Haryana

Yamunanagar

CC/857/2010

Sushma Devi W/o Pardeep 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… 857  of 2010.

                                                                                       Date of institution: 14.9.2010.

                                                                                       Date of decision: 16.11.2015

Smt. Sushma Devi wife of Sh. Pardeep Singh Chauhan, aged about 38 years resident of Vill. Tapu Kamal Pur,  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 Smt. Sushma Devi 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. 15,000/- towards expenditure incurred on the treatment and further to pay Rs. 1, 50,000/- as compensation for mental agony harassment to the complainant alongwith interest as well as cost of proceedings.

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. On 21.8.2009, the complainant felt pain in her abdomen and she was taken to Masih Hospital, Yamuna Nagar where she remained admitted from 21.8.2009 to 23.8.2009 but when no relief was felt by the complainant she was taken to Dr. Sanjiv Ahuja MBBS (MS) of Aarogyam Centre Yamuna Nagar, but no relief was felt by the complainant so she was admitted in S.P. Infertility and Surgical Centre Pvt. Ltd. on 9.9.2009 and was discharged on 13.9.2009 vide IP No. 869/09. As per Annexure C-13 discharge slip the Doctor diagnosed the complainant with “Colitis” and in the history, it has been clearly mentioned regarding complaint of pain abdomen one week. Thereafter, the complainant lodged the claim with the OPs through OP No.1 but she received a letter dated 12.5.2010 reference No. 4570432 from TPA Medi Assist that the claim of the complainant has been repudiated on false and flimsy ground which is great deficiency in service and unfair trade practice on the part of OPs. Hence, this complaint.

3.                     Upon notice, OPs appeared and filed their written statement jointly by taking some preliminary objections such as complaint is not maintainable, no negligence or deficiency in service on the part of OPs and on merit it has been submitted that the complainant lodged a claim with the OPs under Family Medi Claim Policy in question and the claim was duly processed by TPA MEDI ASSIST India Pvt. Ltd. The said TPA on the basis of medical documents submitted by the complainant and after taking into account the terms and conditions of the insurance policy found that the claim was not covered under the terms and conditions of the Insurance Policy. As per exclusion clause No.22 of the Policy, “Treatment of mental disease/illness, stress, psychiatric or psychological disorder is not covered under the policy”. Further as per procedure 3, the company requires the insured to deliver the claim papers to the TPA at their own expenses within 30 days of the insured discharge from the hospital (for post hospitalization expenses, completion of post hospitalization period of completion of treatment, whichever is earlier) Besides this, as per policy condition No.6 the insured person shall keep an accurate record containing all relevant particulars regarding his/her health and shall allow the company to inspect such record. The insured person shall furnish such information as the company may require within one month. In the present case, complainant was admitted in Masih Hospital & S.P. Infertility & Surgical Centre and diagnosed as having emotional attack, headache, backache and colitis. As per discharge & other documents, it is evident that the claimant was suffering from Psychiatric illness. The claimant was discharged on 13.9.2009 whereas the claim documents were submitted on 5.12.2009 with delay of two months. 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.

4.                     To prove the case, counsel for the complainant tendered into evidence affidavit of complainant as Annexure CW/A and documents such as Photo copies of Medicine bills as Annexure C-1 to C-3, C-5 to C-10, Photo copy of detailed bill of Dr. Aditya Goel as Annexure C-4, Photo copy of charge slip of Masih Hospital as Annexure C-11, Photo copy of receipt of Masih Hospital as annexure C-12, Photo copy of discharge summary of S.P. Infertility & Surgical Centre Pvt. Ltd. as Annexure C-13, Photo copy of receipt of Aarogyam Centre for Digestive disease as Annexure C-14, Photo copy of bill of Rajesh Clinical Laboratory as Annexure C-15, Photo copy of receipt of S.P. Infertility & Surgical Centre Pvt. Ltd. as Annexure C-16, Photo copy of receipt of Aarogyam Centre as Annexure C-17, Photo copy of OPD receipt of Masih Hospital as Annexure C-18, Photo copy of receipt of Masih Hospital as Annexure C-19 and closed the evidence on behalf of complainant.

5.                     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 repudiation letter Annexure R-2 and closed the evidence on behalf of OPs.

6.                     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.

7.                      It is admitted fact that the complainant is covered under the family medical insurance policy bearing No.  282510394086 valid w.e.f. 24.2.2009 to 23.2.2010 and charged a sum of Rs. 2737/- as premium issued by the OPs. Learned counsel for the complainant hotly argued that suddenly on 21.8.2009 complainant felt pain in her abdomen and she was taken to Masih Hospital, Yamuna Nagar where she remained admitted from 21.8.2009 to 23.8.2009 but when no relief was felt by the complainant she was taken to Dr. Sanjiv Ahuja MBBS (MS) of Aarogyam Centre, Yamuna Nagar for digestive disease but no relief was felt by the complainant, so she was admitted in S.P. Infertility and Surgical Centre Private Ltd. on 9.9.2009 and was discharged on 13.9.2009 vide IP No. 869/09. As per discharge slip Annexure C-13 the Doctors diagnosed the complainant with “ colitis” and in the history it has been clearly mentioned that complainant is having pain in abdomen one week and the OPs with malafidely intention has repudiated the genuine claim of the complainant.  

8.                     On the other hand, counsel for the OPs advanced his arguments at length that the claim of the complainant has been rightly repudiated and there is no deficiency in service on the part of OPs. In this case complainant has lodged a claim under Medi-claim policy in question and claim was duly processed by the TPA Medical Assist India Pvt. Ltd. and found that the claim was not payable as per exclusion clause No.22 of the policy. “Treatment of mental disease/illness, stress, psychiatric or psychological disorder is not covered under the policy” Further as per procedure 3, the company requires the insured to deliver to the TPA at their own expenses within 30 days of the insured discharged from the Hospital ( for post hospitalization expenses, completion of post hospitalization of period or completion of treatment, whichever is earlier) and further insured shall keep an adequate record containing all relevant particulars regarding her/his health. But in the present case on perusal of the claim document by the TPA it was found that complainant was admitted in Masih Hospital and S.P. Infertility and Surgical Centre and diagnosed as having emotional attach, headache, backache and colitis. As per treatment record it is evident that complainant was suffering from psychiatric illness which is not covered under the policy. Hence, the claim of the complainant has been rightly repudiated vide repudiation letter dated 12.5.2010 (Annexure R-2) and prayed for dismissal of complaint.

9.                     After hearing both the parties at length and going through the documents, we are of the considered view that there is absolutely no justification on the part of Ops to repudiate the medi-claim of the complainant, so the claim of the complainant deserves acceptance.

10.                   The only plea of the OPs that treatment of mental disease/illness, stress psychiatric or psychological disorder is not covered under the policy and further as per procedure 3 company requires the insured to deliver to the TPA his claim within 30 days of the insured discharged from the hospital, is not tenable. From the perusal of discharge summary for the period from 9.9.2009 to 13.9.2009 Annexure C-13 issued by Dr. Aditya Goel it is evident that the patient was having history of pain abdomen one week and diagnosed has been shown as “colitis”. Further from the treatment chart of Masih Hospital dated 21.8.2009 (Annexure C-18) it is also evident that the patient was having slight backache, headache and emotional attack. Further from the Annexure C-14 bill issued by Aarogyam Centre for digestive disease, it is evident that endoscopy was done to diagnosis the disease of the complainant on 9.9.2009 when the complainant was having colitis (i.e. pain and infection of the gut), then the plea of the OPs that the complainant was suffering from mental disease/illness, stress, psychiatric or psychological disorder is not tenable. Even the OPs failed to file any affidavit of the concerned doctor of the TPA in support of his contention mentioned in the repudiation letter. Counsel for the OPs further failed to point out any medicine not prescribed/ recommended for pain in abdomen and headache and backache as mentioned in the treatment chart by the doctors.

11.                   The second plea of the OPs that the claim was not lodged within a stipulated period by the insured is also not tenable. The OPs failed to file any claim form or amount for which the claim was lodged by the complainant whereas, it is evident from the record that complainant was discharged from the hospital on 13.9.2009 and after that she might have taken further treatment at home and the claim documents were submitted on 5.12.2009 with the TPA. So, in our view there is no delay on the part of complainant in lodging her claim with the TPA.                      

12,                   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.

13.                   Resultantly, we partly allow the complaint of complainant and direct the OPs to pay medical expenses to the tune of Rs. 15,000/- incurred on the treatment of complainant (Annexure C-1 to C-11 & C-14 to C-18) alongwith interest at the rate of 9% per annum from the date of repudiation of claim i.e. 12.5.2010 till its realization and also to pay a sum of Rs. 3300/- as compensation for mental agony, harassment as well 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.