THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR

Consumer Complaint No. 534 of 2014

Date of Institution : 7.10.2014

Date of Decision : 15.07.2015

Sh. Manohar Lal Tandon, resident of M/28, Green Avenue, Amritsar

...Complainant

Vs.

The Oriental insurance Company Ltd., Divisional Office No.1, Dwarka Deesh Complex, Queens Road, Amritsar through its Divisional Manager/Person over All Incharge

....Opp.party

Complaint under section 12/13 of the Consumer Protection Act, 1986

Present : For the complainant : Sh. S.K.Davessar,Advocate

For the opposite party : Sh. Subodh Salwan,Advocate

Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member &

Sh.Anoop Sharma,Member

Order dictated by :-

Bhupinder Singh, President

1 Present complaint has been filed by Sh. Manohar Lal Tandon under the provisions of the Consumer Protection Act alleging therein that he had been obtaining mediclaim insurance policies from the opposite party for the last 20-25

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years , the details of which is as under :-

2. According to the complainant in the year 2009 he suffered eye problem and taken treatment of PDT (Photo Dynamic Therapy) treatment from Dr. Daljit Singh Eye hospital and spent Rs. 1,81,068/- which the opposite party has paid to the complainant. Complainant again suffered same eye problem for which 24 hours hospitalization is required and was admitted in Dr. Daljit Singh Eye Hospital on 1.8.2013 and was discharged on 2.8.2013 and spent Rs. 81,200/-. Complainant informed the opposite party vide e-mail on 1.8.2013 and all the relevant documents were submitted vide letter dated 6.8.2013. Again complainant was admitted in the said hospital from 11.1.2014 to 12.1.2014 for the same eye problem and spent Rs. 71200/- on his treatment. Complainant submitted the claim with the opposite party

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alongwith all the relevant papers and original documents on 25.1.2014. But the opposite party vide letter dated 3.7.2014 repudiated the claims of the complainant on the ground that such treatment can be taken as OPD patient . Complainant has alleged that Dr. Daljit Singh's hospital issued a certificate that PDT is always done indoor because the patient is detained for 24 hours in dark room and constantly watched. Complainant has alleged that he has been obtaining insurance covers for the last 20 years but no such instructions/circular have been issued/supplied by the opposite party. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to pay a sum of Rs. 1,52,400/- alongwith interest @ 12% p.a. Compensation of Rs. 25000/- alongwith litigation expenses were also demanded.

3. On notice, opposite party appeared and filed written version in which it was submitted that in the year 2009 circular regarding the said fact was not provided to the TPA and due to this the claim of the complainant was paid at that time. But that has no legal and binding force to decide the present claim case of the complainant . It was submitted that treatment of the ailment of the complainant is that Avastine injections were given to treat the ailment and the admission of the patient is not required in the hospital while taking treatment for the said ailment . As per clause 2.3 of the terms and conditions of the police, procedure/treatment usually done in outpatient department under the policy is not payable. While

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submitting that the claims of the complainant have rightly been repudiated and while denying and controverting other allegations, dismissal of complaint was prayed.

4. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-34.

5. Opposite party tendered into evidence affidavit of Sh. Gurdeep Singh, Divisional Manager Ex.OP1, copy of minutes of meeting Ex.OP2, repudiation letter Ex.OP3, copies of Insurance Policies Ex.OP4 to Ex.OP9, copy of terms and conditions of the policy Ex.OP10.

6. 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.

7. From the record i.e.pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant had been taking mediclaim insurance policies from the opposite party for the last so many years and he has produced the record of policies since 20.7.2003 continuously till 19.7.2014. The complainant submitted that in the year 2009 , he suffered eye problem and undergone PDT (Photo Dynamic Therapy ) treatment. The complainant undergone treatment from Dr. Daljit Singh Eye Hospital and lodged claim with the opposite

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party in the year 2009 and the opposite party paid a sum of Rs. 1,81,068/- to the complainant. The complainant again suffered same eye problem and had undergone treatment for PDT. The complainant was admitted in Dr. Daljit Singh Eye Hosptial on 1.8.2013 and was discharged on 2.8.2013 as per discharge slip Ex.C-32 and spent a sum of Rs. 81200/- as per bill Ex.C-29 on his treatment. Intimation was sent to the TPA of the opposite party through e-mail on 1.8.2013 . Claim was lodged alongwith all the relevant papers and original bills with the TPA vide letter dated 6.8.2013. But the opposite party did not decide the claim case of the complainant. Again the complainant suffered same eye problem . He was admitted in Dr. Daljit Singh Eye Hospital on 11.1.2014 and was discharged on 12.1.2014 as per bill Ex.C-31 and had undergone treatment of PDT for which the patient is required to remain in the specified dark room with specific machinery and this time the complainant spent Rs. 71200/- as per bill Ex.C-30. Intimation was sent to TPA through e-mail and the claim was lodged with the TPA of opposite party alongwith original documents on 25.1.2014. But the opposite party repudiated the claim of the complainant vide letter dated 3.7.2014 Ex.OP3 on the ground that the TPA M/s. Emeditek has stated that as per circular/document pertaining to Avastine injection are not payable. In this regard complainant produced one prospectus Ex.OP10 to the effect that treatment usually done in outpatient department are not payable under the policy. Ld.counsel for the complainant submitted that Dr. Daljit

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Singh Eye Hospital has issued certificate dated 29.9.2014 Ex.C-23 in which he has submitted that PDT treatment is done as an indoor procedure and the patient is retained for 24 hrs in the hospital because the dye which is injected sensitizes the patient to light. The patient for this reason has to be kept in the dark room and is also watched for any photo sensitivity. So this treatment cannot be done in the OPD. Opposite party has wrongly repudiated 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 party qua the complainant.

8. Whereas the case of the opposite party is that in the year 2009 circular regarding the said fact was not provided to the TPA and due to this the claim of the complainant was paid at that time. But that has no legal and binding force to decide the present claim case of the complainant . As per clause 2.3 of the terms and conditions of the policy ; procedure/treatment usually done in outpatient department under the policy is not payable. The treatment record/facts of this case shows that treatment of the ailment of the complainant is for Avastine injection (Intravitreal Injections) were given to treat the ailment and the admission of the patient is not required in the hospital. So the opposite party has repudiated the claim case of the complainant vide letter dated 3.7.2014 Ex.OP3. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party qua the complainant.

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9. From the entire above discussion, we have come to the conclusion that complainant had been getting mediclaim insurance policies from the opposite party for the last so many years continuously and he has produced the insurance policies in this regard Ex.C-2 to Ex.C-12. The complainant suffered Eye problem (P.D.T) and he was admitted in Dr. Daljit Singh Eye Hospital on 1.8.2013 and was discharged on 2.8.2013 and remained there for more than 24 hours as per discharge slip Ex.C-32 and spent a sum of Rs. 81200/- on his treatment as per bill Ex.C-29. Opposite party was duly informed and the claim was also lodged with the opposite party. But the opposite party did not decide that claim case of the complainant. Again on 11.1.2014 complainant suffered same eye problem (P.D.T.) and was admitted in Dr. Daljit Singh Eye Hospital on 11.1.2014 and was discharged on 12.1.2014 as per bill Ex.C-31 and undergone same eye treatment i.e. PDT (Photo Dynamic Therapy) and spent about Rs. 71200/- as per bill Ex.C-30. The opposite party was duly informed and the claim was lodged with the opposite party through their TPA. But the opposite party repudiated the claim of the complainant vide letter dated 3.7.2014 Ex.OP3 on the ground that the record shows that the complainant undergone treatment i.e. Avastine injection were given to treat the ailment for which admission of the patient is not required in the hospital and the amount spent on procedure/treatment usually done in outpatient department under the policy is not covered. Here in this case the complainant has produced on record

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certificate from Dr. Daljit Singh Eye Hospital dated 29.9.2014 Ex.C-23 which certifies that the procedure Photo Dynamic Therapy( PDT) is done as indoor procedure and the patient is retained for 24 hrs in the hospital because the dye which is injected sensitizes the patient to light. The patient for this reason has to be kept in dark room and is also watched for any photo sensitivity which proves that the same cannot be given to the patient in OPD and the hospitalization of the patient is necessary. Opposite party could not produce any expert opinion or any literature to rebut this certificate given by Dr. Daljit Singh Eye hospital Ex.C-23. Apart from this the opposite party could not produce any terms and conditions of the policy to prove the exclusion clause alleged by the opposite party. It has been held by the Hon'ble Punjab State Commission in case New India Assurance Company Limited & Anr. Vs. Arun Kumar Mangal 2010(1) CPJ 189 that where the opposite party failed to prove on record that the terms and conditions of the policy were communicated to the insured, the exclusion clause did not form part of contract of insurance and the opposite party cannot claim benefit of said exclusion clause. Same view has been taken by the Hon'ble Supreme Court of India in case M./s. Modern Insulators Ltd. Vs. Oriental Insurance company 2000 CPJ 1 (SC). Opposite party except the prospectus Ex.C-10 could not produce the terms and conditions of the policy on record. The prospectus of mediclaim insurance policy does not form part of the contract. Moreover, the opposite party has failed to prove

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on record that the treatment undergone by the complainant would have been done in the OPD, so hospitalization of the patient is not required. Whereas the complainant has duly proved the fact that for such treatment of PDT, hospitalization of the patient is required for 24 hours, through certificate issued by Dr. Daljit Singh Eye hospital Ex.C-23.

10. Apart from this the opposite party has paid similar claim of the complainant in the year 2009 but the opposite party has stated that they were not aware of the circular in this regard at that time nor they could supply that circular to TPA in the year 2009 that is why that claim was paid to the complainant. But the opposite party even now also failed to produce any such circular on record.

11. Consequently we hold that opposite party has wrongly repudiated the claim of the complainant vide letter Ex.OP3.

12. Resultantly we allow the complaint with costs and the opposite party is directed to pay Rs. 1,52,400/- (Rs.81200/- + Rs. 71,200/- = 1,52,400/-) to the complainant within one month from the date of receipt of copy of this order ; failing which opposite party shall be liable to pay interest @ 9% p.a on the aforesaid amount from the date of filing of the complaint till payment is made to the complainant. Opposite party is also directed to pay litigation expenses Rs. 2000/- to the complainant. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be

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disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

15.07.2015 ( Bhupinder Singh )

President

( Kulwant Kaur Bajwa) (Anoop Sharma)

/R/ Member Member