BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM; FATEHABAD.
Complaint Case No. 59 of 2017.
Date of Instt.:03.03 .2017.
Date of Decision: 28.11 .2017.
Surjeet Singh son of Shri Om Parkash, resident of village Bisla, Tehsil and District Fatehabad.
..Complainant
Versus
1.Religare Health Insurance Company Limited, D-3, P3B, District Health Centre, Saket, New Delhi-110017 through its Manager.
2.Indusind Bank Limited, Branch G.T. Road, Near Old Bus-stand, Fatehabad, District Fatehabad.
..Respondents/OPs
Before: Sh.Raghbir Singh, President.
Mrs.Ansuya Bishnoi, Member.
Sh.R.S.Panghal, Member.
Present: Sh.Manjeet Kajla, Adv. for the complainant.
Sh.U.K.Gera, Adv. for the OP No.1.
Sh.Amit Wadhera, Adv. for OP No.2.
ORDER
The present complaint under Section 12 of Consumer Protection Act, 1986 has been filed by the complainant against the OPs with the averments that he had purchased a Medi-claim policy under the Group Care (Scheme2-IIB) from OPs on 08.07.2016 vide which health of himself and his family was insured. The above said policy was valid from 05.07.2016 to 04.07.2017 and expenses of hospitalization upto Rs.2,50,000/-, pre-hospitalization medical expenses upto 30 days and post hospitalization medical expenses upto 60 days were covered under the policy and premium of Rs.4325/- was paid by the complainant at the time of purchase of the policy. It is further submitted that thereafter the complainant was admitted in Vim Hans Primamad Super Specialty Hospital, I, Institutional Area, Nehru Nagar, New Delhi on 08.09.2016 for treatment and he was discharged from the hospital on 10.09.2016. Intimation regarding the same was given to the OPs by the complainant and a Claim Reimbursement Form along-with relevant document was submitted with the OP No.1. Thereafter the OP no.1 sent a querry dated 03.10.2016 for submitting of relevant documents by the complainant with regard to the medical treatment taken by him. In response to that letter all the relevant documents along-with bill for the sum of Rs.54,938/- was sent to the OP No.1. The OP No.1 assured to the complainant that his claim will be settled within a short period. Thereafter the complainant was intimated that his claim has been repudiated by the OPs on 16.11.2016 on the ground that the case of the complainant for seeking of Medi-claim does not fall within the purview of the policy as the complainant was admitted in the Hospital for investigation and evaluation.
2. It is further submitted that the genuine claim of the complainant was repudiated by the OPs on false and baseless ground. The complainant thereafter asked several times to the OPs for making payment of Rs.54,938/- along-with interest but nothing has been done on the part of OPs. The above said act in repudiating the Medi-claim of the complainant amounts to deficiency on the part of OPs in rendering service to the complainant and as such the complainant is entitled for getting a payment of Rs.54,938/- along-with interest and compensation. Hence, the present complaint.
3. On being served Op no.1 appeared and resisted the complaint by filing written statement wherein various preliminary objections with regard to cause of action, locus-standi and maintainability etc. have been raised.
4. On merits, it is admitted that the insurance policy was purchased by the complainant from Op No.1. It is further submitted that on receiving the claim of the complainant, the OP No.1 carefully examined the medical treatment documents of the complainant in the light of terms and conditions of the policy and it was concluded on enquiry that the claim was not payable as an admission of the complainant in the Hospital was for investigation and evaluation purpose only and not for treatment of any illness or disease or sickness. It is further submitted in the written statement that as per Clause 3.2.1 read with Annexure B-71 of the policy terms and conditions any admission/ hospitalization for investigation/ evaluation/ diagnostic purpose is not payable. Since the case of the complainant for payment of Medi-claim was falling within the purview of above said exclusion clause as such the Medi-claim of the complainant has been rightly rejected by the answering OP. It is also further submitted that during investigation conducted by the said hospital all the vitals of the complainant were found normal and no disease or illness was diagnosed and as such in view of the terms and conditions of the policy the complainant was not entitled for any payment of Medi-claim. It is also further submitted that the OP No.1 had also obtained an opinion form an independent Doctor regarding the hospitalization of the complainant and the Doctor opined that the patient could have been investigated on Out Patient basis and there was no requirement of hospitalization.
5. OP No.1 further prayed that the present complainant is without any merit and the same deserves dismissal. In the written statement the Op No.1 also placed reliance on judgment dated 5th May, 2015 rendered by District Consumer Forum, Amritsar in case titled as Mansih Kumar Vs, Religare Health Insurance Company Ltd. and judgment titled as Deepak Kaushik Vs. Religare Health Insurance Company Ltd. rendered by District Consumer Forum, Palwal.
6. The Op No.2 also filed a written statement submitting therein that the complainant does not fall under the definition of Consumer Protection Act, 1986, qua OP No.2 as no contract between OP No.2 and the complainant has taken place and no consideration or premium was received by OP NO.2 from the complainant. All the risk and liability are covered by Op No.1 who had issued the policy to the complainant. Op No.2 only has provided banking services to the complainant for deposit and withdrawal of the money. It is also further submitted that it is settled principle of law that an agent can neither sue nor be sued except under the special circumstances mentioned therein. It is also further submitted that all the allegations made against OP No.1 are without any base and the same are denied. There is no deficiency on the part of Op No.2 in rendering service to the complainant and as such the present complainant against OP No.2 is liable to be dismissed.
7. In evidence Surjeet Singh tendered his affidavit as Annexure CW1 along-with documents as Annexure C1 to Annexure C11 and closed his evidence. On the other hand Sh. Parshant Singh filed an affidavit on behalf of OP No.1. OP No.1 also tendered in evidence documents Annexure R1 to Annexure R9 and closed the evidence. Sh. Ajit Chauhan filed an affidavit on behalf of OP No.2.
8. The learned counsel for the complainant in his arguments reiterated the averments made in the complaint and further contended that a Medi-claim policy under the group care was purchased by him thereby getting insured the health of himself and his family. The said policy was valid from 05.07.2016 to 04.07.2017 and hospitalization expenses upto Rs.2,50,000/- pre-hospitalization medical expenses upto 30 days and post hospitalization medical expenses upto 60 days were covered under the policy. A premium of Rs.4325/- was paid by the complainant at the time of purchase of the policy. Therefore the complainant falls within the definition of consumer of OPs as defined in the Consumer Protection Act, 1986.
9. It is further contended by the learned counsel that the complainant was admitted in Vim Hans Primamad Super Specialty Hospital, I, Institutional Area, Nehru Nagar, New Delhi on 08.09.2016 for treatment and he was discharged from the hospital on 10.09.2016. That as per the terms and conditions of the policy the complainant was entitled for benefit of hospitalization expenses upto Rs.2,50,000/- and pre-hospitalization medical expenses upto 30 days and post hospitalization medical expenses upto 60 days and as such as per the terms and conditions of the policy the OPs were bound to make payment of the hospitalization and treatment expenses incurred by the complainant. However, a genuine claim of the complainant has been repudiated by the OPs on false and baseless ground that the case of the complainant for payment of claim does not fall within the purview of terms and conditions of the policy as the complainant was admitted in the hospital for investigation and evaluation purposes. It is further contended by the learned counsel that the complainant was suffering from severe headache followed by loss of consciousness followed by weakness of left upper limb and pain in left half of body. Taking it as a case of emergency the hospital authorities admitted the complainant under the care of Neurologist and further treatment was given. Therefore the case of the complainant is covered under the Medi-claim policy purchased by the complainant and the complainant is entitled for reimbursement of expenses incurred by him for taking treatment in the above-said hospital. It is further contended by the learned counsel that the case of the complainant for payment of Medi-claim is duly supported by the documents Annexure C-8 to Annexure C-10. It is also contended by the learned counsel that the complainant had approached the above said hospital for treatment of his illness i.e. severe headache followed by loss of consciousness and he was admitted in the hospital for treatment of the same as per advice of the hospital authorities. In support of his case the learned counsel relied upon the case law cited as 2012(47) R.C.R. (Civil) 617, case law 2010 (66) R.C.R. (Civil) 717, case law 2002 (1) CLT 207 and 2015 (23) R.C.R. (Civil)74.
10. On the other hand the learned counsel for the OP No.1 rebutted the arguments advanced by the learned counsel for the complainant and vehemently contended that the decision of OP No.1 in repudiating the claim of the complainant is perfectly in accordance with the terms and conditions of the Medi-claim policy issued to the complainant and as such the order dated 16.11.2016 is sustainable in the eyes of law. The learned counsel further contended that the documents of medical treatment taken by the complainant were duly examined by OP No.1 in the light of terms and conditions of the policy and on careful examination it was found by Op no.1 that the Medi-claim was not payable as the complainant was admitted in the hospital for investigation and evaluation purposes and not for treatment of any illness, sickness or injury. The learned counsel in support of his contention has relied upon the Discharge Summary Annexure C-9 wherein it is specifically stated that he was brought to the hospital for further evaluation and management. The learned counsel further contended that after investigation (Annexure C-11) it was found that function of all the vital of the complainant were normal and no illness or disease was diagnosed. Therefore it was perfectly a case of investigation and not a case of treatment of any illness. Therefore the case of the complainant for payment of Medi-claim did not fall within the purview of the policy and as such the same has been rightly rejected. The learned counsel also contended that opinion in the matter was sought by OP No.1 from an independent doctor who after examining the complete medical record of the complainant inter-alia opined that the patient could have been investigated on Out Patient Basis. The learned counsel further contended that there is no deficiency on the part of OP in rendering service to the complainant and as such the present complaint is without any merits and the same deserves dismissal.
11. The learned counsel for OP No.2 argued that the complainant does not fall under the definition of consumer as provided under the Consumer Protection Act, 1986 qua OP NO.2 as no contract between the OP No.2 and the complainant had taken place and no consideration or premium was received by the OP No.2 from the complainant. The policy in question was issued by OP NO.1 and OP No.2 only provides banking facility to the people for deposit and withdrawal of money. The learned counsel further contended that it is settled proposition of law that an agent can neither sue nor be sued except under the special circumstances mentioned therein. The learned counsel in support of his contention placed reliance on the decision rendered by Hon’ble Apex Court in case titled as Virender Khullar Vs. America Consolidation Service Ltd and cited as 2016 (4) CLT Page 1. The learned counsel further prayed for dismissal of the complaint against the OP No.2
12. We have duly considered the arguments advanced by the learned counsel for the parties and have also perused all the material placed on the record of the case. It is the case of the complainant that a Medi-claim policy valid from 05.07.2016 to 07.07.2017 was purchased by him from the OPs and vide the said policy health of the complainant and his family was insured. During the subsistence of the policy i.e. on 08.09.2016 the complainant suffered severe headache followed by loss of consciousness. Therefore he visited the hospital for treatment and the hospital authorities taking it a case of emergency admitted the complainant in the hospital under the care of neurologist for treatment. Therefore the case of the complainant for getting medi-claim on account of treatment expenses incurred by him is perfectly covered within the purview of the policy purchased by him.
13. On the other hand it is the case of the Op no.1 that the medi-claim is not payable to the complainant as he was admitted in the hospital for investigation and evaluation purposes and not for treatment of any illness or disease and as per terms and conditions of the policy any admission/ hospitalization for investigation evaluation/ diagnostic purposes is not payable. So the prime question involved in the present case before this Forum is as to whether the complainant was admitted in the hospital for treatment of illness/ disease or for investigation or evaluation. A perusal of Emergency Certificate Annexure C-8 issued by the hospital reveals that the complainant Surjeet Singh was brought to the Vim Hans Primamed Emergency on 08.09.2016 and admitted in ward under care of Neurologist and diagnosed as a case of Transient / Ischemic Attack. So from the above it is evident that the complainant was admitted in the hospital as emergency case. Further from perusal of Annexure C-9 i.e. Discharge Summary it is revealed that the complainant approached the hospital with complaint of sudden onset of severe headache, followed by loss of consciousness at 4.00 p.m. on 08.09.2016 for 15-20 minutes followed by weakness of left upper limb and pain in left half of body. So from perusal of Annexure C-8 and C-9 it can be inferred that the complainant was admitted for treatment of severe headache followed by loss of consciousness as a case of Transient Ischemic Attack. Moreover the complainant visited the hospital and disclosed his problem and was admitted in the hospital as per advice or asking of the hospital authorities and further investigations were conducted by the hospital authorities at their own during the treatment. In view of the above we are of the considered opinion that the complainant has been able to prove deficiency on the part of Op No.1. Accordingly the present complaint is allowed against OP No.1. Complaint against the OP no.2 is hereby dismissed as no case of deficiency is made out against him. Op No.1 is directed to make a payment of Rs.54,938/- on account of treatment expenses incurred by him to the complainant along-with a compensation of Rs.4,000/- on account of mental agony harassment suffered by him within a period of one month otherwise the above said amount will carry an interest @ 7% per annum from the date of order till actual realization. A copy of this order be furnished to both the parties free of cost as provided in the rules. File be consigned to record room after due compliance.
ANNOUNCED IN OPEN FORUM. Dt.28.11.2017
(Ansuya Bishnoi) (R.S.Panghal) (Raghbir Singh)
Member Member President DCDRF, Fatehabad
