Haryana

Yamunanagar

CC 941/2010

Pardeep Singh S/o Jasbir Singh - Complainant(s)

Versus

Reliance General Insurance Co.Ltd. - Opp.Party(s)

M.L.Bansal

16 Nov 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                       Complaint No… 941  of 2010.

                                                                                       Date of institution: 6.10.2010.

                                                                                       Date of decision: 16.11.2015

Pardeep Singh Chauhan, aged 40 years son of Sh. Jasbir Singh, resident of Vill. Tapu Kamal Pur, P.O. Kalanour, Tehsil Jagadhri, Distt. Yamuna Nagar.    

                                                                                                           …Complainant.

                                    Versus

 

1. Reliance General Insurance Co. Ltd. through Kulbir Rana, Rana Agency, Near Kamani Chowk, Yamuna Nagar.
2. Reliance General Insurance Co. Ltd. S.C.O. No. 145-146, Top Floor, above VLCC, Sector-9C, Chandigarh.
3. Reliance General Insurance Co. Ltd. 570, Naigaum Cross Road, Next to Royal Industrial Estate, Wadala (W) Mumbai-400031.      

 

                                                                                                         …opposite parties.

                        Complaint under section 12 of       

                        the Consumer Protection Act.

 

CORAM:         SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

 

Present:  Sh. M.L.Bansal, Advocate, counsel for complainant.   

               Sh. Rajiv Gupta, Advocate, counsel for OPs.       

             

 

ORDER

 

1.                     Complainant Pardeep Singh filed this complaint under section 12 of the Consumer Protection Act 1986 praying therein that respondents (hereinafter referred as OPs) be directed to pay an amount of Rs. 10,000/- alongwith interest on account of medical claim and further to pay Rs. 50,000/- as compensation and Rs. 11,000/- as litigation expenses.

2                      Brief facts of the present complaint as alleged by the complainant are that complainant is having a family health medical insurance policy bearing No. 282510394086 issued by OPs for the period from 24.2.2009 to 23.2.2010 and paid a sum of Rs. 2736/- as premium. OPs had appointed medi-Assist Third Party Administrator (TPA) for settlement of the claims. In the month of January 2010, the complainant met with an accident and his wrist was fractured and due to this, he remained admitted from 25.1.2010 to 27.1.2010 in the Mahajan Hospital, Yamuna Nagar and plaster was done on the wrist of the complainant and complainant spent about Rs. 10,000/- on his treatment. The complainant, then lodged his medi claim for the amount spend on his above treatment and completed all the necessary formalities but his claim was repudiated vide impugned repudiation letter dated 7.4.2010 (Annexure R-3) mentioning as under:

                        We confirm receipt of your claim as per the reference given above. We state our inability to admit liability due to the following reasons.

Exclusion clause 21- Any stay in a hospital without undertaking any treatment or where there is no active regular treatment by the medical practitioner.

            Definition Clause 10- Insured who is admitted to Hospital/ Nursing Home and stays for at least 24 hours for the sale purpose of receiving treatment.

“ On perusal of the claim documents it is found that claimant covered under the above mentioned policy was admitted in Mahajan Hospital for the treatment of fracture of right wrist with fracture radius lower 1/3 on 25.01.2010 and discharged on 27.01.2010. It is observed that procedure (application of plaster of paris) performed does not require 24 hours of hospitalization. Hence we regret our inability to admit this liability under the present policy conditions. Therefore, this claim is being repudiated under Exclusion 21 and Definition-10 and the same are not payable. We also reserve the right to repudiate the claim under any other grounds available to the subsequently.”

3.                     Pleading aforesaid repudiation of his claim, deficiency in service on the part of OPs, the complainant has lodged this complaint on 6.10.2010 for a direction to opposite parties for the payment of his medical expenses of near about Rs. 10,000/- with up to date interest, besides damages for his harassment and litigation expenses.

4.                     Justifying the repudiation of the claim of the complainant, it is pleaded by the opposite parties, in their reply, that as per the record, submitted by the complainant himself, the claim was duly processed by the TPA Medi Assist India Private Ltd. and on the basis of medical document taking into account the terms and conditions of the insurance policy found that claim was not payable as per exclusion clause No.21 – “Any stay in a hospital without undertaking any treatment or where there is no active regular treatment by the medical practitioner.  Further as per Definition  10 of the policy- the insured means who is admitted to Hospital/ Nursing Home and stays for at least 24 hours for the sale purpose of receiving treatment.” It was observed by the TPA that the procedure (application of plaster of paris) performed does not require 24 hours of hospitalization. Therefore, the claim was rightly repudiated by the OPs and lastly prayed as there is no deficiency in service on the part of OPs. Hence the complaint is liable to be dismissed.

5.                     To prove the case, counsel for the complainant tendered into evidence affidavit of complainant as Annexure CW/A and documents such as Photo copy of Insurance Policy as Annexure C-1, Photo copy of discharge slip of Mahajan Hospital as Annexure C-2, Photo copy of hospital bill amounting to Rs. 4800/- as Annexure C-3,  Photo copies of medicines bills as Annexure C-4 & C-5 and closed the evidence on behalf of complainant.

6.                     On the other hand, counsel for the OPs tendered into evidence affidavit of Krishna Kant, Manager (Legal) Reliance General Insurance as Annexure RW1/A and documents such as Photo copy of Insurance Policy alongwith terms and conditions as Annexure R.1, Photo copy of claim form submitted by complainant as Annexure R-2, Photo copy of repudiation letter Annexure R-3 and closed the evidence on behalf of OPs.

7.                     We have heard the counsels of both the parties and have gone through the pleadings as well as documents placed on the file carefully and minutely. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OPs reiterated the averments made in the reply and prayed for dismissal of complaint.

8.                      It is not disputed that OPs have not issued the family medical insurance policy w.e.f. 24.2.2009 to 23.2.2010 and charged a sum of Rs. 2737/- as premium vide insurance policy bearing No. 282510394086. It is also not disputed that complainant remained admitted in the Mahajan Hospital, Yamuna Nagar w.e.f. 25.1.2010 to 27.1.2010 and the plaster was done on the wrist of the complainant.  The only plea of the OPs that any stay in the hospital without undertaking any treatment or where there is no active regular treatment by the medical practitioner is not payable and further the application for plaster of Paris performed does not require 24 hours of hospitalization is not tenable. It is the case of the complainant that he met with an accident and due to that accident he remained admitted in Mahajan Hospital w.e.f. 25.1.2010 to 27.1.2010 i.e. for 3 days and spent near about Rs. 10,000/- on his treatment. From the perusal of Annexure C-2 discharge slip of Mahajan Hospital, it is evident that complainant suffered multiple fractures on right wrist and fracture radius lower 1/3 of right wrist and was treated conservatively and plaster of paris was done. So, it cannot be said that it was a simple case where no admission in the hospital was not required. Even the OPs failed to file any affidavit of any doctors of the TPA to prove the contention raised by the OPs in their letter.

9.                     The insurance companies in India with a view to escape and avoiding its legal and factual liabilities to make the payment of sum assured are fake acting in dramatically,  opposite of the principle of fairs play and decency and in that series it is not even caring that its wrongly actions are causing wrongful losses to their customers. In the present case instead of acting fairly the insurance company is trying to avoid from its liability by making false pretext, which cannot be allowed to do so.

10,                   After going through the above noted facts, we are of the considered view that the genuine claim of the complainant has been illegally repudiated by the OPs company. So, there is a clear cut deficiency in service on the part of OPs. Hence, the complainant is entitled for relief.

11.                   The contention of the complainant that he has spent Rs. 10,000/- on his treatment and is entitled to get the same from the OPs is not tenable as the complainant filed only medical bills of amounting to Rs. 4800/-, Rs. 605/- and Rs. 537/- Annexure C-3, C-4 and C-5 respectively i.e. total amounting to Rs. 5942/- except these bills complainant has not filed any other documents to prove the expenses to the tune of Rs. 10,000/-. Hence, he is entitled only for  a sum of Rs. 5942/-.

11.                   Resultantly, we partly allow the complaint of complainant and direct the OPs to pay medical expenses to the tune of Rs. 5942/- ( Rs. 4800/-+600+537= 5937/-) alongwith interest at the rate of 9% per annum from the date of repudiation of claim i.e. 7.4.2010 till its realization and also to pay a sum of Rs. 2000/- as compensation for mental agony, harassment as well as Rs. 1000/-  as litigation expenses. Order be complied within 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court.16.11.2015.                

                                                                                    (ASHOK KUMAR GARG )

                                                                                    PRESIDENT,

                                                                                     

 

                                                                                    (S.C.SHARMA )

                                                                                     MEMBER.