PER:
Charanjit Singh, President;
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 13 against the opposite parties on the allegations that the opposite party No. 1 is a private limited company engaged in the business of selling health insurance and other insurance related services and are promulgating services through a network of agents and partners. The complainant was also contacted by one of the agents of the opposite party No. 1 who had assured and allured the complainant that the opposite party No. 1 offers health policy, that is the best in the market and they offer cashless hospitalization to their customers. The complainant has purchased one policy bearing No. 10233001 on 18.3.2015 which was valid up to 17.3.2016 which was again renewed by the complainant for a period of one year. During the period of the said policy, the complainant was hospitalized for treatment on the advice of doctor on 3.10.2016 at Apollo Hospital, Amritsar and had been treated for ailments and was duly discharged by the hospital on 5.10.2016 and the complainant had duly informed the opposite party No. 1 about the said hospitalization and had completed all the formalities as sought for by the opposite party No. 1 and a claim bearing No. 90267056-00 was lodged. Thereafter, the complainant had visited the office of the opposite party No.1 various times and had requested them to process his claim and reimburse the expenses paid by the complainant from his pocket. Their representatives/ agent have been dilly delaying the matter on one pretext or the other and the complainant had various times visited their office in this regard. After a delay of nearly one year the representative of opposite party No. 1 has verbally informed the complainant that his claim has been rejected and had even not provided any plausible and cogent reasons thereof. The complainant even asked for a rejection letter in writing to which he refused and due to such deliberate, arbitrary and whimsical acts, the complainant has been harassed and has suffered great mental tension and agony. The opposite party No. 1 has wrongly rejected the claim of the complainant without providing any reasons thereof and hence, are guilty of deficiency in services and unfair trade practice and due to such acts of the opposite party No. 1 the complainant has suffered mental tension, pain and agony. The complainant has served a legal notice to the opposite party No. 1 through his counsel on 11.10.2017 and sought the redressal of his grievance at the earliest. Thereafter, the opposite party No. 1 had sent a written repudiation letter cum reply to the legal notice assigning vague and vexatious reasons. There is negligence/ deficiency in service and unfair trade practice on the part of the opposite party No. 1. The complainant has prayed that prayed that the opposite party No. 1 may be directed to make the payment of claim as per claim intimation form and reimburse the expenses paid by the complainant during hospitalization as per the terms and conditions of the policy and prayed Rs. 25,000/- as compensation and Rs. 15,000/- as litigation expenses.
3 After formal admission of the complaint, notice was issued to Opposite Parties and opposite party No. 1 appeared through counsel and filed written version and contested the complaint by taking the preliminary objections that the present complaint is pre mature in nature as the complainant has failed to provide any deficiency in service prima facie and as such, the present complaint is to be dismissed. The opposite party No. 1 herein vide policy bearing No. 10233001 insured the complainant herein alongwith her spouse subject to the policy terms and conditions w.e.f. March 18, 2015 till March 17, 2016. The said policy was subsequently renewed from March 23, 2016 till March 22, 2017 subject to the policy terms and conditions only. During the currency of the policy, the complainant was admitted at Apollo Hospital in Amritsar from October 3, 2016 till October 5, 2016 for the treatment of viral fever. Accordingly, the complainant herein filed for Reimbursement claim with opposite party on October 21, 2016 with bill details of Rs. 15,748/-. The said claim was rejected as per policy terms and conditions under clause 4.3(a)(i) read with Annexure C(71) as Hospitalization for investigation and evaluation is permanent excluded from the Policy Coverage. Basis the documents received, it was observed that as per the Vital Charts prepared by the Hospital Authorities, the complainant is marked to have his body vitals including blood pressure, pulse rate and Respiration Rate to be in limit with only a single temperature reading of 101 F which does not necessitate in patient Treatment. The complainant herein was subjected to various investigations throughout the period of hospitalization which included Blood Sugar Tests, Lipid Profile Test and Blood Count Test. On perusal of the said Tests reports, complainant’s condition can be seen to be stable and did not require in-patient treatment. In the light of the above stated facts and observations, the opposite party company took a medical opinion from an independent medical practitioner pertaining to hospitalization of the complainant herein. Dr. C.H. Asrani opined that “The patient Mr. Vijay Goel was hospitalized mainly for investigation/ diagnostic purposes and treatment for his symptoms was possible on OPD basis. The medical management did not need indoor hospitalization. Considering the facts of the case and the opinion given by Dr. CH. Asrani the opposite party company vide letter dated December 13, 2016 rejected the complainant’s claim in accordance with the policy terms and conditions. The relevant clause is reproduced herein for your reference.
4.3 Patient Exclusion
(a) Any claim in respect of any insured person, arising out of or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the policy terms and conditions
(1) Any item or condition or treatment as specified in Annexure C
Annexure C-List of Expenses Generally excluded (Non Medical_ in hospital indemnity Policy
(71) Hospitalization for Evaluation/ Diagnostic Purpose
In this case, the complainant is not entitled for any claim and in view of the facts mentioned above, the claim has been rightly repudiated as per the Policy Terms and conditions only. As such, there is no deficiency on the part of the opposite party company. The complainant has filed the present complaint without any cause of action against the opposite party No. 1, therefore, liable to be dismissed. The complainant has no locus standi to file the present complaint. On merits, it was pleaded that after perusal of record, it was found that the claim is not payable, due intimation of rejection of the claim was given to the complainant, therefore, there was no occasion to visit the office as alleged. The claim of the complainant was rightly repudiated as the complainant’s Hospitalization was primarily for the purpose of investigation and evaluation and is permanently excluded from the scope of the Coverage of the policy issued to the complainant. Accordingly, the claim of the complainant after due consideration was rejected in adherence to the policy terms and conditions only. After receiving the notice from the complainant, a due reply of the same was given by the opposite party No. 1 vide letter dated November 2, 2017. The opposite party No. 1 has denied the other contents of the complaint and prayed for dismissal of the same.
4 During the pendency of the present complaint, the opposite party No. 2 was arrayed as party in the present complaint and due notice was issued to the opposite party No. 2 and it was duly served but it opted not to come forward to contest the complaint and consequently, the opposite party No. 2 was proceeded against ex-parte vide order dated 7.11.2019.
5 To prove his case, the complainant has tendered in evidence his affidavit Ex. CW1/A, copy of legal notice dated 11.10.2017 Ex. C-1, Copy of reply of legal notice Ex. C-2, Copy of the claim form Ex. C-3, Copy of claim form part B Ex. C-4, Copy of the discharge card Ex. C-5, Copy of treatment record dated 3.10.2017, 4.10.2017, 5.10.2017 Ex. C-6 to C-8, Copy of prescription slip dated 5.9.2017, 4.10.2017 are Ex. C-9, C-10, Copy of the patient record with date of admission dated 3.10.2016 Ex. C-11, Copy of the treatment record Ex. C-12 to Ex. C-14, Copy of the bills for treatment Ex. C-15 to Ex. C-23, Copy of the letter for name declaration Ex. C-24 and closed the evidence. On the other Hands, the opposite party No. 1 has tendered in evidence affidavit of Sh. Arwinder Singh Naruka Ex.OP1/A, copy of policy Ex. OP1/1, copy of policy Ex. OP1/2, Copy of hospital record Ex. OP1/3, Copy of the investigation report Ex. OP1/4, Copy of the certificate of Dr. C.H. Asrani Ex. OP1/5, Affidavit of Dr. C.H. Asrani Ex. OP1/6, Copy of rejection letter Ex. OP1/7, Copy of the terms and conditions Ex. OP1/8, Legal notice Ex. OP1/9, Copy of reply to legal notice Ex. OP/10, copy of certificate Ex. OP1/11, affidavit of Dr. C.H. Asrani Ex. OP1/12 and closed the evidence.
6 We have heard the Ld. counsel for the complainant and opposite party No. 1 and have gone through the record on the file.
7 The combined and harmonious reading of the pleadings and documents is going to prove that the complainant has purchased one policy bearing No. 10233001 on 18.3.2015 which was valid up to 17.3.2016 which was again renewed by the complainant for period of one year. During the currency of said policy, the complainant was hospitalization for treatment on the advice of Doctor on 3.10.2016 at Apollo Hospital, Amritsar. After availing the treatment the complainant was duly discharged from hospital on 5.10.2016. Thereafter, the complainant duly informed the opposite party No. 1 about the said hospitalization and submitted the claim after completing all the formalities as sought by the opposite party No. 1. Thereafter opposite party No. 1 repudiated the claim submitted by the complainant.
8 On the other hands, the opposite party No. 1 rejected the claim as per their policy terms and conditions under clause 4.3 (a) (i) read with Annexure C(71) as hospitalization for Investigation & Evaluation is permanent Excluded from the policy coverage. The opposite party contended that it was observed that as per Vital Charts prepared by the Hospital Authorities, the complainant is marked to have his Body Vitals including Blood Pressure, Pulse temperature reading 101 F which does not necessitate in patient Treatment. It was further observed that the complainant herein was subjected to various Investigations throughout the period of Hospitalization which included Blood Suger Test, Lipid Profile Test and Blood Count Test.
9 In this regard the opposite party No. 1 company took a medical opinion from an independent Medical Practitioner pertaining to Hospitalisation of the complainant herein. Dr. C.H. Asrani opined that patient Mr. Vijay Goyal was hospitalized mainly for investigation/ diagnostic purposes and treatment for his symptoms it was possible on OPD basis. The medical management did not need indoor hospitalization. Copy of medical opinion by Dr. C.H. Asrani is Annexure 4. The opposite party No. 1 rejected the claim on the opinion given by Dr. C.S. Asrani and in accordance with policy terms and conditions. The relevant clause is reproduced herein for reference
4.3 Patient Exclusion
(a) Any claim in respect of any insured person, arising out of or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the policy terms and conditions
(1) Any item or condition or treatment as specified in Annexure C
Annexure C-List of Expenses Generally excluded (Non Medical_ in hospital indemnity Policy
(71) Hospitalization for Evaluation/ Diagnostic Purpose
10 The opposite party has rejected the claim of the complainant on the opinion which was given by Dr. C.H. Asrani though the doctor has gone through the record of the patient and reached at the conclusion that the admission of the patient was not at all required in the hospital. It is beyond any stretch of imagination how the doctor who is sitting in Mumbai can opined that the admission of the complainant was not required in the Hospital. The said doctor has just seen the record of the patient and he has not physically examined the complainant. He cannot say that the complainant was not required to be admitted in the hospital. However Dr. C.H. Asrani is not M.D. in Medicine. He is DNB (Family medicine) MBBS. On the other hands as per Ex. C-5 i.e. discharge summary, the complainant was admitted in Apollo Hospital for the treatment of Viral Fever by Dr. Pawan Bhatia M.B.B.S, M.S. M.N.A.M.S (I) Surgical Specialist. The doctor of Apollo Hospital has admitted the complainant in hospital. He was admitted n hospital on the advice of Doctor of Apollo Hospital and the doctor of Apollo Hospital is the best person who can advise the patient as per the examination of the body of the complainant. On the other hands, doctor who has opined from Mumbai merely gone through the medical record of the complainant has suggested that the admission of the complainant is not required no the hospital. We are of the considered opinion that it is only the treating doctor who can give best advice to the patient as per current situation of the patient and as per advice of the doctor of Apollo Hospital, the complainant was admitted in the hospital. So merely on the opinion of Doctor C.H. Asrani who is sitting in Mumbai, the opposite party has rejected the claim of the complainant amounts to deficiency in service on the part of the opposite party.
11 Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
12 In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Party is directed to reimburse the expenses paid by the complainant during hospitalisation to the complainant. The complainant has been harassed by the opposite party unnecessarily for a long time. The complainant is also entitled to Rs.4,000/- ( Rs. Four Thousand only) as compensation on account of harassment and mental agony and Rs 3,000/- ( Rs Three Thousand only) as litigation expenses. Opposite Party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
14.07.2022
