Haryana

Ambala

CC/243/2015

Dr. G.S. Walia - Complainant(s)

Versus

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

In Person

24 May 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

Complaint Case No.    : 243 of 2015

Date of Institution       : 02.09.2015

Date of Decision         : 24.05.2017

 

 

Dr. G.S. Walia son of Late Sh. Balbir Singh, resident of 53, Sec. D, Ext. Defence Colony, Ambala Cantt.

                                                                                               

……Complainant.

 

Versus

 

Branch Manager, The New India Assurance Company Ltd. 5406, IInd Floor, Cross Road No. 3, Punjab Mohalla, Ambala Cantt.

  

                                                                                    ……Opposite Party.

 

Complaint Under Section 12 of the Consumer Protection Act.

 

 

BEFORE:       SH. D.N. ARORA, PRESIDENT.

                        SH. PUSHPENDER KUMAR, MEMBER.

                        MS. ANAMIKA GUPTA, MEMBER.

                       

Present:          Complainant in person.

                        Sh. U.S. Mahi, counsel for the OP.

 

ORDER.

 

                        In nutshell, brief facts of the complaint are that the complainant is a regular mediclaim policy holder bearing policy No. 35350134142500000251  valid from 25-06-2014 to 24-06-2015 (including his spouse) issued by the OP in favour of the complainant. The complainant is a Super Senior Citizen of 77 years of age and a regular medicalaim policy holder for last many years. It is submitted that during indemnified period i.e. from 25-06-2014 to 24-06-2015 the complainant suffered the problem of retention of urine. The complainant went to Dr. N.P. Singh Hospital, Ambala city. After various blood test, ultrasound and P.S.A. test and biopsy test Dr. N.P. Singh diagnosed a case of Prostate Cancer, Dr. N.P Singh performed two operation on the complainant on 06-03-2015 and discharged on 09-03-2015. The operation were of diagnostic in nature. It is further submitted that after receiving the Biopsy report it was confirmed that the complainant is suffering from Prostate Cancer and further informed the complainant that this is a serious problem and require long term therapy, various test from time to time and regular treatment. Doctor further told the complainant that this is a serious problem and require long term therapy, various test from time to time and regular treatment. Dr. further told the complainant that he was putting the complainant on surveillance.  The complainant was put on medicine and was advised to visit for checkup during the 1^st week of June 2015. The complainant was paid reimbursement of Rs. 26,826/- for the expenses incurred by the complainant on 27-05-2015 for the treatment during March, 2015. Thereafter, on 02-06-2015 the complainant visited the hospital for checkup. After PSA test of complainant, Dr. N.P. Singh further put the complainant on medicine for two months. The total medical expenses of the complainant from 02-06-2015 to 06-06-2015 was Rs. 3,344/-. The detail of mediclaim is as under:-

1. Hospital visit                        :           200/-
2. PSA test charges       :           630/-
3. Cost of medicine      :           2,514/-

Total              :           3,344/-

 

                        It is further submitted that the opposite party rejected the claim of the complainant of Rs. 3,344/- citing the reason of Time Bar Bill vide letter dated 14-07-2015. It is further submitted that the actual treatment of the complainant only started after two operations and biopsy report. The complainant was not cured after the operation (during hospitalization) rather the treatment of the complainant was started and till date complainant is under the regular treatment for Prostate Cancer. The complainant was insured indemnified for a sum of Rs. 3,75,000/- (including his spouse) and the complainant has paid the premium of Rs. 20,933/- only. The rejection of medicalaim of the complainant of Rs. 3,344/- is wrong and arbitrary illegal as the complainant is still not cured and still under the treatment of Dr. N.P. Singh. It is further submitted that the clause of 2.20 of policy condition is not applicable as complainant is not cured during hospitalization from 06-03-2015 to 09-03-2015 but the complainant was diagnosed as a case of Prostate Cancer. It is further submitted that the opposite party was served with three letters for clarification but the opposite party failed to reimburse the medical expenses. As such, the complainant, has prayed that the Ops are liable to pay a sum of Rs. 3,344/- along with interest @ 18 % per annum and Rs. 10,000/- as damages for mental as well as physical harassment, to the complainant.

2.                     Upon notice, OP appeared through counsel and tendered reply raising preliminary objection qua maintainability of complaint, cause of action and concealment of true facts.  On merits, it has been submitted that OP has rightly rejected the claim of the complainant amounting to the Rs. 3,344/- on 14-07-2015 being time bar bill. It is further submitted and the complainant was paid his claim which was genuine and reasonable as per terms and conditions of the policy. It is further submitted that the complainant was discharged on 09-03-2015 after operation from Dr. N.P. Singh Hospital and the expenses of OPD treatment is not covered under the terms and conditions of the policy.  As such, the OP has prayed that the complaint is liable to be dismissed with costs.

3.                     To prove his version, complainant tendered affidavit as Annexure CX alongwith documents as annexure C1 to annexure C-9 and closed the evidence whereas on the other hand, counsel for OP tendered affidavit Annexure RX alongwith document as Annexure R-1 and closed the evidence.

4.                     We have heard learned counsel for the parties and gone through the case file very carefully. It is admitted that the complainant is a mediclaim policy holder bearing policy No. 35350134142500000251  valid from 25-06-2014 to 24-06-2015 (including his spouse) issued by the OP in favour of the complainant. It is not disputed that the complainant was diagnosed by Prostate cancer and Dr. N.P. Singh operated him on 06-03-2015 and discharged on 09-03-2015. It is also admitted that claim of the complainant for the period 06-03-2015 to 09-03-2015 was duly reimbursed to the complainant i.e. amounting to Rs. 26,826/- on 27-05-2015.

                         Now, grievance of the complainant is that he incurred the medical expenses of Rs. 3,344/- on his treatment for the period 03-06-2015 to 08-06-2015 but the opposite party has rejected the above said claim on the ground being time bar bill vide letter dated 14-07-2015. Counsel for the opposite parties has draw our attention towards the clause 5.5 (d)  of terms and conditions of the policy, in which clearly mentioned that in case of post-hospitalization treatment (limited to sixty days), submit all claim documents within seven days after completion of such treatment.

                        After going through the claim form, it is mentioned that the post treatment bill are of dated 03-06-2015 to 11-06-2015 as annexure C7 and C8. It is cleared that the complainant has incurred the above said post treatment expenses after period of 60 days of discharge i.e. 09-03-2015.

                        Complainant has argued that the above said terms and conditions are not applicable in his case, because the Doctor has advised to the complainant to regular check up after average two months to assess the response of medicine given by him and time bar and OPD terms are not applicable to the complainant’s case as he was regular under treatment. We are in view that the above said arguments has no force as there is no any such clause, vide which the follow up expenses incurred during the follow up period is to be considered. So, this Forum cannot go beyond the terms and condition of the policy and cannot take the contrary view.

                        Hence, in view of the above discussion as well as perusal of the terms and conditions of the policy as annexure R1, the complainant has incurred the post medical expenses after period of 60 days from the date of discharge and the clause 5.5 (d) of terms and conditions is fully applicable on the present case, hence, complainant is not entitled to the claim of Rs. 3,344/- as prayed by him. Accordingly, the complaint of complainant is hereby dismissed with no order as to costs.  Copies of the order be sent to the parties concerned free of costs. File after due compliance be consigned to record room.

 

ANNOUNCED ON:  24.05.2017                                              (D.N. ARORA)

                                 PRESIDENT    

           

(PUSHPENDER KUMAR)

                                                                                                            MEMBER

 

 

   (ANAMIKA GUPTA)

                                                                                                            MEMBER