BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 415of 2015
Date of Institution: 1.7.2015
Date of Decision: 25.02.2016
Mr.Arvind Poddar S/o Sh. H.P.Poddar R/o 255, S.G. Enclave, Majitha Road, Amritsar aged 49 years
Complainant
Versus
The Oriental Insurance Company Ltd, through its Chairman/Managing Director/Principal Officer service through its branch office at Dwarka Deesh Complex, Queens Road, Amritsar through its Branch Manager
Opposite Party
Complaint under section 11 and 12 of the Consumer Protection Act, 1986
Present: For the Complainant : Sh. Deepinder Singh,Advocate
For the Opposite Party : Sh.Subodh Salwan,Advocate
Quorum:
Sh.Bhupinder Singh, President
Ms.Kulwant Kaur Bajwa, Member
Sh.Anoop Sharma, Member
Order dictated by:
Sh.Bhupinder Singh, President.
1. Present complaint has been filed by Arvind Poddar under the provisions of the Consumer Protection Act alleging therein that he has obtained health Insurance policy namely (Family Floater) from the opposite party for himself, his wife and two children bearing No. 233300/48/2015/3383 Ex.C-2 for the period from 2.11.2014 to 1.11.2015. Son of the complainant namely Aryaman Poddar fell ill and was admitted in Hartej Hospital on 13.3.2015 at 9.30 a.m. and was discharged on 14.3.2015 at 11.03 a.m. The claim for his hospitalization and medical treatment was referred to the opposite party for cashless treatment which the opposite party denied on the ground that the treatment required OPD procedure . Complainant has alleged that the treating doctor gave the certificate to the opposite party that the treatment required for the son of the complainant needs hospitalization and the complainant paid the amount of treatment to the hospital from his own pocket. The complainant then lodged claim with the opposite party for the medical treatment of his son insured Aryaman Poddar to the tune of Rs. 18378/-. Thereafter complainant made several visits to the opposite party and the opposite party has verbally told that the said claim is not payable being the procedure can be conducted in OPD basis. Complainant has alleged that no policy condition is communication to the complainant and the opposite party has illegally repudiated the claim of the complainant . Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to pay the claim of Rs. 18378/- alongwith interest . Compensation of Rs. 50000/- alongwith litigation expenses were also demanded.
2. On notice, opposite party appeared and filed written version in which it was submitted that the claim of the complainant has been scrutinized and has been processed by TPA namely E-Meditek Service Limited on the basis of medical record submitted by the complainant for processing his claim and the claim of the complainant is rightly repudiated vide letter dated 17.6.2015 on the ground that procedure can be done on OPD basis, hospitalization not justified, so claim is not payable. It was submitted that as per section 3 clause 3.12 the claim is not payable and the same is reproduced hereinbelow:-
REASONABLE AND NECESSARY EXPENSES:-
- For a network hospital, means the rate pre agreed between network hospital and TPA/Company, for surgical/medical treatment that is necessary for treating the insured person who was hospitalized.
- For any other hospital, it shall mean cost of surgical/medical treatment that is necessary and reasonable for treating the condition for which the insured person was hospitalized.
So in view of the aforesaid terms and conditions of the policy, the claim is rightly repudiated vide letter dated 17.6.2015 and there is no deficiency of service on the part of the opposite party.
3. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-7.
4. Opposite party tendered into evidence affidavit of Sh.Gurdeep Singh, Divisional Manager Ex.OP1/A , copy of terms and conditions of the policy Ex.OP1/1, copy of repudiation letter Ex.OP1/2, copy of insurance policy Ex.OP1/3.
5. 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 the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant got health Insurance policy bearing No.233300/48/2015/3383 Ex.C-2 for the period from 2.11.2014 to 1.11.2015 for himself, his wife Pragya Poddar and two children Anany Poddar and Aryaman Poddar. Son of the complainant namely Aryaman Poddar fell ill and was admitted in Hartej Hospital on 13.3.2015 at 9.30 a.m. and was discharged on 14.3.2015 at 11.03 a.m. as per discharge summary Ex.C-4, where he was medically treated. The complainant spent Rs. 18,378/- on the medical treatment of his son insured Aryaman Poddar as per bills dated 13.3.2015 , 14.3.2015 and 19.3.2015. The complainant lodged claim with the opposite party but the opposite party firstly declined cashless request of the complainant vide letter dated 13.3.2015 Ex.C-3 and finally repudiated the claim of the complainant vide letter dated 17.6.2015 Ex.C-7 on the ground that as per section 3 clause 3.12 of the policy, the opposite party is liable to pay claim only in the case of surgical /medical treatment that is necessary for treating the condition for which the insured person was hospitalized. In the present case the hospitalization of insured Aryaman Poddar was not necessary as he could be treated in OPD. The reconstruction of nail bed procedure could be done on OPD basis. So the opposite party denied the claim of the complainant. Ld.counsel for the complainant submitted that hospital authorities issued certificate Ex.C-6 dated 13.3.2015 in this regard that hospitalization for treatment of insured Aryaman Poddar was necessary. But inspite of that the opposite party declined the claim of the medical treatment of insured Aryaman Poddar arbitrarily and all this amounts to deficiency of service on the part of the opposite party qua the complainant.
7. Whereas the case of the opposite party is that the claim of the complainant was scrutinized and processed by TPA E-Meditek Services Ltd on the basis of medical record submitted by the complainant, for processing his claim and the claim of the complainant has been rightly repudiated vide letter dated 17.6.2015 Ex.C-7 on the ground that the procedure for which insured Aryaman Poddar was admitted in Hartej Hospital, can be done on OPD basis, hospitalization not justified, so claim is not payable. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party qua the complainant.
8. From the entire above discussion, we have come to the conclusion that complainant got health insured policy Ex.C-2 for the period from 2.11.2014 to 1.11.2015 (Family Floater policy) from the opposite party for himself, his wife Pragya Poddar and two children Anany Poddar and Aryaman Poddar. During the subsistence of the policy period, son of the complainant namely Aryaman Poddar fell ill and was admitted in Hartej Hospital on 13.3.2015 at 9.30 a.m. and was discharged on 14.3.2015 at 11.03 a.m. and the complainant spent Rs. 18,378/- on the treatment of insured Aryaman Poddar and bills in this regard have been produced by the complainant. Claim was lodged by the complainant with the opposite party regarding reimbursement of the medical expenses spent by the complainant on the treatment of insured Aryaman Poddar. But the opposite party repudiated the claim of the complainant vide letter dated 17.6.2015 Ex.C-7/Ex.OP2 on the ground that the procedure for which Aryaman Poddar insured was admitted in Hartej Hospital could be done on OPD basis and hospitalization was not justified The authorities of Hartej Hospital have issued certificate Ex.C-6 dated 13.3.2015 in this regard that the hospitalization of insured Aryaman Poddar was necessary for the medical treatment of insured Aryaman Poddar and the same could not be done on OPD basis. The patient remained admitted in Hartej Hospital for more than 24 hours . The opposite party could not rebut this certificate issued by hospital authorities Ex.C-6.
9. Resultantly we hold that opposite party has wrongly repudiated the claim of the complainant vide letter dated 17.6.2015 Ex.C-7/Ex.OP2.
10. Consequently we allow the complaint with costs and the opposite party is directed to pay this amount Rs. 18378/- 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 Rs. 18378/- 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 orders be furnished to the parties free of costs. 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.
25.02.2016 ( Bhupinder Singh )
President
/R/ (Anoop Sharma) ( Kulwant Kaur Bajwa)
Member Member
