BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.503 of 2014

Date of Institution: 12-09-2014

Date of Decision: 23-06-2015  

S.Balwinder Singh son of S.Joinder Singh, House No. 2027/14, Bazar Jattanwala, Inside Gilwali Gate, Amritsar.

Complainant

Versus

1. The Oriental Insurance Company, Divisional Office-I, Queen’s Road,  Amritsar through its Divisional Manager/ Person over all incharge.
2. The Oriental Insurance Company, Branch Office, Vishwakarma Chowk, G.T.Road, Miller Ganj, Ludhiana through its Branch Manager/ Person over all incharge.
3. Oriental Bank of Commerce, Sharifpura Branch, Amritsar through its Manager/ Person over all incharge. 

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act, 1986.

Present: For the Complainant: Sh. Raman Sharma, Advocate.

              For the Opposite Parties No.1 & 2: Sh.P.N.Khanna, Advocate.

            For Opposite Party No.3: S.Munish Kohli, Advocate.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member     

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Balwinder Singh under the provisions of the Consumer Protection Act alleging therein that he is a saving bank account holder having account No.01562010031660 with Opposite Party No.3. Complainant alleges that he alongwith his family members insured themselves with Opposite Parties  No.1 & 2 under the policy namely Oriental Bank Mediclaim Policy vide policy No.233902/48/2014/516 for the period from 10.5.2013 to 9.5.2014 for a sum insured of Rs.3 lacs and in respect thereof a new premium of Rs.4620/- was received from the complainant. During the currency of the impugned insurance, in the month of August 2013 the complainant underwent some treatment due to health problem and was admitted in EMC Super Specialty Hospital Private Limited, Amritsar on 4.8.2013  and was discharged on 8.8.2013 and thereafter, the complainant was admitted in Mahajan Hospital, Amritsar on 8.8.2013 and was discharged on 18.8.2013 and during the course of said treatment, the complainant spent an amount of Rs.1,84,692/- towards hospitalization charges and medical expenses, etc. The intimation was given to the Opposite Parties  on 5.8.2013 by the complainant and thereafter, the complainant submitted a claim of Rs.1,84,692/- to the Opposite Party No.1 alongwith all the requisite original documents for  settlement and payment under the said insurance  policy, but to the utter surprise, the complainant received a letter dated 17.12.2013 form Opposite Party No.2 whereby Opposite Party No.2 rejected the claim of the complainant on flimsy grounds vide their letter dated 17.12.2013. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to pay a sum of Rs.1,84,692/- to the complainant i.e. the amount spent by the complainant towards medical treatment alongwith interest @ 12 % per annum. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Parties  No.1 & 2  appeared and filed written version in which it was submitted that the claim preferred by the complainant was considered by Medi Assist TPA on behalf of the answering Opposite Parties who after going through the terms and conditions of the insurance policy and discharge card of the patient issued by Mahajan Hospital, Amritsar, repudiated the claim of the complainant vide their letter dated 9.12.2013 stating that the patient was suffering on account of non–healing of wound on his left foot and as such the expenses on treatment of ailment of disease / surgeries of diabetes disease for specified period of two years are not payable if contracted/ manifested during the currency period. It was also made clear that the ailment of diabetes is pre-disposing factor to the development of non –healing of wounds. So, the claim was  repudiated under the permanent exclusion No. 4.2 of the policy in question.   While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Party No.3 appeared and filed written version  in which it was submitted that  the answering Opposite Party  has unnecessarily been impleaded as party to the present complaint. The Opposite Party No.3 is  having its branch office at Ludhiana and the insurance policy regarding which the present complaint has been filed, was also issued by Ludhiana office of the insurance company and therefore, the complaint lies against Oriental Bank of Commerce, at Ludhiana Branch and not  against Opposite Party No.3 and as such, the complaint is liable to be dismissed qua Opposite Party No.3. While denying and controverting other allegations, dismissal of complaint was prayed.
4. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C75 and closed the evidence on behalf of the complainant.
5. Opposite Parties No.1 and 2 tendered into evidence affidavit of Sh.Gurdeep Singh, Divisional Manager Ex.OP1-2/1, affidavit of Mr.Abha Mathur, Branch Manager of Medi Assist India TPA Ex.OP1-2/2 alongwith documents Ex.OP1-2/3 to Ex.OP1-2/7 and closed the evidence on behalf of the Opposite Parties No.1 and 2.
6. Opposite Party No.3 tendered into evidence affidavit of Sh.Deepak Bhardwaj, Branch Manager Ex.OP3/1 and closed the evidence on behalf of Opposite Party No.3.
7. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
8. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant has  saving bank  account No.01562010031660 with Opposite Party No.3. Complainant alleges that he alongwith his family members insured under the policy namely Oriental Bank Mediclaim Policy bearing No.233902/48/2014/516 for the period from 10.5.2013 to 9.5.2014 for a sum insured of Rs.3 lacs under Opposite Parties  No.1 & 2. In the month of August 2013, the complainant underwent some treatment due to health problem and he was admitted in EMC Super Specialty Hospital Private Limited, Amritsar on 4.8.2013 and was discharged on 8.8.2013 and thereafter, the complainant was admitted in Mahajan Hospital, Amritsar on 8.8.2013 and was discharged on 18.8.2013 and during this period, the complainant spent an amount of Rs.1,84,692/- towards hospitalization charges and medial expenses, etc. The intimation  in this regard was given to the Opposite Parties  on 5.8.2013 and thereafter, the complainant lodged a claim of Rs.1,84,692/-  with  the Opposite Party No.1 alongwith all the requisite documents for  settlement of the claim, but the Opposite Parties  No.1 & 2 did not settle the claim of the complainant despite so many  requests made by the complainant. Ultimately, vide letter dated 17.12.2013, Opposite Party No.2 rejected the claim of the complainant on the ground that amount is not payable as per the  terms and conditions of the policy. The complainant submitted that  such terms and conditions of the policy were not supplied to the complainant nor explained/ communicated  to the complainant. The exclusion clause mentioned in the repudiation letter is also not applicable to the claim of the complainant.     Ld.counsel for the   complainant  submitted that all this amounts to deficiency of service on the part of the opposite parties.
9. Whereas the case of the Opposite Parties  No.1 & 2 is that the claim preferred by the complainant was considered by Medi Assist TPA of the Opposite Parties  No.1 & 2  who after going through the terms and conditions of the insurance policy and discharge card of the patient issued by Mahajan Hospital, Amritsar, repudiated the claim of the complainant vide their letter dated 9.12.2013 stating that the patient was suffering on account of non–healing of wound on his left foot and as such the expenses on treatment of ailment of disease / surgeries of diabetes disease for specified period of two years are not payable if contracted/ manifested during the currency period. It was also made clear that the ailment of diabetes is pre-disposing factor to the development of non –healing of wounds. So, the claim was  repudiated under the permanent exclusion No. 4.2 of the policy in question. The terms and conditions of the policy were duly supplied to the complainant alongwith policy document. The complainant has admitted the receipt of repudiation letter dated 17.12.2013. The complainant himself has mentioned the policy number in the complaint and also the policy period. It was submitted that where the party admits receipt of policy schedule, but take plea that no terms and conditions of the policy were supplied to the complainant, concerned party taking such plea is not competent to make any complaint, because in such circumstances in fact there is no contract of insurance. The complainant never raised any complaint earlier to Opposite Parties  No.1 & 2 that the terms and conditions of the policy and the exclusion clause of the policy have not been supplied to the complainant with the policy schedule. Ld.counsel for the Opposite Parties  No.1 & 2 submitted that Opposite Parties  No.1 & 2 have rightly repudiated the claim  of the complainant as per terms and conditions of the policy in question. Therefore, there is no deficiency of service on the part of the Opposite Parties  No.1 & 2.           
10. From the entire above discussion particularly from the perusal of the documents produced by both the parties, it is clear that the complainant obtained mediclaim policy bearing  No.233902/48/2014/516 from Opposite Parties  No.1 & 2 for himself and his family members for the period from 10.5.2013 to 9.5.2014 for a sum insured of Rs.3 lacs on payment of premium of Rs.4620/-. The complainant suffered some health problem and he was admitted in EMC Super Specialty Hospital Private Limited, Amritsar on 4.8.2013 and was discharged on 5.8.2013 as per discharge card Ex.C20. Complainant was again admitted in Mahajan Hospital, Amritsar on 8.8.2013 and was discharged on 17.8.2013 as per discharge card Ex.C75. The complainant alleges that he spent  Rs.1,84,692/- towards hospitalization charges and medial expenses, etc. In this regard, he produced the bills Ex.C7 to Ex.C70. As per discharge card of the complainant Ex.C75, the complainant was diagnosed as a case of non-healing of wounds on his left foot on account of diabetes. The complainant lodged  claim with Opposite Parties  No.1 & 2. TPA of Opposite Parties  No.1 & 2 thoroughly investigated the case of the  complainant and on the report of TPA,  Opposite Parties  No.1 & 2 came to the conclusion that the complainant was admitted at Mahajan Hospital, Amritsar  for the treatment of NIDDM, B/L Pneumonitits Non Healing Wound Left Foot, Septicaemia (alongwith NIDDM) which was due to diabetes. The Opposite Parties  No.1 & 2 vide letter dated 17.12.2013 Ex.OP1-2/5 repudiated the claim of the complainant clearly stating that as per the policy terms and conditions, during the period of insurance cover the expenses on treatment of ailment/ diseases/ surgeries for diabetes disease for specified period of 2 years are not payable if contracted & manifested during the currency of the policy. The ailment diabetes is redisposing factor to the development of non healing wounds. As per the terms and conditions of the policy purchased by the complainant, the expenses on treatment of ailment/ diseases/ surgeries for diabetes diseases for specified period of 2 years are not payable. The complainant could not produce any evidence that this treatment was not relating to the disease of diabetes. Moreover, the complainant also could not produce any document to prove that his policy with Opposite Parties  No.1 & 2 was for more than  2 years prior to his admission/ treatment in the aforesaid hospitals. The complainant also could not produce any evidence that he did not receive the terms and conditions of the policy. He never wrote any letter to the Opposite Parties  No.1 & 2 to the effect that he did not receive the terms and conditions of the policy alongwith policy schedule.  In the  light of above discussion, we hold that Opposite Parties  No.1 & 2 were justified in repudiating the claim of the complainant as per the terms and conditions of the policy in question.
11. Resultantly, the complaint is without merit and the same is hereby dismissed with no order as to cost. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 23-06-2015.                                          (Bhupinder Singh)                                                                                                President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member