Clause 2.5 of the Insurance Policy, it is clear that “patient normally taken on an out-patient basis is not included in the scope of this definition.” But in this case, the patient is indoor patient and not outdoor patient, it was cleared from Ex.C-10 discharge summary placed on record. As per document Ex.C-5 surgery/procedure : INJ Avastin L/E Under LA was operated upon the complainant. The definition of Avastin L/E is as under :-

“A drug used alone or with other drugs to treat certain types of cervical, colorectal, lung, and kidney cancer, and glioblastoma (a type of brain cancer). It is also used to treat certain types of ovarian epithelial, fallopian tube, and primary peritoneal cancer. Avastin is also being studied in the treatment of other types of cancer. It binds to a protein called vascular endothelial growth factor (VEGF). This may prevent the growth of new blood vessels that tumors need to grow. Avastin contains the active ingredient bevacizumab. It is a type of antiangiogenesis agent and a type of monoclonal antibody.”

Avastin (uh-VAS-tin) A drug used alone or with other drugs to treat certain types of cervical, colorectal, lung, and kidney cancer, and glioblastoma (a type of brain cancer). It is also used to treat certain types of ovarian epithelial, fallopian tube, and primary peritoneal cancer.

11. In view of case law laid down by Hon’ble Allahabad High Court in case titled as Smt. Santosh Kumari and others versus Santosh Kumari and others, decided on 20.03.2018, wherein it has been held that insurance company is liable to pay the claimants the insurance amount. As per rules and regulations of IRDA, Insurance company do not reject the claim on the basis of exclusions relating to genetic disorder. Hon’ble Supreme Court in case titled as Rani and others versus National Insurance Company and others, reported in Civil Revision No. 9078-79 of 2017 directed the insurance company to pay the compensation amount to the respective claimant as determined by Hon’ble Court or Tribunal.

12. It is established fact the complainant has purchased the insurance policy in question bearing no. 233200/48/2018/3975 from OP no. 2 but other OPs lingered on the matter on one pretext or the other, but OPs are liable to pay the insured amount, as per terms and conditions of OPs.

13. There is no material evidence produced on record by counsel for OPs that repudiation of the insurance claim of the complainant is justified. OPs have failed to produce anything in support of their case whether the treatment of the complainant is within currency period of the policy or not. This act of OPs proves clear cut deficiency in service and unfair trade practice on the part of OPs. 

14. In the light of our above discussion and citations as mentioned above, we allow the complaint of the complainant against the opposite parties No. 2 and 3 and OPs no.2 and 3 are directed to refund the amount of Rs.12,100/- to the complainant which has been spent by complainant on his treatment, jointly and severally. The opposite parties No. 2 and 3 are also directed to pay Rs. 2,000/- as compensation to the complainant on account of mental tension and harassment and Rs. 1,000/- as cost of litigation. Compliance of the order be made within a period of one month from the date of the receipt of copy of this order. Copies of the order be supplied to the parties free of costs. File be indexed and consigned to record room after due compliance. 

  ANNOUNCED IN THE OPEN FORUM:

23rd Day of July 2019

 

 

 

            (Kuljit Singh)

           President

 

 

           (Tejinder Singh Bhangu)                Member