BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.830-13

Date of Institution:04-12-2013

Date of Decision:02-03-2015  

1. Ranjit Singh son of Sh.Ram Singh, resident of House No. 87, Gali No.3, Gokal Nagar, Majitha Road, Amritsar.
2. Kaushalya wife of  Sh.Ranjit Singh son of Sh.Ram Singh, resident of House No. 87, Gali No.3, Gokal Nagar, Majitha Road, Amritsar.

Complainants

Versus

1. The New India Assurance Company Limited, having its office at BO-310904, 2^nd Floor, Vandana Building, 11, Tolstoy Marg, New Delhi-110001 through its Branch Manager/ Legal Representative. 
2. Standard Chartered Bank, having its office at 360, The Mall, Amritsar through its Branch Manager/ Legal Representative. 

Opposite Parties

Complaint under section 12 and 13 of the Consumer Protection Act.

Present: For the Complainants: Sh.Ramandeep Singh Bhullar, Advocate

              For the Opposite Party No.1: Sh.P.N.Khanna, Advocate

              For the Opposite Party No.2: Exparte.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, 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.1 was an ex-employee of Opposite Party No.2 having its Ex-Employee No. 15079, Pension No. 7299. Opposite Party No.2 entered into an  Memorandum of Understanding with Opposite Party No.1 in order to provide Medi Claim Insurance Policy for 10 years to their employees, who have opted for early retirement under VRS Scheme. The complainant No.1 had opted for early  retirement under VRS Scheme, and as per the policy, Opposite Party No.2 issued with two Medi Claim Insurance Policies of Opposite Party No.1 to complainant No.1 bearing Policy Numbers 310700/48/01/00828 for the period from 1.2.2002 to 31.1.2012 and 310700/48/01/0965 valid for the period from 14.3.2002 to 13.3.2012 alongwith endorsement numbers 310700/48/01/30032 and 310700/48/01/30033 respectively. The complainant No.2 due to her acute back pain problem, was referred for hospitalization in Neuro Pain Center, Majitha Verka Bye-Pass, Amritsar, where she was hospitalized for 12 days i.e. from 17.6.2011 to 29.6.2011 for the treatment of Chronic PID with acute exaggeration with RSS. The complainant No.1 informed the Opposite Party No.1 in writing about the hospitalization of complainant No.2 vide letter dated 20.6.2011 and thereafter, complainant No.1 lodged a medical claim of Rs. 31100/- by submitting claim form dated 10.9.2011 alongwith all the bills  of hospitalization including X-ray and MRI expenses with Opposite Party No.1, but the Opposite Party No.1 treated the claim of the complainant No.2 as ‘No Claim’ vide letter dated 19.12.2011 for the reasons that as per their panel doctors, the treatment is unrecognized and not authentic, further the centre was not registered and equipped as per policy condition.    Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to make the payment of claim amount of Rs.31100/- alongwith interest. 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 as per panel of doctors, the treatment is unrecognized and not authentic one. Moreover, the centre where the alleged treatment is stated to have been taken, is neither registered nor equipped as per policy terms and conditions. In fact it is a palliative Gimmic. The term  unrecognized means that the line of treatment given in the present case is not authentic and not recognized by any medical Board or Council of India. Moreover, the Centre  where the treatment has been taken is neither registered nor does it comply with definition of Hospital/ Nursing Home as laid down in terms and conditions of the Medi Claim Insurance Policy. However, being not satisfied with the said decision, the case of the complainant is that he had made lengthy correspondence with the Opposite Party No.1 for considering the claim of Mrs.Kaushalaya, complainant No.2 again. In this regard, the said request of the complainant was also considered by the Opposite Party and matter was referred to the competent authority who after examining the matter, again came to the conclusion that the claim has rightly been repudiated and the matter was again taken up with Medical Board who opined that the treatment is unrecognized. While denying and controverting other allegations, dismissal of complaint was prayed.
3. None appeared on behalf of Opposite Party No.2, so Opposite Party No.2 was proceeded against exparte vide order dated 25.2.2014 of this Forum. 
4. Complainants tendered into evidence the affidavit of complainant No.1 Ex.C1 alongwith documents Ex.C2 to 27.
5. Opposite Party No.1 tendered into evidence affidavit of Sh.Sunil Mahajan, Sr.Divisional Manager Ex.OP1/1, affidavit of Dr.Arun Aggarwal Ex.OP1/2 alongwith documents Ex.OP1/3 to Ex.OP1/ 7 and closed the evidence on behalf of the Opposite Party No.1.
6. 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.
7. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that complainant No.1 being as  an ex-employee of Opposite Party No.2-Bank had medical insurance policy with Opposite Party No.1 as the complainant No.1  had opted for early  retirement under VRS Scheme. As per the policy, Opposite Party No.2 issued two Medi Claim Insurance Policies of Opposite Party No.1 to complainant No.1 bearing Policy Number 310700/48/01/00828 for the period from 1.2.2002 to 31.1.2012 and 310700/48/01/0965 valid for the period from 14.3.2002 to 13.3.2012 alongwith terms and conditions of the policies. The aforesaid policies cover complainant No.2 Kaushalya wife of complainant No.1.  The complainant No.2 suffered acute back pain problem and she was admitted in Neuro Pain Center, Majitha Verka Bye-Pass, Amritsar, where she was hospitalized from 17.6.2011 to 29.6.2011 for the treatment of Chronic PID with acute exaggeration with RSS, as per Discharge Summary Ex.C14 and this Neuro Pain Centre is being run by Dr.Ravi Pal. Opposite Party No.1 was informed in this regard vide letter dated 20.6.2011 Ex.C3. The   complainant No.1 spent  Rs. 31100/- on the medical treatment of his wife Smt.Kaushalya complainant No.2. The claim was lodged with Opposite Party No.1 vide claim form dated 10.9.2011 Ex.C6, but the Opposite Party No.1 treated the claim of the  complainants as ‘No Claim’ on the ground that the treatment of complainant No.2 is unrecognized and not authentic, further the centre was not registered and equipped as per policy condition. Thereafter, the complainant wrote letter dated 17.2.2012 Ex.C21 to Opposite Party No.1 alongwith certificate dated 4.2.2012 regarding the recognition of the centre and authenticity of treatment given to complainant No.2 Ex.C16 and also issued reminder dated 16.8.2012 Ex.C23 and the Opposite Party No.1 sent reply dated 22.8.2012 Ex.C25 vide which they submitted that the matter of the complainant was once again taken up with their medical board who are of the opinion that the treatment is unrecognized and centre is also not recognized. So, the claim is not admissible. The complainant also sent notice Ex.C26, but all in vain and the Opposite Party No.1 did not  pay the aforesaid claim to the complainant. Ld.counsel for the complainants  submitted that all this amounts to deficiency of service on the part of the opposite party No.1.
8. Whereas the case of the opposite party No.1 is that the claim of complainant No.1 with respect to  treatment of his wife Smt.Kaushalya is not payable because as per the  panel of doctors, the treatment undergone by complainant No.2 is unrecognized and not authentic one. Moreover, the centre where the alleged treatment stated to have been taken is neither registered nor equipped as per policy terms and conditions. In fact it is a palliative Gimmic. The term  unrecognized means that the line of treatment given in the present case is not authentic and not recognized by any medical Board or Council of India. Moreover, the Centre  where the treatment has been taken is neither registered nor does it comply with definition of Hospital/ Nursing Home as laid down in terms and conditions of the Medi Claim Insurance Policy.  The claim of the complainant was repudiated vide letter dated 19.12.2011 Ex.Op1/4. The complainant No.1 made another request for reviewing the decision again. Said  request of the complainant was considered by Opposite Party No.1 and the matter was referred to  the competent authority who after examining the matter again came to the conclusion that the claim has rightly been repudiated by Opposite Party No.1.  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
9. From the entire above discussion, we have come to the conclusion that  the complainant No.1 being an ex-employee of Opposite Party No.2-Bank had two medical insurance policies as the  complainant No.1 had opted for early  retirement under VRS Scheme, as is evident from the contract of insurance between the Opposite Parties vide agreement Ex.C2. Smt.Kaushalaya wife of complainant No.1 was also covered as per these policies. The complainants submitted that complainant No.2 suffered due to her acute back pain problem, was referred for hospitalization in Neuro Pain Center, Majitha Verka Bye-Pass, Amritsar, where she was hospitalized for 12 days i.e. from 17.6.2011 to 29.6.2011 for the treatment of Chronic PID with acute exaggeration with RSS (Back Ache due to disc protrusion). The complainant No.1 informed the Opposite Party No.1 in writing about the hospitalization of complainant No.2 vide letter dated 20.6.2011 and thereafter, complainant No.1 lodged a medical claim of Rs. 31100/- by submitting claim form dated 10.9.2011 alongwith all the bills  of hospitalization including X-ray and MRI expense, vide claim dated 10.9.2011 Ex.C6 with Opposite Party No.1 under the aforesaid policies, but the Opposite Party No.1 treated the claim of the complainant No.2 as ‘No Claim’ vide letter dated 19.12.2011 for the reasons that as per their panel doctor, the treatment is unrecognized and not authentic, further the centre was not registered and equipped as per policy condition. It is just a palliative Gimmic. Opposite Party No.1 has obtained a report of Dr.Arun Aggarwal who vide his report Ex.Op1/6 has submitted that the complainant No.2 Mrs.Kaushalya wife of Ranjit Singh had back pain and she was being treated by Dr.Ravi Pal since 20.5.2011 and after tests, she was diagnosed as a case of degenerative disc disease-disc bulge and protrusion with compression of nerve roots and annular tear. She was referred  to neuro pain center which was run and owned by same doctor Dr.Ravi Pal and one of his colleague Dr.Jagdeep who is a psychiatrist. But this Neuro Pain Centre is neither  registered one or recognized. However, another centre Bhatia Neurosurgical Hospital is registered as de-addiction clinic, but said de-addiction clinic had no authority to open Neuro Pain Centre without getting the same registered. The registration as per rules is given to each centre differently and one registration can not be effective for another centre in different location. He further submitted that the treatment undergone by complainant No.2 is basically an alternative therapy profile like acupuncture, acupressure, electromagnetic, physiotherapy. The treatment is palliative and acts as placebos and not a curative treatment.  Moreover, it is not an indoor treatment. The system is computerized electro magnetic machine parented by the authority does not authenticate the treatment genuinely. CDD sessions given daily with required desiccation physiotherapeutic technique. These sessions are of 35 minutes each and done as day sitting and does not require any admission. Center does not fulfill the laid down criterion of nursing home guidelines  for infrastructure and facilities and staff. This report Ex.Op1/6 has been duly proved by Dr.Arun Aggawal vide his affidavit Ex.Op1/2. The complainant could not rebut this report. However, the complainant produced on record a certificate from Bhatia Neuro Psychiatric Hospital & De-Addiction Centre, Amritsar Ex.C16 dated 4.2.2012 vide which Dr.Ajit Inder Singh Bhatia has certified that Neuro Pain Centre, Majitha-Verka Bye-Pass Road, Amritsar is their branch and working under their hospital. But in this certificate, it has been admitted by Dr.Ajit Inder Singh Bhatia that the aforesaid Neuro Pain Centre is not registered. However, their hospital is registered with Registration No.PSY-22. So, it stands admitted on record that the Neuro Pain Centre in which the complainant No.2 remained admitted is not a registered Nursing Home/Hospital or Centre. As such, it can not be said that it is fully equipped with all medical facilities which are required by a registered Nursing Home/ Hospital or Centre. Further, through his report Ex.Op1/6 which was duly proved by Dr.Arun Aggarwal vide his affidavit Ex.Op1/2, it has been clearly mentioned that the treatment undergone by complainant o.2 is basically an alternative therapy profile like acupuncture, acupressure, electromagnetic, physiotherapy. The treatment is palliative and acts as placebos and not a curative treatment.  Moreover, it is not an indoor treatment. The system is computerized electro magnetic machine parented by the authority does not authenticate the treatment genuinely, for which the admission is not required. As per terms and conditions of the policy Ex.C2, such like treatment is not covered under the policy. The complainant has failed to  rebut this documentary evidence produced  and proved on record by Opposite Party No.1. Consequently, we hold that the Opposite Party No.1 was justified in treating the claim of the complainant as ‘No Claim’ as per terms and conditions of the policy Ex.C2.
10. Resultantly the complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. 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: 02/03/2015.                                                  

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