BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.75 of 2018

      Date of Instt. 23.02.2018

      Date of Decision:10.05.2022

Sandeep Kumar aged 43 years son of R. K. Sharma, R/O 58, Shanker Garden, Model Town, Jalandhar City-144003.

..........Complainant

Versus

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

2.       Raksha Health Insurance TPA Pvt. Ltd. C/o Escorts Corporate          Center, 15/5 Mathura Road, Faridabad, Haryana-121003.   Through its authorized officer.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)   

Present:       None for the Complainant.

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

                   None for OP No.2.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein he has alleged that on inducement and allured and tempted obtained insurance policy Oriental Bank Mediclaim Policy for himself. Mrs. Mona Sharma-wife, Miss Vanshika-Daughter and Akshit-Son. The mediclaim insurance policy covered risk to reimburse/indemnify expenses for any disease contracted or suffered from any illness/ailments/disease or injury sustained by the insured person. The policy was taken from OP No.1 through its authorized agent for the period stated in the Policy Schedule by renewal for the period of insurance from 11.04.2017 to 10.04.2018 and allotted policy No.233108/48/2018/28 as per policy schedule dated 05.04.2017. The complainant has been continuously and uninterruptedly insured himself and his family members for mediclaim insurance policy since year 2011 without any gap/brake and strings by OP No.1. The policy schedule of mediclaim insurance policy was issued in the name of the complainant insured. The total amount of renewal premium inclusive of all taxes of Rs.6990/- as consideration was paid to OP No.1 through its agent/representative which was accepted after fully satisfying the continue insurability and without questioning the credentials of the insured person without any demur. The OP No.1 issued/delivered to the complainant policy schedule and dated 05.04.2017 only from the inception of the risk coverage under mediclaim insurance policy and on its renewal. The policy document was not ever issued/delivered to the complainant by OP No.1, during the whole period of the policy. It is pertinent to submit that it was mandatory and obligatory upon OP No.1 to have issued policy document which expresses the contract of insurance between the insurer i.e. OP No.1 and the insured complainant. There is/was no ground or reason or occasion for not issuing the policy bond. Normally cover note/policy schedule is only interregnum during which policy is prepared and issued. The terms and conditions including exclusion clauses were not ever communicated and explained nor made known to the complainant and were not part of insurance. The OP No.1 has agreed and undertaken to indemnify for medical and surgical expenses or illness/sickness, accident and surgical operation etc contracted within the period of insurance to the full extent without any limitation and deduction. Accordingly, the complainant has got the right of indemnification/reimbursement for the whole amount of mediclaim insurance policy expenses incurred against peril covered under mediclaim insurance policy. The complainant daughter Vanshika co-insured with OP No.1 had chief complaints and history of fever high grade on and off 1015 day, L.M., Vomiting Oral Intake, Body aches and was admitted as in patient on 02.10.2017 and discharged as inpatient in Nipun Nanda Nursing Home, Jalandhar and was referred to higher centre (DMCH Ludhiana) for further management where she was admitted as inpatient in on 07.10.2017 and discharged on 13.10.2017. The complainant remained under treatment of Consultant Dr. Ajit Sood, Department G.E.I on evaluation clinical findings, tests and investigations essential and necessary related to victor borne diseases Malaria and Dengue, it was finally diagnosed AFI-Dengue Hepatitis. The reason for admission on being referred to higher center of Vanshika daughter of the complainant was also given in Discharge Summary and condition of the complainant at the time of admission which on discharge was stable. The DMCH Hospital is on the panel of OPs and authorized under Cashless Facilities Scheme of OPs Mediclaim payment for hospitalization and treatment expenses. Accordingly, under cashless facility extended to insured patient daughter of the complainant, OP No.2 vide Claim Settlement Voucher dated 10.11.2017 made partial drastically reduced claim bill payment of the sum of Rs.31,300/- only after deduction of an amount of Rs.40,486/- from Claim total amount of Rs.71,786/- in full and final settlement of DMCH Hospital computerized bill. However, OP No.2 pass amount of Rs.31,617/- and further deducted Rs.317/- on account of TDS and paid amount of Rs.31,300/- to DMCH through NEFT and coerced the complainant to bear balance expenses of amount of Rs.40,169/- of remaining outstanding of mediclaim bill by the complainant. As such, the complainant had no other option and paid amount Rs.40,169/- from his own pocket against full and final payment against total bill of medical expenses, treatment and hospitalization expenses ante. The claim was registered under No.233108/48/20/28. To utter surprise and dismay of the complainant, OP No.2 declined genuine bonafide legitimate mediclaim full expenses of the complainant on flimsy and strange purported reason that “Dengu Fever-Rs.200/- for dedication non payable, Rs.29,2970/- non payable as per investigated not related to Dengue, Rs.70/- CSSD charges, Rs.600/- for misc. charges non payable Rs.1500/- for admission fee non payable Rs.750/- as per room rent capping, 10% TDS deduction Rs.6714/-, 20% hospitalization discount deducted. The OP No.2 failed to disclose and gave any reason with any specific exclusion clause and policy condition of policy under which such alleged deduction in the guise of non-payable could be made by OP No.2 on its volition arbitrarily unilaterally unauthorized though all such purported deductions were integral part of hospitalization and treatment and as such could not be severed from final total mediclaim bill dated 13.09.2017 during hospitalization. Dengue fever tests were done to determine cause of fever for final diagnosis for treatment and medication. Moreover, OP No.2 has no authority competence and jurisdiction either to make any deduction or to reject/repudiate health insurance mediclaim as clearly and categorically stipulated in HIR regulations, 2016.

2.                The repudiation and denial of genuine and bonafide full claim amount was made on lame excuses in mechanical and routine manner and wrongly assumed and presumed and misconceived that the treatment fall in realm of exclusion clause of the policy. The repudiation of mediclaim was founded on speculation and merely on guess, conjectures and surmises. The OPs are guilty of rendering deficient service, negligent and adopted unfair trade practice in unilateral arbitrary and malafide rejection of mediclaim of the complainant as fully described ante and as such the present complaint filed with the prayer that the complaint of the complainant may kindly be allowed and OP No.1 be directed to pay/reimburse amount of Rs.40,486/- to complainant alongwith interest @ 12% per annum from the date of payment to DMC Hospital, Ludhiana till date of actual payment to the complainant and further OPs be directed to pay compensation of Rs.20,000/- for causing mental tension and harassment to the complainant and Rs.10,000/- as litigation expenses.

3.                Notice of the complaint was given to the OPs and accordingly, OP No.1 appeared through its counsel and filed its written reply and contested the complaint by taking preliminary objections that there is no deficiency of service or unfair trade practice on the part of the answering OP and that being so the present complaint is not maintainable. It is further averred that the amount due under the insurance issued to the complainant i.e. Rs.31,300/- has already been paid to the complainant. It is not out of place to mention here that the complainant has lodged claim for a sum of Rs.71,786/- with the OP No.2 i.e. the claim settling agency of OP No.1, for hospitalization of the complainant from 07.10.2017 to 13.10.2017 at DMC Hospital. The claim of the complainant was registered vide claim No.556221718263695 and accordingly, a sum of Rs.31,300/- was paid to the complainant as per the terms and conditions of the policy of insurance. The split up of the deducted amount was also supplied to the complainant in claim settlement letter dated 10.11.2017 which is as under:-

                   That being so the claim of the complainant has already been settled as per terms and conditions of policy of insurance, thus the present complaint is not maintainable. On merits, the factum with regard to the obtaining medical policy by the complainant is admitted, but the other allegations as made in the complaint by the complainant are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

4.                OP No.2 appeared through its authorized representative and filed its separate written reply, whereby contested the complaint by submitting that the mediclaim policy which the complainant had filed the claim, was issued by the Oriental Insurance Co. Ltd. The OP No.2 registered under the Companies Act 1956 is licensed TPA under IRDA Act 2001 to act as a facilitator for the processing of the claim. The insurance contract is between the insured and the insurer i.e. The Oriental Insurance Co. Ltd. As per the privity of the contract, the insurance company by itself or its TPA is obliged to process the claim as per the terms and conditions of the policy. It is further averred that the complainant has entered into the contract with OP No.1. The insurance contract is between the insured and OP No.1 i.e. The Oriental Insurance Co. Ltd. as respondent No.2 is just a third party administrator who acts on the basis of policy entered between the complainant and the OP No.1 and lastly prayed that the OP No.2 is liable to be deleted as OP No.2 is neither a proper nor necessary party to the present complaint.

5.                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-19 and closed the evidence.

6.                In order to rebut the evidence of the complainant, the counsel for the OP No.1 tendered into evidence affidavit of Sandeep Thapa as Ex.OP1/A alongwith some documents Ex.OP1/1 and Ex.OP1/2 and closed the evidence. Similarly, OP No.2 tendered into evidence affidavit of Vinay Batra as Ex.OP2/A and closed the evidence.

7.                We have heard the learned counsel for the OP No.1 only as none has appeared on behalf of the complainant and OP No.2 since last so many dates and have also gone through the case file as well as written arguments submitted by counsel for the OP No.1, very minutely.

8.                It is not disputed that the complainant obtained insurance policy Oriental Bank Mediclaim Policy for himself, his wife, his daughter and his son. It is also not disputed that the policy was renewed from 11.04.2017 to 10.04.2018. It has also not been disputed that this was a family insurance and the daughter of the complainant namely Vanshika was co-insured. The illness of the daughter of the complainant Vanshika is also not disputed. It has been admitted and proved on record that the minor daughter of the complainant was admitted in the DMCH, Ludhiana on 07.10.2017 and was discharged on 13.10.2017. Ex.C-5 and Ex.C-6 have been proved on record which is the mediclaim policy schedule, Ex.C-3 and Ex.C-4, Ex.C-7 to Ex.C-16 are the documents showing the admission of the daughter of the complainant and the tests conducted for the diagnose of the minor Vanshika, Ex.C-17 is the discharge summary, which shows that the daughter of the complainant was admitted and found to have Dengue positive and hepatitis and she was discharged in stable condition. All these documents are not disputed. It is also not disputed that the complainant filed a claim of Rs.71,786/- in full and final settlement of DMCH, Ludhiana, computerized bill is Ex.C-18. The OPs have settled the claim for Rs.31,300/- after the deduction of amount of Rs.40,486/- from the claim amount.

9.                The contention of the complainant is that the terms and conditions were not explained to the complainant at the time of the policy and exclusion clauses were also not supplied or delivered to the complainant during the subsistence of the mediclaim insurance policy or on renewal and from its inception.

10.              To rebut the contention of the complainant, it has been alleged by the OP No.1 that as per the clause 4.10 of the policy, the deductions have rightly been done from the claim amount, which were not permissible as per the terms of the policy. The policy of the complainant was renewed and the OPs have produced on record the schedule Ex.OP-1/1 (Ex.C-6). It has been mentioned in this schedule that the insurance under this policy is subject to the conditions, clauses, warranties and endorsements. It has further been mentioned that the policy shall pay for hospitalization expenses for medical/surgical treatment at any Nursing Home/Hospital in India and in-patient defined in the policy, meaning thereby that it has specifically been mentioned in the schedule that the policy shall be subject to the terms and conditions, supplied therewith.

11.              Perusal of the deducted amount alongwith clause 4.10 of policy shows that there is no illegality and the amount has been deducted as per the terms and conditions and as per the exclusion clause of the policy. The complainant himself has filed on record Ex.C-6, the schedule of the policy, in which it has been specifically mentioned that the policy will be subject to the terms and conditions. The complainant has not produced any document to show that alongwith this, he has not got terms and conditions, when the schedule was issued to the complainant. Thus, the complainant has failed to prove his case and accordingly, the complaint of the complainant is dismissed with no order of costs. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.

12.              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          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

10.05.2022         Member                          Member              President