Punjab

Faridkot

CC/16/89

Rupinder Singh - Complainant(s)

Versus

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

Sarnam Singh Sandhu

16 Jan 2017

ORDER

      DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      89

Date of Institution: 01.04.2016

Date of Decision :   16.01.2017

 

Rupinder Singh son of Sukhwant Singh r/o village Pakhi Kalan, District Faridkot.

...Complainant

Versus

1. New India Assurance Company Ltd, Branch Office (360703) Ground Floor, Jeevan Jyoti Building Opp. Verma Petrol Pump, Gaushala Road, Abohar-152116.

2. New India Assurance Building.87 M G.Road Fort, Mumbai-400001Regd. & Head Office.

3. Raksha TPA Pvt Ltd. Through its Chief Executive Officer Mr. Pawan Bhalla c/o Escorts Corporate Centre, 15/5, Mathura Road, Faridbad (Haryana).

4. 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,

               Sh P Singla, Member.

 

Present: Sh  Gurjagpal Sigh Brar, Ld Counsel for complainant,

              Sh Yash Pal Bansal, Ld Counsel for OP-1 & 4,

              OP-2  & 3 Exparte.

 

(Ajit Aggarwal, President)

                                      Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment on account of medical claim of complainant and for further directing OPs to pay Rs.50,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.5,000/-.

2                               Briefly stated, the case of the complainant is that vide cover note bearing no. 3607033414280000013, complainant was insured under OP-3 for a sum of Rs. two lacs with Ops for a period from 21.11.2014 to 20.11.2015 and during this period he fell ill and remained admitted in hospital from 17.03.2015 to 24.03.2015 and he spent Rs.93,605/-on his treatment and thereafter, he remained under treatment and paid Rs.18,185/-vide bill dated 12.05.2015. employees of OP-3 asked for Opinion Report of treating doctor and doctor concerned mentioned in his report dt 23.03.2015 that “Patient is suffering from Acute Pancreatic Pseudocoist and GOO (Gastric Outlet Obstruction)  and it was also mentioned that there is no personal history of smoking, tobacco chewing, alcohol and drugs etc. thereafter, complainant duly informed OPs through phone as well by sending reference about his treatment, but they did not settle the claim and 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 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 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 29.04.2016, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                              On receipt of the notice, OP-1 and 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         filed written statement taking preliminary objections that complainant is not the consumer of OP-1 and 4 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 of pancreavititis’ As per clause 4.4.6 of the Policy terms and conditions, the treatment related to alcoholic disorder is not payable. 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 OP-1 and 4 further asserted that there is no deficiency on their part and prayed for dismissal of complaint with costs.

5                             Notice of complaint was issued to OP-2 and 3 through registered post, but same did not receive back. Acknowledgment might have been mis-laid or lost in transit and it is deemed that they would have sufficient knowledge of complaint against them. Both OP-2 and 3 did not appear despite making several calls in the Forum on date fixed, therefore after waiting for long period till 4.00 pm, OP-2 and 3 were proceeded against exparte vide order dated 5.06.2016.

6                                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 25 and then, closed his evidence.

7                             In order to rebut the evidence of the complainant, the ld Counsel for OP-1 and 4 tendered in evidence, affidavit of Deen Dyal, Div. Manager as Ex OP-1 and documents Ex OP-2 and then, closed the same on behalf of OP-1 and 4.

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

9                         Ld Counsel for complainant has vehementally argued that complainant was insured under OP-3 for a sum of Rs. two lacs with Ops for a period from 21.11.2014 to 20.11.2015 and during this period of insurance, he fell ill and remained admitted in hospital from 17.03.2015 to 24.03.2015 and spent Rs.93,605/-on his treatment and thereafter, he remained under treatment and paid Rs.18,185/-vide bill dated 12.05.2015. Employees of OP-3 asked for Opinion Report of treating doctor and doctor concerned mentioned in his report dt 23.03.2015 that “Patient is suffering from Acute Pancreatic Pseudocoist and GOO (Gastric Outlet Obstruction)  and it was also mentioned that there is no personal history of smoking, tobacco chewing, alcohol and drugs etc. thereafter, complainant duly informed OPs through phone as well by sending reference about his treatment, but they did not settle the claim and 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 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 25.

10                              To controvert the allegations of complainant, ld counsel for OP-1 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. It is averred that 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. It is  reiterated that there is no deficiency on their part and stressed on documents Ex OP-1 and 2.

11                     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 got his treatment from Medanta The Medicity, Global Health Pvt Ltd, New Delhi and he remained admitted in said hospital from 17.03.2015 to 24.03.2015 and paid Rs.93,605/- to hospital authorities and even after being discharged from hospital, he remained under their treatment and spent Rs.18,185/-vide bill dt 12.05.2015. 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, 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.

12                                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 C-24, which is copy of certificate issued by Dr Vivek Mishra the doctor, who treated complainant in response to query of OP-3, it is clear specifically mentioned on it at point no. 2 that “ there is no personal history /habit of smoking, tobacco chewing, alcohol, drugs etc or any other addiction to complainant. At point no. 1, it is clearly written in his own writing that complainant is suffering from Acute pancreatitis pseudocyst GOO (Gastric Outlet Obstruction) and it is totally denied 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 this document Ex C-24, 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 OPs. Complainant has also produced on record copy of bills and reports from Ex C-3 to 25. 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 document Ex C-24, which bears report of doctor who treated the complainant, clearly stating the fact that complainant was not having any past history of alcohol or tobacco chewing or any other king of drug addiction. This report cannot be ignored and in this light of this report Ex C-24, it is observed that OPs have wrongly denied the claim of complainant and it amounts to deficiency in service on their part.

13                       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 to entire amount of expenses borne by him for his treatment during the period of insurance.  OPs are directed to pay Rs.93,605/-, which he paid as an indoor patient and Rs.18,185 for treatment taken thereafter, paid vide bill dt 25.03.2015 and 12.05.2015 respectively alongwith interest at the rate of 9 % per anum from 25.04.2015 the date, when they repudiated the claim of complainant vide letter dt 25.04.2015 Ex C-25 till final realization. Ops are further directed to pay Rs.3000/- 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 : 16.01.2017                 

                                        Member                          President

          (P Singla)                      (Ajit Aggarwal)