DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.547 of 02-12-2010 Decided on 21-04-2011
Om Parkash Singla, aged about 48 years, s/o Sh.Mahavir Parshad, r/o Singla Traders, 100 ft. Road, Bathinda. .......Complainant
Versus The New India Assurance Co. Ltd., Red Cross Complex (Gole Diggi), The Mall, Bathinda, through its Branch Manager. The New India Assurance Co. Ltd., 2090, The Mall, Bathinda, through its Divisional Manager. M/s.Alankit Health Care Ltd., Alankit House, 2E/21, Jhandewala Extension, New Delhi-110055, through its Branch Manager.
......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM
Smt. Vikramjit Kaur Soni, President. Dr.Phulinder Preet, Member. Sh.Amarjeet Paul, Member. Present:- For the Complainant: Sh.Lovenish Garg, counsel for the complainant. For Opposite parties: Sh.Vinod Garg, counsel for opposite party Nos.1&2. Opposite party No.3 exparte. ORDER
VIKRAMJIT KAUR SONI, PRESIDENT:-
1. The present complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended up-to-date (Here-in-after referred to as 'Act'). The brief facts of the complaint are that the complainant had obtained Medi Claim Insurance Policy (Hospitalization Benefit Policy) from the opposite party No.1 bearing policy No.360601/34/ 08/11/00000119, valid from 15.10.2008 to 14.10.2009 for himself and his wife Swaran Singla for Sum Assured of Rs. 2 Lacs after paying the premium of Rs.11,018/- to the opposite party No.1 and covered all medical expenses and hospitalization etc., if any, during this period of the Insurance Policy. On 11.02.2009, the complainant suffered from fever and urine problem and consulted with local doctor who recommended him some tests which were done from Religare SBL Diagnostic Centre, Gurgaon through Bathinda, patient service center and report of the same has been received on 14.02.2009. On 16.02.2009, the complainant consulted with Dr.Anshuman V.Kapoor of Kapoor's Kindey & Uro Stone Centre Pvt. Ltd., Chandigarh with regard to the above said problem. Dr. A.V.Kapoor had thoroughly checked the complainant and conducted some pathology tests (Laboratory Tests) from outside as well as his hospital. After going thorugh the said tests, the doctor detected the exact problem of Stricture Urethra and advised the complainant for admission and laser operation. On 17.02.2009, the complainant admitted in the hospital of Dr.A.V.Kapoor who has conducted the operation of the complainant. The complainant was discharged on 18.02.2009 and advised for routine checking on 23.02.2009 and on various dates. The complainant has spent Rs.50,000/- approximately on his treatment and the complainant intimated the opposite party no.1 and submitted his all original medical reports, medical bills and completed other formalities which are required for processing the claim of the complainant. When the complainant approached the opposite party No.1 for releasing the claim amount of his mediclaim, the opposite party No.1 told the complainant that his claim has been settled by their counter part M/s Alankit Healthcare Ltd. i.e. opposite party No.3 and they will release the claim amount. The complainant was very much surprised with the said version of the opposite party No.1 because the complainant had obtained the insurance policy from the opposite party No.1 and paid the premium to it but they sent the matter to another department i.e. opposite party No.3 for harassing the complainant. The complainant alleged that till date, the opposite parties neither settled nor repudiated the claim of the complainant. Hence, the complainant has filed this complaint. 2. The opposite party Nos.1&2 have filed their joint written statement and pleaded that the said policy was in its first year i.e. the same was not renewed from any earlier policy. In the said policy, the opposite party No.3 was TPA i.e. third party administrator to decide the claim as per terms and conditions of the policy. The opposite party Nos.1&2 have denied that it is wrong to state that all medical expenses and hospitalization etc. were covered under the said policy. The opposite party Nos.1&2 have admitted the fact that the complainant has suffered from stricture urethra which is not covered during the first 2 years of the policy and comes under exclusion clause 4.3 of the policy, the claim was rightly repudiated by the opposite party No.3 vide letter dated 17.06.2009 which was sent at the address supplied by the complainant at the time of getting insurance. Letter dated 18.02.2010 was also sent by the opposite party Nos.1&2 intimating the complainant about the rejection of the claim. The opposite party Nos.1&2 have denied that the complainant has spent Rs.50,000/- approximately on his treatment rather he himself has submitted the claim amount to the tune of Rs.40,436/- which was payable only in cash, the claim was held genuine and payable as per terms and conditions of the policy. It was in the knowledge of the complainant that the claim is to be decided by TPA, since the name of TPA is mentioned in the policy it self. The claim of the complainant has already been repudiated by the opposite party No.3 vide letter dated 17.06.2009 for reasons stated therein. 3. The opposite party No.3 despite service of notice, has failed to appear before this Forum. Hence, exparte proceedings are taken against the complainant. 4. Parties have led their evidence in support of their respective pleadings. 5. Arguments heard. Record alongwith written submissions submitted by the parties perused. 6. The learned counsel for the complainant has submitted that the complainant-Om Parkash purchased Medi Claim Insurance Policy (Hospitalization Benefit Policy) bearing policy No.360601/34/08/11/000 00119, from the opposite party No.1 which was valid from 15.10.2008 to 14.10.2009. The complainant purchased this policy for himself and his wife Swaran Singla for Sum Assured of Rs. 2 Lacs after paying the premium of Rs.11,018/- to the opposite party No.1 and covered all medical expenses and hospitalization etc., if any. On 11.02.2009, the complainant suffered from fever and urine problem and consulted with doctor who recommended him some tests which were got done on 14.02.2009. On 16.02.2009, the complainant consulted Dr.Anshuman V.Kapoor who diagnosed the complainant suffering problem of stricture urethra and advised him to under go for laser operation. On 17.02.2009, the complainant was admitted in the hospital of Dr.A.V.Kapoor who has conducted the operation of the complainant and discharged him on 18.02.2009 and advised for routine checking on 23.02.2009 and on various dates. The complainant had spent Rs.50,000/- approximately on his treatment. The complainant intimated the opposite party no.1 and submitted his all original medical reports, medical bills and completed other formalities to the opposite party No.1 but the opposite party No.1 told the complainant that his claim would be settled by the opposite party No.3. The complainant has alleged that the opposite parties neither settled nor repudiated the claim of the complainant till date. 7. The learned counsel for opposite party Nos.1&2 has submitted that the said policy was in its first year and it was not renewed from any earlier policy. According to the said policy, the opposite party No.3 i.e. TPA (third party administrator) to decide the claim as per terms and conditions of the policy. 8. Admittedly, the complainant suffered from stricture urethra which is not covered during the first 2 years of the policy rather comes under exclusion clause 4.3 of the policy, the claim was repudiated by the opposite party No.3 vide letter dated 17.06.2009 which was sent at the address supplied by the complainant at the time of getting insurance. Letter dated 18.02.2010 was also sent by the opposite party Nos.1&2 intimating the complainant about the rejection of the claim. As per claim submitted by the complainant himself, the claimed amount was Rs.40,436/- not Rs.50,000/-. The complainant was admitted in A.V.Kapoor Hospital where laser operation stricture urethra was done. 9. Vide Ex.C-3, the complainant was got operated on 17.02.2009 and discharged on 18.02.2009. When the complainant filed the claim, the opposite party No.3 rejected the claim on the ground that exclusion clause 4.3 is applicable on the complainant and done the claim of the claimant as 'No Claim' and closed the claim file on the ground of following reasons:- the claim comes under exclusion 4.3 of the policy vide Ex.C-20 and further contended that the disease is not covered during first 2 years of the policy for the said disease. It is quite ironical that they are issuing the policy for one year and imposing the clause which according to them, is applicable during first 2 years of the policy. 10. The complainant has informed the opposite party No.1 vide letter Ex.C-32 that he has been suffering from stricture urethra and will be admitted in the hospital on 17.02.2009. Thereafter, after under going the operation, he filed the claim with the opposite parties who sent the case of the complainant to TPA. The TPA rejected the claim of the complainant on the ground that the clause 4.3 is applicable on the complainant. 11. A perusal of Ex.R-3 clause 4.3 which is reproduced as under:- “During the first year of the operation of insurance cover, the expenses on treatment of diseases such as cataract, Benign, Prostatic Hypertrophy, Hysterectomy for Menomhagia or Fibromyoma,Hernia, Hydrocele, Congenltal, internal diseases, Fistula in arms, Plles, Shnustlis and related disorders are not payable. If these are pre existing at the time of proposal they will not be covered even during subsequent period of renewal too.” According to this clause, it has not been specifically mentioned that stricture urethra is not covered. The opposite parties cannot interpreted the clause in their favour only. As per the law laid down by Hon'ble Supreme in case titled United India Insurance Co. Ltd. Vs. M/s Prshpalaya Printers, 2004(1) SC 23, wherein it has been held that :- “Interpretation: Two interpretations possible one beneficial to insured should be accepted: Words of documents if ambiguous, shall be constructed against party who prepared it.” The claim of the complainant has been rejected only on this exclusion clause where no any words like stricture urethra are written. Moreover, their plea that disease of the complainant is not covered during first 2 policy years is not tenbale as the policy is of 1 year only. The opposite parties have wrongly rejected the claim of the complainant. 12. Hence, in view of what has been discussed above, this Forum is of the considered view that there is deficiency in service on the part of the opposite parties for not settling the claim of the complainant. Therefore, this complaint is accepted with Rs.5,000/- as cost and compensation against all the opposite parties and the opposite party Nos.1&2 are directed to pay Rs.40,436/- alongwith interest @ 9% p.a. from the date of filing of this complaint till realization. The amount of cost and compensation will be paid by the opposite parties jointly or severally. Compliance of this order be done within 45 days from the date of receipt of copy of this order. 13. A copy of this order be sent to the parties concerned free of cost and file be consigned for record. '
Pronounced in open Forum 21-04-2011 (Vikramjit Kaur Soni) President
(Dr.Phulinder Preet) Member
(Amarjeet Paul) Member
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