Chandigarh

DF-II

CC/539/2020

Jasbir Kaur - Complainant(s)

Versus

The Oriental Bank of Commerce - Opp.Party(s)

Devinder Kumar

27 Aug 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	539 of 2020
Date  of  Institution	:	19.10.2020
Date   of   Decision	:	27.08.2021

 

 

 

 

 

Jasbir Kaur wife of Late Sh.Jagdhir Singh, aged about 70 years, H.No.127, New Officer Colony, Patiala, Punjab

             …..Complainant

 

Versus

 

1]  The Oriental Bank of Commerce, New Officer colony, Branch Patiala through its Branch Manager

 

2]  Oriental Insurance Company Limited, Sai Market, Lower Mall, Patiala through its Branch Manager.

    2^nd Address:-

    Oriental Insurance Company Limited, SCO No.48-49, Sector 17-A, Chandigarh through its Branch Manager.

 

3]  M/s Rakesh TPA Private Limited, SCO No.39, First Floor, Sector 26, Chandigarh through its Branch Manager.  

 

    ….. Opposite Parties

 

 

BEFORE:  SH.RAJAN DEWAN              PRESIDENT

         SMT.PRITI MALHOTRA             MEMBER

        SH.B.M.SHARMA                      MEMBER

 

 

Argued By: Sh.Devinder Kumar, Adv. for the complainant.

Sh.Ajay Sepahia, Adv. for OP No.1

Sh.Krishan kant, Adv. for OPs No.2 & 3.

 

PER PRITI MALHOTRA, MEMBER

         Concisely put, the complainant obtained OBC-Oriental Mediclaim Policy (Ann.C-1) of OP No.2 company, through OP No.1 Bank, effective from 17.4.2017 to 16.4.2018 and the same stands renewed from 17.6.2019 to 16.4.2020 vide Ann.C-2. During subsistence of the policy period, the complainant on 13.2.2020 was admitted in Fortis Hospital, Mohali with complaint of breathlessness, where she remained admitted from 13.2.2020 to 17.2.2020 and discharged on 17.2.2020 (Ann.C-3). Stated that due information about the treatment of complainant was given to OP Insurance Company to provide cashless facility, which they illegally denied vide letter dated 15.2.2020 (Ann.C-4), as a result, the complainant had to pay the medical bill amount of Rs.1,62,905/- at her own.  Thereafter, the complainant lodged claim with OP Insurance
Company for reimbursement of said medical bill, which too was rejected by the OP Company as ‘Claim Recommended for Non-Payment’, when it was checked on the app through online website of OP Company.  Hence this complaint has been filed alleging the said rejection of claim as illegal, amounting to deficiency in service on the part of OPs.  

 

2]       The OP NO.1 Bank has filed reply and while admitting that complainant is account holder with it as well as issuance of the policy in question to her and payment of premium thereof, denied other allegations of the complaint being not related to it and for want of knowledge. Pleading no deficiency in service, a prayer for dismissal of the complaint qua OP No.1 has been made.

         The OPs No.2 & 3 have also filed reply and while admitting the factual matrix of the case, stated that a bare perusal of the Discharge Summary of complainant dated 17.2.2020 reveals that she was diagnosed of severe OSA (Obstrutive Sleep Apnea) Type II respiratory failure, Ist degree AV Block, Morbid Obesity, Diabetes Mellitus, Hypertension, Hypothyroidism and that the patient is a known case of DM, HTN on medication, Obesity, Hypothyroidism, OSA on home BIPAP (Ann.OP-2&3/2).  While admitting the denial of cashless facility as well as repudiation of claim lodged by complainant, it is stated that the claim so submitted by the complainant to the TPA for Rs.1,62,905/- is not admissible.  It is also stated that all the expenses claimed by the complainant are not payable, even if the claim otherwise would have been admissible as per the terms and conditions of the insurance policy, the expenses pertaining to medical consumables amounting to Rs.15,036.97 as per IRDA Circular, Admission Charge Rs.1500/- and Rs.4100/- are not payable as per the insurance policy.  Submitted that the claim has rightly been repudiated being not admissible.  Denying other allegations, prayed for dismissal of complaint.

 

3]       Replication has also been filed by complainant controverting the assertions made by OPs in their reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the OPs and have also perused the entire record.

 

6]       It is admitted between the parties that the complainant availed Medical Insurance Policy in question from OP No.2 and the same is running in 3rd year in continuation.  Further, it is not in dispute that during the subsistence of the policy period, the complainant/insured remained admitted in Fortis Hospital, Mohali from 13.2.2020 to 17.2.2020.  It is also a proven fact on record that the complainant when approached the OPs for the cashless facility, the same was declined vide letter dated 15.2.2020.  Thereafter, the claim raised for the reimbursement of medical expenses incurred by the complainant on her treatment, was not settled and that too was declined by the OP Insurance Company.  It is the grouse of the complainant that OP Insurance Company failed to convey the fate of the claim till filing of the present complaint challenging the repudiation of the claim, knowledge of which she gained from the website of OPs No.2 & 3.  The complainant also agitated about the wrong denial of the cashless facility while she remained admitted in Fortis Hospital Mohali.

 

7]       In reply to the complaint, the OPs No.2 & 3 admitted about the repudiation of the claim in question.  It is their stand that OP NO.3/TPA of OP No.2 processed and verified the claim raised by the complainant, reported the same to OP No.2, which OP No.2 eventually conveyed to the complainant.  The OPs NO.2 & 3 have placed on record the copies of the letters on record i.e. letter dated 04.06.2020 (Ann.OP-2&3/3) of TPA addressed to the Insurance Company and letters dated 26.10.2020 & 9.11.2020 (Ann.OP-2&3/4 & OP-2&3/5) of the Insurance Company addressed to the complainant, but nowhere the OPs come up with any proof about the dispatch of the said letters dated 2.6.2020 & 9.11.2020 respectively conveying the repudiation of the claim to the complainant, which discloses the irresponsiveness of the OPs No.2 & 3, as they failed to covey the outcome of the claim raised by the complainant forcing her to engross into avoidable litigation.

 

8]       The deficiency which has been observed on the part of OPs No.2 &3 is not only on account of wrong denial of cashless facility, but for not disclosing the reason for such denial in the letter issued.  For the sake of convenience, the reference of the cashless denial issued by OP No.3/TPA vide letter dated 15.2.2020 (Ann.C-4) is reproduced as under:-

 

“After primary perusal of the documents, we regret to inform you that the cashless facility can not be sanctioned due to the following reason)s).

                             Case Summary:

Female pt age 71 complains of breathlessness with suggestive diagnosis of LVF ACS”

   

9]       The denial of cashless facility, referred above, without disclosing any reason for the same, is not only an arbitrary action on the part of OPs, but also devoid of due service which the OPs are under obligation to provide under the policy in question.

 

10]      Now we divert to the moot question about the repudiation of the claim for which the OPs No.2 & 3 have quoted Clause NO.4.20 of the terms & conditions of the Policy.  For the sake of convenience, we are reproducing Clause NO.4.20 of the Policy as under:-

               4. General Exclusions:

4.20 Treatment of obesity or condition arising there from (including morbid obesity) and any other weight control programme, and similar services or supplies.”

 

11]      The clause mentioned above, in our opinion, is not applicable in the case of the complainant as her case is not covered by above clause.  The complainant in the present case has not taken any treatment for obesity or any related matter, rather she was diagnosed with the problem of OSA Type II Respiratory Failure and other ailments.  No treatment has been availed of by the complainant exclusively to treat the obesity as such or for any matter related therewith, thus the denial on that account is totally baseless, unjustified and amounts to deficiency in service on the part of OPs No.2 & 3.

 

12]      In their reply, the OPs No.2 & 3 in Para No.8 have mentioned about the deduction to be made from the claim amount of complainant on variant accounts, but they have not placed on record any of the document to support or justify such deduction as claimed.  Thus we are of the view that the complainant is fully entitled for the reimbursement of medical claim in toto.

 

13]      Taking into consideration the above discussion &findings, we are of the opinion that the deficiency in service on the part of OPs NO.2 & 3 has been proved.  Therefore, the present complaint is allowed against the Opposite Parties No.2 & 3 with directions to reimburse an amount of Rs.1,62,905/- to the complainant. The OPs No.2 & 3 are also directed to pay an amount of Rs.15000/- to the complainant towards compensation for causing her mental agony & harassment, along with litigation expenses of Rs.10,000/-.

         This order shall be complied with by the Opposite Parties No.2 & 3 within a period of 30 days from the date of receipt of certified copy of this order, failing which they shall be liable to pay the above awarded amount along with interest @9% p.a. from the date of order fill realization.

14]      The complaint qua OP No.1 Bank stands dismissed.

         Certified copy of this order be sent to the parties, free of charge. After compliance, file be consigned to record room.

Announced

27^th August, 2021                                                                                                                                                               sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

 

Sd/-

(B.M.SHARMA)

MEMBER