Punjab

Faridkot

CC/17/345

Rupinder Singh - Complainant(s)

Versus

The New India Assurance Co. Lt. - Opp.Party(s)

Sarnam Singh Sandhu

07 May 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :             345 of 2017

Date of Institution:    17.10.2017

Date of Decision :       7.05.2019

 

Rupinder Singh aged about 32 years, son of Sukhwant Singh, r/o Village Pakhi Kalan, District Faridkot.

...Complainant

Versus

1. The New India Assurance Company Limited, Branch Officer (360703) Ground Floor, Jeevan Jyoti Building Opp.Verma Petrol Pump, Gaushala Road, abohar-152116.
2. New India Assurance Company Bldg.87 M G Road Fort, Mumbai-400001Regd. & Head Office.
3. The New India Assurance Company Faridkot, Micro Office Shop No.69-70, Baba Farid Market, Faridkot, through its Branch Manager.

.....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Param Pal Kaur, Member.

 

Present: Sh Sarnam Singh Sadhu, Ld Counsel for Complainant,

              Sh Yash Pal Bansal, Ld Counsel for OPs.

 

ORDER

(Ajit Aggarwal, President)

cc  no. 345 of 2017

 

                                         Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of insurance claim worth  Rs.1,56,000/-with interest and for further directing OPs to pay Rs.50,000/- as compensation for deficiency in service, harassment, inconvenience, mental agony alongwith litigation expenses of Rs.11,000/-.

2                                        Briefly stated, the case of the complainant is that vide cover note bearing no. 3607033416280000056, complainant was insured with OPs for a sum of Rs. Two Lakhs for a period from 21.11.2016 to 20.11.2017 and during this period he fell ill and remained admitted in Sukhmani Hospital, Faridkot from 14.01.2017 to 16.01.2017 and from 7.03.2017 to 18.03.2017 in Dayanand Medical College and Hospital, Ludhiana and from 23.03.2017 to 27.03.2017 in Sukhmani Hospital and Heart Care Centre, Faridkot. He spent more than Rs.95,000/-on his treatment and thereafter, he duly informed OPs through phone as well by sending reference about his treatment, but they did not settle the claim  and refused to accept the claim of complainant on the basis of report given by Medanta Hospital, Gurgaon but same report was duly rejected by this Forum in complaint no.89 of 2016 decided on 16.01.2017. Due to non settlement of claim by OPs, complainant has been suffering great economic problems and hardships. Complainant made many requests to Ops to settle his claim, but all in

cc  no. 345 of 2017

vain. This act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for directions to OP to pay Rs.50,000/-as compensation alongwith Rs.11,000/-as cost of litigation besides the main relief. Hence, the present complaint.

3                                       The counsel for complainant was heard with regard to admission of the complaint and vide order dated 17.11.2017, complaint was admitted and notice was ordered to be issued to the opposite parties.

4        On receipt of the notice, OPs filed written statement taking preliminary objections that this Forum has no jurisdiction to hear and try the present complaint and there is no deficiency in service on the part of answering OPs and therefore, present complaint is liable to be dismissed. It is averred that complaint involves complex questions of law and facts, which require voluminous evidence and it can not be decided by this Forum having limited jurisdiction and limited time span and therefore, it is liable to be referred to competent Civil Court. It is averred that claim of complainant was rejected as per terms and conditions of the Policy under clause 4.4.6 as OP-3/TPA scrutinized all the papers submitted by complainant and observed that “the Patient is diagnosed with recurrent acute pancreatitis managed conservatively, as per prescription of Endocrinology Deptt of Medanta Hospital, patient is chronic alcoholic, alcohol consumption is the cause

cc  no. 345 of 2017

of Pancreavititis’ As per clause 4.4.6 of the Policy terms and conditions, the treatment related to alcoholic disorder is not payable. As per clause 4.4.6 Convalescence, General Debility, Rundown Condition or Rest Cure, Obesity treatment and its complications congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating, drugs alcohol, use of  tobacco leading to cancer. Complainant is not the consumer of OPs and no cause of action arises against OPs. It is further averred that OPs are liable to pay only upto Rs.49,735/-as he lodged claim of treatment from 7.03.2017 to 18.03.2017 from DMC, Ludhiana.  It is further averred that Raksha TPA Pvt Ltd is a necessary party as per terms and conditions as claim is to be lodged with them and therefore, present complaint is liable to be dismissed on this score.  However, on merits, ld counsel for OPs have denied all the allegations of complainant and reiterated the same pleadings as taken in preliminary objections. Ld counsel for OPs further asserted that there is no deficiency on their part and prayed for dismissal of complaint with costs.

5                                                 Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to 107 and then, closed his evidence.

6                                               In order to rebut the evidence of the complainant, the ld Counsel for OPs tendered in evidence,

cc  no. 345 of 2017

affidavit of Deen Dyal, Div. Manager as Ex OP-1 and documents Ex OP-2 to Ex OP-6 and then, closed the same on behalf of OPs.

7                                              We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

8                                                 Ld Counsel for complainant has vehementally argued that complainant was insured with OPs under Policy in question for a sum of Rs. two lakhs  for a period from 21.11.2016 to 20.11.2017 and during this period of insurance, he fell ill and remained admitted in Sukhmani Hospital, Faridkot from 14.01.2017 to 16.01.2017 and from 7.03.2017 to 18.03.2017 in Dayanand Medical College and Hospital, Ludhiana and from 23.03.2017 to 27.03.2017 in Sukhmani Hospital and Heart Care Centre, Faridkot and spent Rs.95,000/-on his treatment and thereafter, he lodged claim with OPs, but they refused to settle the claim of complainant on the basis of report given by Medanta Hospital, Gurgaon though same report was rejected by this Forum in complaint no.89 of 2016 decided on 16.01.2017. complainant made several requests to OPs and even issued legal notice to OPs wherein requested them to pass his genuine claim but all in vain. This act of OPs amounts to deficiency in service and it has caused harassment and mental agony to him. He has prayed for accepting the present complaint alongwith compensation and litigation expenses. He has stressed on documents Ex C-1 to 107.

cc  no. 345 of 2017

9                            To controvert the allegations of complainant, ld counsel for OPs argued before the Forum that complaint filed by complainant is not maintainable in present form and is liable to be dismissed as complainant is not the consumer of OPs and this Forum has no jurisdiction to decide the same. It is further averred that claim of complainant has rightly been rejected as per terms and conditions of the Policy given under clause 4.4.6. as OP-3/TPA scrutinized all the papers submitted by complainant and observed that “the Patient is diagnosed with recurrent acute pancreatitis managed conservatively, as per prescription of Endocrinology Deptt of Medanta Hospital, patient is chronic alcoholic, alcohol consumption is the cause of Pancreavititis’ As per clause 4.4.6 of the Policy terms and conditions, the treatment related to alcoholic disorder is not payable. As per clause 4.4.6 Convalescence, General Debility, Rundown Condition or Rest Cure, Obesity treatment and its complications congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating, drugs alcohol, use of  tobacco leading to cancer. Complainant is not the consumer of OPs and no cause of action arises against OPs. It is further averred that OPs are liable to pay only upto Rs.49,735/-as he lodged claim of treatment from 7.03.2017 to 18.03.2017 from DMC, Ludhiana. Raksha TPA Pvt Ltd is a necessary party as per terms and conditions and claim was to be lodged with them and therefore, present complaint is liable to be dismissed. OPs have denied all the allegations of complainant and reiterated that there is

cc  no. 345 of 2017

no deficiency in service on their part and stressed on documents Ex OP-1 to Ex OP-6.

10                                               After careful perusal of the record available on file and going through the evidence led by parties, it is observed that case of the complainant is that he was insured with OPs and during the period of insurance, he fell ill and he undertook his treatment from Sukhmani Hospital, Faridkot from 14.01.2017 to 16.01.2017 and from 7.03.2017 to 18.03.2017 in Dayanand Medical College and Hospital, Ludhiana and  he again underwent treatment in Sukhmani Hospital and Heart Care Centre, Faridkot from 23.03.2017 to 27.03.2017. He paid Rs.95,000/- to hospital authorities for his treatment. Main contention of complainant is that he was insured with OPs and submitted his claim documents with them, but despite this, OPs refused to make payment of genuine Mediclaim of complainant on false grounds. On the other hand plea taken by OPs is that complainant was an alcoholic and they have rightly rejected his claim as per terms and conditions of Insurance Policy. As per OPs, TPA scrutinized all the papers submitted by complainant and observed that “the Patient is diagnosed with recurrent acute pancreatitis managed conservatively, as per prescription of Endocrinology Deptt of Medanta Hospital, patient is chronic alcoholic, alcohol consumption is the cause of pancreavititis’ As per clause 4.4.6 of the Policy terms and conditions, the treatment related to alcoholic disorder is not payable.

 

cc  no. 345 of 2017

11                                From the careful perusal of record placed on record by complainant it is observed that complainant was neither an alcoholic nor had any addiction for drugs. In document Ex 13 which is copy of discharge summary dated 9.02.2017 issued by Dayanand Medical College and Hospital, Ludhiana it is specifically mentioned that cause of admission in hospital is vomiting for ten days and indigestion of food. Further from document Ex C-49 that is also copy of discharge summary dated 18.03.2017 issued by Dayanand Medical College and Hospital, Ludhiana, it is clearly written that cause of admission of complainant in said hospital is vomiting for five days and pain in abdomen. No where in any documents it is mentioned that complainant was in habit of taking tobacco or alcoholic substances. It is observed that there is no personal history /habit of smoking, tobacco chewing, alcohol, drugs etc or any other addiction to complainant. It is clearly written  that complainant suffered from Mild Acute Pancreatitis Status Gastrojejunostomy (Deodenal Stricture) and there is no report that complainant was having any personal history or habit of smoking, tobacco chewing, alcohol, drugs etc or any other addiction. Thus, in the light of these documents, how can OPs even presume or come to conclusion that complainant is an alcoholic or is a drug addict and thus, there is no ground for rejection of genuine Mediclaim of complainant. Repudiation of claim of insured complainant by OPs totally on false grounds amounts to deficiency in service and trade mal practice. Ex C-2 is the copy of insurance policy proving the fact that he was insured with

cc  no. 345 of 2017

OPs. Complainant has also produced on record copy of bills and reports from Ex C-4 to 104. Thus, complainant has placed on record sufficient and cogent evidence to prove his pleadings. Moreover, there is not even an iota of doubt over the authenticity of documents produced by complainant and it is made out that complainant was not having any past history of alcohol or tobacco chewing or any other king of drug addiction. It is observed that OPs have wrongly denied the claim of complainant and it amounts to deficiency in service on their part.

12                                      From the above discussion and evidence produced by the complainant, we are of considered opinion that Ops have wrongly and illegally repudiated the claim of complainant on false grounds of terms and conditions of Policy. The present complaint is hereby accepted and complainant is entitled for insurance claim on account of expenditure incurred by him on his treatment during the period of insurance. However, complainant has claimed Rs.95,000/- as allegedly spent by him for his treatment from 14.01.2017 to 16.01.2017 at Sukhmani Hospital, Faridkot, from 7.03.2017 to 18.03.2017 in DMC, Ludhiana and from 23.03.2017 to 27.03.2017 in Sukhmani Hospital, Faridkot, but as per OPs, complainant has lodged claim for reimbursement of expenses borne by him with DMC, Ludhiana for his treatment from 7.03.2017 to 18.03.2017 and he has not lodged any claim regarding his treatment with Sukhmani Hospital, Faridkot from 14.01.2017 to 16.01.2017 and from 23.03.2017 to 27.03.2017. Therefore, in these circumstances, complainant is entitled only for the

cc  no. 345 of 2017

claim amount regarding which he lodged claim with OPs and is not entitled for the amount for which has never lodged claim with OPs and therefore,  OPs are directed to pay Rs.50,435/-against the treatment taken by complainant at Dayanand Medical College and Hospital, Ludhiana from 7.03.2017 to 18.03.2017 alongwith interest at the rate of 9 % per anum from 26.07.2017 the date, when they repudiated the claim of complainant vide letter dt 26.07.2017 Ex C-105 till final realization. Ops are further directed to pay Rs.5000/- as litigation expenses to complainant. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 7.05.2019         

 

(Param Pal Kaur)                     (Ajit Aggarwal)

           Member                                               President