BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 334 of 2015

Date of Institution: 26.05.2015

Date of Decision: 05.02.2016 

1. Raj Rani, aged 63 years, wife of Sh.Parshotam Lal, resident of H.No. 49, Gali No. 3, New Jawahar Nagar, Batala Road, Amritsar.
2. Parshotam Lal, aged 73 years son of Sh.Jagdish Ram, resident of H.No. 49, Gali No. 3, New Jawahar Nagar, Batala Road, Amritsar.

Complainants

Versus

1. The New India Assurance Company Limited, Divisional Office, 80 Court Road, Amritsar, through its Divisional Manager.
2. The Senior Divisional Manager, Life Insurance Corporation of India, Divisional Office, near M.K.Hotel, Ranjit Avenue, Amritsar. 

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act.

Present: For the Complainants: Sh.Vikram Puri, Advocate

              For the Opposite Party No.1: Sh.Vikas Mahajan, Advocate

              For the Opposite Party No.2: Sh.J.K.Singh, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by the complainants  under the provisions of the Consumer Protection Act alleging therein that complainant No.2 is retired employee of Opposite Party No.2 and he purchased group medi claim insurance policy from Opposite Party No.1 through Opposite Party No.2 for himself and his wife Raj Rani-complainant No.1, for a sum of Rs.4 lacs valid for the period from 1.4.2014 to 31.3.2015. Complainants allege that on 27.2.2015, complainant No.1 suffered some problems and she consulted Dr.U.S.Dhaliwal and the doctor advised certain tests i.e. x-ray, ultrasound and other clinical tests, etc. which the complainant No.1 got conducted and doctor perused the report and diagnosis PUO & Generalized weaknesses and advised the complainant No.1 to admit in the hospital to get treatment on the basis of report and after clinically examined the complainant No.1. Complainant No. 1 was admitted in Dhaliwal Hospital, Batala Road, Amritsar on 27.2.2015 and discharged on 5.3.2015 and spent total sum of Rs.26,074/- for hospitalization, medicine, tests and clinical test, etc. Thereafter,  complainant No.1 submitted the claim with Opposite Party No.2 who in turn sent it to Opposite Party No.1 for paying the claim amount. But Opposite Party No.1 rejected the claim in question vide letter dated 7.5.2015 on flimsy  and baseless grounds. The impugned rejection of claim in question by Opposite Party No.1 is illegal and without any reason & cause and it amounts to deficiency in service on the part of the Opposite Parties.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to pay the claim amount of Rs.26,074/- alongwith interest @ 24% per annum till actual payment. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party No.1 appeared and filed written version in which it was submitted that the there is no negligence or deficiency in service on the part of Opposite Party No.1 and the Opposite Party No.1 has rejected the claim on the ground that the patient was admitted in Dhaliwal Hospital, Batala Road, Amritsar on 27.2.2015 with the diagnosis of PUO and generalized weakness. Moreover, fever of the patient remained 98°f  throughout stay at hospital which excludes the need for hospitalization. The medi claim policy clearly rules out admission need for general weakness and convalescence. The medi claim has been rejected on the aforesaid ground and more particularly exclusion clause F (xi) of Group mediclaim policy states that diagnosis, x-ray or lab-examination not consistent with or incident to diagnosis of positive existence and treatment or ailment, sickness or injury, for which confinement is required at hospital the claim is not admissible.   While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Party No.2 appeared and filed written version in which it was submitted that as per the record maintained in their office, the claim papers alongwith the bills, etc. received from  complainant No.1 and all the documents were forwarded to Opposite Party No.1 vide letter dated 7.2.2015, but the Opposite Party No.1 rejected the claim of complainant No.1 vide their letter dated 7.5.2015. It is further submitted that Opposite Party No.2 merely acts as a mediator between the insurer i.e. Opposite Party No.1 and insured i.e. complainant. The decision to admit or reject the claim is to be taken by Opposite Party No.1.  While denying and controverting other allegations, dismissal of complaint was prayed.
4. Complainants tendered into evidence the affidavit of complainant No.1 Ex.C1 alongwith documents Ex.C2 to Ex.C19 and closed the evidence on behalf of the complainants.
5. Opposite Party No.1 tendered into evidence affidavit of Sh.Sukhdev Singh Gill, Divisional Manager Ex.OP1/1 alongwith documents Ex.OP1/2 to Ex.OP1/17 and closed the evidence on behalf of the Opposite Party No.1.
6. Opposite Party No.2 tendered into evidence the affidavit of Sh.Y.S.Sisodhia, Manager (Legal) Ex.OP2/1 and closed the evidence on behalf of Opposite Party No.2.
7. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
8. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that Parshotam Lal, complainant No.2 was employee of Opposite Party No.2 and he purchased group medical insurance policy from Opposite Party No.1 through Opposite Party No.2 for himself and wife Raj Rani-complainant No.1 for a sum of Rs.4 lacs valid for the period from 1.4.2014 to 31.3.2015. On 27.2.2015, Smt.Raj Rani- complainant No.1 suffered some problems and she consulted Dr.U.S.Dhaliwal of Dhaliwal Hospital, Batala Road, Amritsar who advised certain tests i.e. x-ray, ultrasound and other clinical tests, etc.  which the complainant No.1 got conducted. From the perusal of the reports of clinical tests, Dr.U.S.Dhaliwal diagnosis a case of  PUO & Generalized weaknesses Complainant No. 1 was admitted in Dhaliwal Hospital, Batala Road, Amritsar on 27.2.2015 and discharged on 5.3.2015 and she spent  Rs.26074/- for hospitalization, medicine, tests and clinical test, etc. Thereafter, the complainant No.1 submitted her claim with Opposite Party No.2 who in turn sent it to Opposite Party No.1 for paying the claim amount, but Opposite Party No.1 rejected the claim in question vide letter dated 7.5.2015 on flimsy  and baseless grounds. The complainant No.1 received the copy of letter dated 7.5.2015 of Opposite Party No.1 alongwith letter of Opposite Party No.2 dated 18.5.2015. Ld.counsel for the   complainants  submitted that all this amounts to deficiency of service on the part of the opposite party No.1 qua the complainant No.1.
9. Whereas the case of the Opposite Party No. 1 is that as per the complainants version, the patient was admitted in Dhaliwal Hospital, Batala Road, Amritsar on 27.2.2015 with  the diagnosis of PUO and generalized weakness on the basis of clinical tests i.e. x-ray, ultra sound and other tests, etc. From the perusal of the record of Dhaliwal Hospital, Batala Road, Amritsar, it was found that   the fever of the patient remained 98°f throughout stay at hospital which excludes the need for hospitalization. The medi claim policy clearly rules out admission need for general weakness and convalescence. The medi claim has been rejected on the aforesaid ground and more particularly exclusion clause F (xi) of Group mediclaim policy Ex.OP1/2. Dr.Sunil Grover investigated the record of the complainant No.1 and submitted his report Ex.OP1/4 dated 7.5.2014 which has been duly proved by Dr.Sunil Grover through his affidavit Ex.Op1/3. In the said report, Dr.Sunil Grover has categorically stated that in the discharge slip of complainant No.1 Ex.C8, there is no mention about history/ duration or type of fever to declare it as PUO. Secondly, fever of the complainant No.1  remained 98 degree Fahrenheit through out the admission/ stay of complainant No.1 in Dhaliwal Hospital, Batala Road, Amritsar as is evident from Nursing Care Record Ex.OP1/6 which excludes the need for hospitalization. However, the claim of the complainant No.1 is not admissible as per exclusion clause F(xi). So the claim of  complainant No.1 is not admissible as per the terms and conditions of the policy. Ld.counsel for Opposite Party No.1 submitted that Opposite Party No.1 has rightly repudiated the claim of complainant No.1 vide letter dated 7.5.2015 Ex.C19  which was conveyed to the complainant vide letter dated 18.5.2015 Ex.C18.  Ld.counsel for the opposite party No.1 submitted that there is no deficiency of service on the part of the Opposite Party No.1.
10. Whereas the case of Opposite Party No.2 is that complainant No.2 was employee of Opposite Party No.2 and he got group medi claim policy for himself and his wife complainant No.1  from Opposite Party No.1 through Opposite Party No.2. Opposite Party No.2 has nothing to do with the claim case of the complainant No.1. As per the record of Opposite Party No.2, the claim papers alongwith bills, etc. were received from Raj Rani complainant No.1 wife of Parshotam Lal retired employee of Opposite Party No.2. Consequently, all the documents were forwarded to Opposite Party No.1 vide letter dated 7.2.2015. However, Opposite Party No.1 rejected the claim case of complainant No.1 vide letter dated 7.5.2015 which where forwarded to complainant No.1 vide letter dated 18.5.2015. So, there is no deficiency of service on the part of Opposite Party No.2.      
11. From the entire above discussion, we have come to the conclusion that complainant No.2 being the employee of Opposite Party No.2 got medi claim policy Ex.Op1/2 for himself and his wife Raj Rani complainant No.1 from Opposite Party No.1 through Opposite Party No.2 for the period from 1.4.2014 to 31.3.2015 for a sum of Rs.4 lacs. Complainant No.1 Raj Rani suffered some problem on 27.2.2015 and she consulted Dr.U.S.Dhaliwal of Dhaliwal Hospital, Batala Road, Amritsar and she was advised certain clinical tests i.e. x-ray, ultra sound and other tests which she got conducted and she was admitted in Dhaliwal Hospital, Batala Road, Amritsar on 27.2.2015 and discharged on 5.3.2015 as per discharge slip Ex.C8. She was diagnosed   PUO and generalized weakness. As per definition of PUO, it is a case where the fever for about 3 weeks duration that remains undiagnosed after one week in hospital is of little help to patient and in such case, any patient who has fever that after routine history, examination and basic investigations remains undiagnosed should be investigated systematically to try and reach a diagnosis as quickly as possible. The most common cause of PUO  is infection specifically tuberculosis, other common infections are HIV, etc. But the treatment record of complainant No.1 at Dhaliwal Hospital, Batala Road, Amritsar Ex.Op1/5 and Nursing Care Record Ex.Op1/6 fully prove that the temperature of complainant No.1 through out her admission in Dhaliwal Hospital, Batala Road, Amritsar remained 98°f. In discharge slip Ex.C8, there is no mention about history/ duration or type of fever to declare it as PUO. Apart from this, the pulse rate, blood pressure of complainant No.1 remained almost normal, nor complainant No.1 could produce any certificate from Dhaliwal Hospital, Batala Road, Amritsar that the admission of complainant No.1 in that hospital was necessary or that it was a case of PUO that is why complainant No.1 could not file any affidavit from Dr.U.S.Dhaliwal who treated the patient in Dhaliwal Hospital, Batala Road, Amritsar, to prove that it was a case of PUO. Consequently, we hold that the complainant No.1 has failed to prove on record that her case was diagnosed as PUO. Further, the patient was admitted for generalized weakness. Medi claim policy Ex.OP1/2 clearly rules out the need of hospitalization for generalized weakness and convalescence. Exclusion clause F (xi) of Group medi claim policy Ex.OP1/2 clearly states that diagnosis, X-ray or laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital are excluded from the policy. Therefore, that is not covered under the policy in question. Opposite Party No.1 examined Dr.Sunil Grover, M.D. (TB & Respiratory Diseases) who examined the case of  complainant No.1 and submitted his report Ex.OP1/4 and proved the same through his affidavit Ex.OP1/3. In the said report, Dr.Sunil Grover has categorically stated that in the discharge slip of complainant No.1 Ex.C8, there is no mention about history/ duration or type of fever to declare it as PUO. Further, fever of the complainant No.1  remained 98°f through out the admission/ stay of complainant No.1 in Dhaliwal Hospital, Batala Road, Amritsar, as is evident from Nursing Care Record Ex.OP1/6; which excludes the need for hospitalization. Further there was no need for admission of complainant No.1 for generalized weakness and convalescence, therefore, hospitalization of complainant No.1 was not required and all  this could be done in OPD of the aforesaid hospital. This witness Dr.Sunil Grover was not cross examined by complainants nor the complainants could produce any expert witness to prove that admission of complainant No.1 was necessary in the hospital.
12. Resultantly, as per the terms and conditions of the policy Ex.OP1/2, the Opposite Party No.1 was justified in repudiating the claim of complainant No.1 vide letter dated 7.5.2015 (Ex.C19) which was conveyed by Opposite Party No.2-LIC vide letter dated 18.5.2015 (Ex.C18) to complainant No.1  
13. Consequently, we hold that the complaint is without merit and the same is hereby dismissed with no order as to cost. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated:05.02-2016.                                                             (Bhupinder Singh)                                                                                                                                                                                                        President

hrg                                                                   (Kulwant Kaur Bajwa)   

                                    Member