BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.254 of 2014

Date of Instt. 04.08.2014

Date of Decision :02.02.2015

Krishan Lal aged about 61 years son of Sahia Ram R/o 97, Adarsh Nagar, Jalandhar.

..........Complainant

Versus

1. New India Assurance Company Ltd, through its authorized signatory, New India Assurance Building, 87, Mahatma Gandhi Road, Fort, Mumbai-400001.

2. New India Assurance Company Ltd, through its Branch Manager, 16, Patel Chowk, Jalandhar.

3. Raksha TPA Pvt Ltd, through its authorized signatory, 2nd Floor, SCO-181, Sector-7C, Chandigarh-160019.

.........Opposite parties

Complaint Under the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Present: Sh.Gagandeep Adv., counsel for complainant.

Sh.Raman Sharma Adv., counsel for opposite parties.

Order

J.S Bhatia (President)

1. The complainant has filed the present complaint under the Consumer Protection Act, against the opposite parties on the averments that the complainant is handicap. The complainant purchased a mediclaim policy 2007(hospitalization benefit policy) bearing policy No.36100234130100000045 from the opposite party No.2, which was renewed on 2.5.2014 and valid upto 1.5.2015. The policy number issued to the complainant on renewal of policy is 36100234142500000020 and ID of the complainant is 8H3238885. Since the beginning of the policy only cover notice was provided to the complainant without actually providing the policy document to the complainant. The complainant was not fine during March, 2014, so he has got himself examined and treated from Ranjit Hospital Chest & Sleep Disorders Care Centre, Patel Chowk, Jalandhar. The complainant was treated by Ranjit Hospital from 12.3.2014 to 21.3.2014. After discharge from hospital the complainant lodged mediclaim of Rs.1,43,747/- with the opposite party No.2 on 22.4.2014, as the complainant has purchased a medical policy 2007 from opposite party No.2 which was renewed on 2.5.2014 and valid upto 1.5.2015. The opposite party No.3 is third party administrator, Vide letter dated 28.4.2014 and 1.5.2014 addressed to the complainant, the opposite party No.3 asked for the documents which the complainant supplied, but despite providing the documents as requested by the opposite party No.3, the complainant was astonished to see that only claim of Rs.79247/- was passed by the opposite party No.3, despite the fact that the complainant lodged claim of Rs.1,43,747/- with the opposite party No.2. The opposite party No.3 wrongly deducted the claim amount of the complainant. The opposite party No.3 nowhere in letters dated 28.4.2014 and 1.5.2014 gave the alleged reason of deduction as alleged in claim status issued by the opposite party No.3. The complainant approached opposite parties number of times and requested them to release the deducted claim amount of Rs.64,500/- i.e Rs.59,500 for Remstar and Rs.5000/- for Bipap, but the opposite parties put off the complainant with one pretext or another. The complainant even wrote a letter dated 23.5.2014 to the opposite party No.2 but in vain. On such like averments, the complainant has prayed for directing the opposite parties to pay him the remaining amount of Rs.64,500/- i.e Rs.59,500 for Remstar and Rs.5000/- for Bipap. He has also claimed compensation.

2. Upon notice, opposite parties appeared and filed a written reply pleading that the claim payable as per terms and conditions of the insurance policy was approved by the opposite party No.3 for Rs.79,247 out of Rs.1,43,747/- as bill of Rs.59,500/- for the purchase of instrument/Device Remstar Auto used for breathing was not payable as per terms and conditions of the insurance policy and so also Rs.5000/- spent on BiPAP(bi-level positive airway pressure) which is a type of noninvasive ventilation that helps keep the upper airways of the lungs open by providing a flow of air delivered through a face mask. The certificate issued by Ranjit Hospital, Near Kapurthala Chowk, Jalandhar clearly shows that Krishan Lal is suffering from OSA with COPD i.e Obstructive Sleep Apnea Syndrome with chronic obstructive pulmonary disease and he needs long term treatment with CPAP machine i.e continuous positive airway pressure machine that uses mild air pressure to keep the airways open. CPAP is typically used by people who have breathing problems, such as obstructive sleep apnea syndrome which is a specific exclusion under exclusion clause 4.4.15 of the insurance policy and not cover under insurance policy, as such the complaint is liable to be dismissed. The amount of Rs.79,247/- payable under policy as per terms and conditions already stands paid to the complainant. They denied other material averments of the complainant.

3. In support of his complaint, learned counsel for the complainant has tendered affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C17 and closed evidence.

4. On the other hand, learned counsel for opposite parties has tendered affidavit Ex.OA alongwith copies of documents Ex.O1 to Ex.O8 and evidence of opposite parties was closed due to non payment of cost.

5. We have carefully gone through the record and also heard the learned counsels for both the parities.

6. The facts involved in the present case are not much disputed. It is not disputed that complainant has obtained mediclaim policy from the opposite party insurance company. The complainant fell ill during March 2014 and got treatment from Ranjit Hospital from 12.3.2014 to 21.3.2014. After discharge from the hospital, he lodged claim of Rs.1,43,747/- with opposite party insurance company and opposite party insurance company paid him Rs.79,247/- out of the above said amount. The insurance company disallowed the claim of Rs.64,500/- i.e Rs.59,500 for Remstar and Rs.5000/- for Bipap. According to the opposite parties, the above said amounts have been deducted as per terms and conditions of the policy and further as per exclusion clause 4.4.15 of the insurance policy. Ex.O4 is certificate issued by Ranjit Hospital wherein it is mentioned as under:-

"This is to certify that Krishan Lal is suffering from severe OSA-COPD and he need long term treatment-CPAP machine at home".

7. It is also in the affidavit Ex.OA of Sunil Mahajan, Senior Divisional Manager of opposite party insurance company that the certificate issued by Ranjit Hospital, Near Kapurthala Chowk, Jalandhar clearly shows Krishan Lal suffered from OSA with COPD i.e Obstructive Sleep Apnea Syndrome with chronic obstructive pulmonary disease and he needs long term treatment with CPAP machine i.e continuous positive airway pressure machine that uses mild air pressure to keep the airways open. CPAP typically is used by people who have breathing problems, such as obstructive sleep apnea syndrome which is a specific exclusion under exclusion clause 4.4.15 of the insurance policy. Ex.O2 contains terms and conditions of mediclaim policy. Exclusion Clause 4.4.15 is as under:-

"Instrument used in treatment of Sleep Apnea Syndrome(CPAP) and Continuous Peritoneal Ambulatory Dialysis(CPAD) and Oxygen Concentrator for Bronchial Asthamtic condition".

8. So from the above exclusion clause it is evident that the CPAP machine is excluded. Similarly cost of BiPAP(bi-level positive airway pressure) which is a type of noninvasive ventilation is also excluded from the claim under the insurance policy. Counsel for the complainant contended that complainant was supplied only the cover note and not the policy or its terms and conditions. This version of the complainant can not be accepted. Ex.O1 is policy schedule and in it date of issuance of first policy is mentioned as 2.5.2002. At the time of arguments, the complainant was also present and he admitted at bar that he is obtaining mediclaim policy 2007 since year 2007. So complainant is obtaining mediclaim policy since 2002 i.e for the last 12 years. So it is not probable and believable that he was not aware of the terms and conditions of the policy in question and had not received the same during all this period. So opposite party insurance company has rightly excluded the cost of CPAP and BiPAP machine as per exclusion clause 4.4.15 of the terms and conditions of the policy which are Ex.O2 on record.

9. In view of above discussion, we hold that there is no merit in the present complaint and same is dismissed with no order as to cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Jyotsna Thatai Jaspal Singh Bhatia

02.02.2015 Member President