BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.208 of 2016

      Date of Instt. 11.05.2016

      Date of Decision: 17.03.2020

1.       Mrs. Kavita Mahindru aged 50 years W/o Shri Sanjiv Kumar   resident of B-14/5959, Ramesh Colony, S. D. College Road,          Jalandhar City-144001.

2.       Sanjiv Kumar Mahindru husband of Kavita Mahindru resident of      B-14/5959, Ramesh Colony, S. D. College Road, Jalandhar City-        144001.

..........Complainants

Versus

1.       The Oriental Insurance Co. Ltd, Divisional Office, 32, G. T.    Road, Jalandhar-144001 through its Senior Divisional Manager.

2.       E-MEDITEK TPA Pvt. Ltd., Corporate Office, Plot No.577,   Udyog Vihar, Guru Gram (Haryana). Through its    Director/Authorized Officer.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Sh. Karnail Singh           (President)

Smt. Jyotsna                   (Member)

Present:       Smt. Harleen Kaur, Adv. Counsel for the Complainants.

Sh. A. K. Arora, Adv. Counsel for the OP No.1.

OP No.2 exparte.

Order

Karnail Singh (President)

1.                The instant complaint has been filed by the complainants, wherein alleged that she took Happy Family Floater Insurance Policy (Mediclaim insurance policy) from OP No.1 through its authorized agent by renewal effective from 14.05.2013 to 13.05.2014. The complainants have been continuously and un-interruptedly insured themselves i.e. Kavita Mahindru, Sanjiv Kumar and their son Nitish Mahindru under Mediclaim insurance policy since year 2009 without any gap/break. The coverage note and policy schedule was issued in the name of complainant No.1 Kavita Mahindru. The total premium renewal amount of Rs.8780/- was paid to the OP No.1 through its authorized agent. The OP No.1 delivered to the complainants only a cover note and policy schedule of mediclaim insurance policy only from the inception of the risk coverage and on its renewal. The policy document was never delivered to the complainant by OP No.1 during the whole of the period of the policy. Even the terms and conditions including exclusion clauses were not ever communicated and explained nor made known to the insured and as such, were not part of the insurance.

2.                 That the OPs have agreed and undertook to reimburse/indemnify reasonable and necessary expenses of domiciliary hospitalization only for illness/diseases or injury sustained by accident by the insured persons during the period of insurance fully without any deduction in any manner. Accordingly, the complainant has the right of indemnification/reimbursement for whole amount of medical and surgical expenses incurred and for any loss or damage of peril covered during the term of mediclaim insurance policy. The complainant No.2 Sanjiv Kumar co-insured with OP No.1 had complaint of Eye Trouble and consulted with Dr. Mrs. Shelly Goel of Dr. Goel’s Neuro & Eye Hospital, Jalandhar on 10.08.2013. Dr. Mrs. Shelly Goel after physical, clinical check and examination and prescribed test referred patient Sanjeev Kumar Mahindru, co-insured to Mahajan Eye Hospital & Maternity Home, Jalandhar for further management and treatment. He was diagnosed both eye OCT and was admitted on 10.08.2013 and discharged on 10.08.2013. Subsequent to the discharge from the given treatment by said hospital, the complainants made two claims for Rs.7059/- as well as Rs.10,198/-, in total Rs.17,257/- and submitted to the OP for reimbursement, alongwith all the required documents, but till today, the said claim of the complainant has not been settled by the OPs. The mediclaim of the complainant has been illegally withheld by the OPs and as such, there is a deficiency in service on the part of the OPs and accordingly, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the mediclaim amount of Rs.17,257/- alongwith interest @ 12% per annum from the date of lodgment of claim upto date of actual payment to the complainant and further, OPs be directed to pay compensation for causing mental tension and harassment, to the tune of Rs.10,000/- and be also directed to pay litigation expenses of Rs.5000/-.

3.                Notice of the complaint was given to the OPs, but despite service OP No.2 did not come present and ultimately, OP No.2 was proceeded against exparte, whereas OP No.1 appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that the claims filed by the complainant have been rightly repudiated by the answering OP. Sh. Sanjeev Kumar covered under the Family Floater Policy No.233100/48/2014/124 from 14.05.2013 to 13.05.2014 has taken treatment from Dr. Goel’s Neuro & Eye Hospital on 10.08.2013 for the treatment of his eye and he was only given Avastin Injection by the said hospital. Sh. Sanjeev Kumar has further taken treatment from Mahajan Eye Hospital and Maternity Home for the treatment of Blurring of Vision-Diabetic Retinopathy with Catract immature on 03.10.2013. The claims were repudiated as the treatment provided i.e. Administration of Injection Traimcinolone and Avastin, which do not require hospitalization and is only a OPD procedure. No surgery of the patient was done in the hospital. No treatment requiring hospitalization has been mentioned in the discharge summary. As per the terms and conditions of the policy of insurance, the expenses incurred by the insured qua hospitalization are only payable as per clause 2.3 of the policy of insurance. Eye surgery is an exception detailed in clause 2.3 of the policy of insurance in which hospitalization of 24 hours is not required. In the present case, no eye surgery was performed on the patient. Sh. Sanjeev Kumar has been admitted in the hospital only for OPD procedure and not for any eye surgery. Thus, the claims of the complainant, which did not fall within the scope of policy of insurance issued to the complainant by the answering OP was repudiated. It is further averred that there is no deficiency of service or unfair trade practice on the part of the OP that being so the present complaint is liable to be dismissed with cost. On merits, it is admitted that the insurance policy was taken by the complainants and insurance claim has been also submitted, but further took a plea that the said insurance claim was repudiated being not payable as per terms and conditions. The other averments as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

4.                In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB alongwith some documents Ex.C-1 to Ex.C-18 and closed the evidence.

5.                Similarly, counsel for the OP No.1 tendered into evidence affidavit of Sandeep Thapa as Ex.OP1/A alongwith some documents Ex.OP1/1 to Ex.OP1/4 and closed the evidence.

6.                We have heard the learned counsel for the respective parties and have also gone through the written arguments submitted by counsel for the both the parties as well as case file very carefully.

7.                From the overall circumstances as elaborated in the complaint as well as in its reply of the OPs, it reveals that the factum in regard to purchase of Happy Family Floater Insurance Policy has been admittedly obtained by the complainants from OP No.1 after paying renewal charges of Rs.8780/- and policy period was 14.05.2013 to 13.05.2014 and during the inception of policy, the insured Sanjeev Kumar was got some eye problem and accordingly, he got treatment from Goel Hospital as well as Mahajan Eye Hospital and thereafter, submitted an insurance claim for an amount of Rs.17,257/- and as per version of the complainants, the said insurance claim has yet not been settled by the OP till today, but on the other hand, the OPs admitted all the facts as stated above and further took a plea that the insurance claim of the complainant has been repudiated, being reason the same is not covered under Clause 2.3 of the insurance policy. This plea has been taken by the OPs in Para No.1 of the preliminary objections and also submitted that there is no deficiency or unfair trade practice on the part of the OPs. No doubt, the OP has brought on the file Photostat copy of the terms and conditions of the policy i.e. Ex.OP1/2 and accordingly, we have gone through the Clause 2.3 as referred by OP in Para No.1 of the preliminary objections and find that the said clause 2.3 is not relevant for the case of the complainants, rather it pertain to some other matter. Apart from aforesaid clause 2.3 as referred in preliminary objections, the counsel for the OP in addition to that clause, referred in written argument clause 3.23 as well as Clause 3.17, without discussing upon the aforesaid clause 3.17 and 3.23, we have to analyze the fraudulent attitude of the OP, as the OP alleged in Para No.1 of preliminary objections of written statement that insurance claim of the complainant has been repudiated, being reason the same is not covered under the policy terms and referred clause 3.17, wherein categorically described the definition of hospitalization, means admission in hospital for a minimum period of 24 hours in-patient care consecutive hours except for specified procedures/treatments. No doubt, in clause 3.17 the minimum period for admission in the hospital is 24 hours, but in Para No.1 of the preliminary objections, wherein categorically referred, which is as under:-

                             “Eye Surgery is an exception detailed in clause 2.3 of the policy of insurance in which hospitalization of 24 hours is not required."  

                    Here the OP itself stated that 24 hours hospitalization is not required. So, if we accept this version of the OP, then the complainant Sanjeev Kumar, who remained in the hospital for a one day less than 24 hours, apparently covered under insurance coverage, but the insurance medical claim of the complainant Sanjeev Kumar has not been decided by the OP for a long time, which itself a deficiency in service. We will talk about the fraudulent attitude of the OPs, as the OP alleged in the written statement in Para No.1 of the preliminary objections that the insurance claim of the complainant Sanjeev Kumar has been repudiated, but there is no repudiation letter, means the OP took a plea in the written statement without any footing, there is no evidence. So, it means the OP has not settled the claim of the complainant till today on either side, which is a glaring and un-acceptable negligence and deficiency in service for which the OPs are liable to compensate the complainant and accordingly, we hold that the complainant is entitled for the relief claimed.

8.                 In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay mediclaim amount of Rs.17,257/- to the complainant Sanjeev Kumar with interest @ 12% per annum from the date of filing complaint i.e. 11.05.2016, till its realization and further, OPs are directed to pay compensation to the complainant, to the tune of Rs.7000/- for causing mental tension and harassment and also directed to pay litigation expenses of Rs.3000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

 This complaint could not be decided within stipulated time frame due to rush of work.

9.                Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated                                       Jyotsna                           Karnail Singh

17.03.2020                              Member                          President