Chandigarh

DF-II

CC/306/2018

Kuldip Singh Rajput - Complainant(s)

Versus

Punjab National Bank - Opp.Party(s)

Advocate Devinder Kumar

12 Dec 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	306 of 2018
Date  of  Institution	:	30.05.2018
Date   of   Decision	:	12.12.2018

 

 

 

 

Kuldip Singh Rajput son of Sh.Kishan Chand, aged about 70 years, r/o H.No.64/1, Sunny Enclave, Sector 125, Kharar, District Mohali.       

 

             ……..Complainant

 

Versus

 

1]  Punjab National Bank, Ropar Road, Kharar, through its Branch Manager.

 

2]  The Oriental Insurance Company Limited, Sai Market, Lower Mall, Patiala through its Branch Manager.

 

3]  Raksha TPA Private Limited, 15/5, Mathura Road, Faridabad, Haryana through its Managing Director.

 

4]  Raksha TPA Private Limited, SCO No.359-360, First Floor, Sector 44-D, Chandigarh through its Branch Manager

 

………. Opposite Parties

 

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

SMT.PRITI MALHOTRA        MEMBER

            SH.RAVINDER SINGH         MEMBER

 

Argued By: Sh.Devinder Kumar, Adv. for Complainant.

Sh.Ram Avtar, Adv. for OP No.2

OPs No.1,3 & 4 exparte.

 

 

PER PRITI MALHOTRA, MEMBER

 

         The case of the complainant, in brief is that, he purchased a PNB-Oriental Royal Mediclaim Policy through Opposite Party No.1 valid from 22.7.2016 to 21.7.2017 (Ann.C-1).  It is averred that the complainant is continuously renewing the Medical Policy from the OPs since 2013. 

         It is averred that in April, 2017, the wife of complainant suffered vision problem termed as Diplopia problem on the right eye and as such consulted M/s Mirchia Eye Hospital, Sector 22, Chandigarh, who referred her to Neurologist in Max Hospital.  Accordingly, the complainant got treatment from Max Hospital and remained admitted there on 19.4.2017 and was discharged on 20.4.2017.  It is also averred that the complainant spent an amount of Rs.63,561/- on the said treatment.  The complainant submitted a claim with the OPs along with all requisite documents, but the Opposite Parties kept on delaying the matter on one pretext or other.  Ultimately, after persuasion, the OPs processed the claim and illegally repudiated the same vide email dated 17.3.2018 (Ann.C-9) on the ground that no active treatment was done during the claimed hospitalization. Alleging the said repudiation as illegal and deficiency in service, hence this complaint has been filed.

 

2]       The Opposite Party No.2 has filed reply and while admitting the factual matrix of the case, stated that the documents submitted by the complainant were thoroughly examined by TPA and after going through the same, it was observed that the patient was admitted for 6^th nerve palsy/diplopia with diabetes mellitus and underwent treatment with investigation only.  It is stated that as per observations of TPA, no active treatment was done during the claimed hospitalization and in this situation, the claim was not payable and recommended for repudiation as per terms of the policy.  It is also stated that the claim of the complainant has rightly been repudiated as per terms of the policy.  Pleading no deficiency in service and denying other allegations, the OPs NO.2 has prayed for dismissal of the complaint. 

 

        The OPs No.1, 3 & 4 did not turn up despite service of notice sent through regd. post on 7.6.2018, hence they were proceeded exparte vide order dated 2.8.2018.

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of Opposite Party No.2 made in reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the complainant, ld.Counsel for Opposite Party No.2 and have perused the entire record.

 

6]       It is an evident fact that complainant, covered under the policy PNB-Oriental Royal Mediclaim Policy, issued by Opposite Party No.2 for the period from 22.7.2016 to 21.7.2017 (Ann.C-1), was diagnosed with 6^th nerve palsy/diplopia during the subsistence period of the policy.  Discharge Summary (Ann.C-3) further divulge that the complainant remained admitted in the Hospital for One day and was thereafter discharged with further advice to follow-up.  The copy of the bills placed on record reveals that the complainant paid an amount of Rs.60,055/- for the period she remained under hospitalization and further copies of bills Ann.C-3 (Colly.) reveals that the complainant, as per advice of the treating doctor, followed up the treatment and for the same also spent certain amount.

 

7]       The dispute between the parties cropped up when the claim raised by the complainant with Opposite Party No.1 for reimbursement under the policy issued by it was repudiated.  The reason assigned to refuse the claim of the complainant is highly unrealistic.  Record, in particular the repudiation letter reveals that the claim was rejected for the reason that the complainant was not given any active treatment during her stay in the Hospital (whereas the record reveals otherwise). This reason for repudiation in itself projects the malfunctioning of the system of insurance company showing its inclination to repudiate the claim without giving any second thought and also without going through the genuinity of the claim raised.  In the given case in hand, how it can be presumed that the person, who was diagnosed with the problem of Diplopia, will not be given any treatment when she was especially advised for the admission in the Hospital.  The perusal of the terms & conditions of the policy in question nowhere defines the term “active treatment”, so how can the insurance company reject the claim when the insured was not only remained admitted, but was further treated for the diagnosed Diplopia and was discharged with advice to further follow-up.  It is only the qualified doctor, who is eligible to decide about the course of treatment to be given for the treatment of particular ailment. The procedure adopted for the treatment of the disease suffered by the complainant is sufficient enough to establish that the complainant was hospitalized not only for any investigation purposes, but was after being thoroughly investigated, was diagnosed and treated for Diplopia.  However, it is also not the case of the complainant that the disease suffered by the insured falls under any exclusion clause, so, the repudiation of the genuine claim of the complainant, in the present complaint, is a clear cut case of deficient services rendered by the OP No.2, 3 & 4. 

 

8]       In view of the above discussion & findings, the present complaint is allowed against the Opposite Parties No.2, 3 & 4 with following directions:-

1. To reimburse the claim amount of Rs.63,561/- to the complainant along with interest @9% p.a. from the date of filing the complaint i.e. 30.6.2018 till realization;
2. To pay an amount of Rs.10,000/- as compensation for causing harassment & mental agony to the complainant on account of deficient services;
3. To pay an amount of Rs.5000/- towards litigation expenses.

 

         This order be complied with by the Opposite Parties No.2, 3 & 4 jointly & severally within a period of 30 days from the date of receipt of its certified copy, failing which they shall also be liable to pay additional cost of Rs.15,000/- apart from the above relief.

 

9]       However, the complaint qua Opposite Parties No.1 stands dismissed.

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

12^th December, 2018                                                              Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER