The present complaint filed U/s 12 of the Consumer Protection Act' 1986 (for short, 'the Act') by the complainants Deepak Mahajan  and Satish Kumar for the necessary directions to the opposite parties to pay claimed amount of Rs.1,60,800/- alongwith interest @ 12% p.a. to them alongwith Rs.20,000/- as damages for harassment and Rs.20,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that complainant no.1 purchased health insurance policy from opposite party no.3 for his family members i.e. complainant no.2 (father) and Smt.Shashi Bala (mother) vide policy no.10155436 w.e.f. 15.10.2014 to 14.10.2017 and paid Rs.55,801/- as one time premium for the same  and as such they are consumer of opposite parties. Opposite party no.3 approached them being known to them and asked them to get health insurance  policy of opposite party as he was working with company as agent and assured them of coverage of all types of health hazards for three years cashless treatment and hospitalization of insured persons by getting one time premium and on assurance of the opposite party no.3 and in good faith the complainant no.1 paid the premium for health insurance in the shape of cheque which was received by opposite party no.3 from complainants at their address at Dhariwal. In the year 2015, during the insurance cover, insured i.e. complainant no.2 got problem in his left eye which was diagnosed as CNVM (Choroidal Neovascular Membrane) from Dr.Om Parkash Eye Institute (P) Ltd., 117-A, The Mall Amritsar and during his treatment the complainant had spent Rs.1,60,800/- on different dates as injections were injected in eye of the  complainant no.2. To their utter surprise, the opposite parties repudiate their claim which was forwarded by Hospital to Insurance Company on the ground that “INJ ACCENTRIX CAN BE GIVEN ON OPD BASIS AND NOT COVERED AS PER DAYCARE LIST MENTIONED IN THE POLICY AND BENEFIT NOT COVERED IN POLICY'. They spent huge amount on treatment and got no benefit from the opposite parties of which they paid heavy amount of Rs.55,801/- as premium and now the opposite parties refused to pay the amount of treatment expenses on flimsy grounds. They requested so many times to the opposite parties for payment in question, but of no use. Hence this complaint.

3.       Upon notice, the opposite party no.1 and 2 filed their written reply through their counsel taking the preliminary objections that the complainant has no cause of action to file the present complaint;  the Hon'ble Forum has no jurisdiction to entertain this complaint; the complainant does not fall within the definition of consumer as provided  under the Consumer Protection Act; the insurance is a contract between the two parties; the liability of the insurance company is only as per terms and conditions of the policy and the claim of the complainant is not within limitation. On merits, it was admitted that complainant's parents were insured from 15 October 2014 to 14 October 2017 by paying a single premium, which was subject to the policy terms and conditions. The cashless facility is only a facility offered by the company to its policy holders and cannot be claimed as a matter of right by the policy holder. The Insurance Company approves the Cashless Facility of the Policy holder only when it is sure that request/claim lodged is payable as per the Policy Terms and Conditions only. It was next admitted that the complainant underwent the same on different dates, and hence the complainant no.2 was treated as an out-patient basis. Actually, the claim of  Rs.34,521/- only has been raised from the company but same has been denied as not covered under the policy terms and conditions. The complaint has rightly been repudiated as  the alleged treatment is not covered under the terms and conditions of the policy. The liability is only as per terms and conditions of the policy. All other averments made in the complaint have been vehemently denied and prayed for dismissal of the complaint.

4.         Notice issued to the opposite party no.3 had not been received back. Case called several times, but none had come present on its behalf, it is therefore, proceeded against exparte vide order dated 7.8.2017. 

5.    Counsel for the complainant tendered into evidence affidavits of complainant Ex.CW1 and of Satish Kumar son of Sh.Ram Dass Ex.CW-2/A, alongwith other documents Ex.C1 to Ex.C23 and closed the evidence.

6.       Ld.counsel for the opposite party no.1 and 2 has tendered into evidence affidavit of Ramnique Sachar, Corporate Manager Ex.OP-1 alongwith other documents Ex.OP-2 to Ex.OP-22 and closed the evidence.

7.      We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for of some of the evidentiary documents that have been somehow ignored to be produced by the contesting litigants along with the scope of adverse inference that may be discretionarily/judicially drawn on account of the intentional non-participation/ex-parte proceedings by one of the titled opposite parties despite the proven service of the summons; of course, in the very back-drop of arguments as put forth by the learned counsel(s) for the attending litigants.

8.       We observe that the prime dispute that had prompted (affidavit Ex.Cw/1) the present complaint pertained to the alleged repudiation of the complainant’s insurance claim by the OP insurers on the pretext that the eye-treatment/procedure ‘ACCENTRIX’ Eye-Injection taken by the patient (complainant2) could have been given/received at the treating Hospital on OPD (Out Patient Department) basis and moreover the same is not covered as per Daycare List mentioned in the Policy. Further, the OP1 insurers admit having rightly repudiated the insurance claim (in question) vide its written statement per the affidavit (Ex.OP1/1) since the claimed-benefit was not covered under the applicable policy and being not in conformity with the terms of the applicable policy was not payable and thus rightly repudiated.

9.       The OP insurers have also questioned/contested the territorial jurisdiction of the local forum in the light of the fact that they do not have any branch/office under its local jurisdiction over the revenue districts of Gurdaspur/Pathankot. However, we find that the complainant(s) had purchased the related health policy at Dhariwal (Gurdaspur) from the OP3 Agent and even the policy was delivered/received at their place of residence/ business at Dhariwal i.e., the determining factor ‘cause of action/ part of cause of action’ had indeed arisen/erupted/occurred within the territorial jurisdiction of the local district of Gurdaspur and that satisfactorily bestows ‘territorial’ jurisdiction to the local forum.

10.     We find  refusal by the treating Hospital to provide cashless medical-treatment (free of cost) to the patient/complainant despite its being one of the Network Hospitals has been due to the denial by the OP insurers on the same grounds of the related ‘medical procedure’ not covered in the policy Daycare List. However, we find that the treating Hospital has been the one of eminent repute and it has provided the treatment through its ‘one-day’ hospitalization/admission as is evident from the discharge summary formats Ex.C9/Ex.C11/Ex.C13/Ex.C15/Ex.C17/ Ex.C19 & Ex.C21 and thus the related bills are entitled to reimbursement by the OP insurers under the related health policy. Further, the sanction Ex.C22 shows that other insurers do reimburse all such expenses incurred by their consumers. However, the OP insurers (here) had been also liable to refund the incurred hospitalization expenses to the insured but at their network-hospital contracted-rates against those incurred/paid at other than network Hospitals for treatment in urgent emergency situations.

11.     We get firm support to the above proposition/finding in the light of the judgment of the honorable State Consumer Commission, Punjab; in FA # 1100 of 2010 titled Fortis Hospital, Mohali vs. Medsave Healthcare (TPA) Ltd. & Ors; wherein, paragraph ‘22’ reads as: “After producing the ID Card, respondent no. 6 was to get cashless treatment but that was not provided for the reasons known to the appellant hospital or the insurance company (appellant in other appeal). The appellant Hospital has given the treatment and obtained the expenses for the treatment and the insurance company was liable to reimburse the same, but the District Forum held the appellant hospital liable to pay the expenses, compensation and costs jointly and severally and the said order is required to be modified”. However, in the light of the recent ruling by the honorable State Consumer Commission, Punjab in FA # 1105 of 2014 titled: Sukhdev Singh Nagpal vs. New Karian Pehalwal Co-op Ag Service Society & Ors., the insurers are liable to reimburse but only up to the standard-expenses fixed with the network hospitals for that particular medical treatment. The legal proposition has been made ample clear in its paragraph ‘21’ reading as: “…”.       

12.     Further, we find that then insurance claim has been duly filed by the complainant with the OP insurers (competent authority) who have somehow repudiated the same citing the policy terms (Ex.OP2) that has not even been proved to have been dispatched so as to reach/have been served upon the complainants. The expert opinion Ex.OP3 of Dr Nitin Balakrishanan is somehow not admissible since he has neither been the TPA (Third Party Administrator) nor he has diagnosed the patient in person and moreover the contents of his opinion are not supported by the requisite deposition etc. We also find that the terms and conditions of the related policy as exhibited here (Ex.OP2) has been an annexed document and it does not stand proved on record that these ‘claim settlement terms’ stood communicated to the insured and in the absence of the same these cannot enforced upon them at the stage of settlement of reimbursement claim(s).       

13.     In the light of the all above, we partly allow the present complaint and thus ORDER the titled opposite party (1 & 2) insurers to reimburse the medical expenses incurred by the complainants for the treatment of the ailment suffered/treatment undergone by the complainant no.2 besides to pay him Rs.10,000/- as cost and compensation (for having suffered undue harassment) within 30 days of the receipt of the copy of these orders otherwise the awarded amount shall attract interest @ 9% PA form the date of the orders till actual payment.  

14.     Copy of the order be communicated to the parties free of cost. After compliance, file be consigned to records.

                                                                 (Naveen Puri)                                                                                President

ANNOUNCED:                                           (Jagdeep Kaur)              

April 20, 2018.                                     Member                       

*MK*