DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/182

Date of Institution : 12.03.2018/29.11.2021

Date of Decision : 21.07.2022

Sh. Vinod Kumar Bhatia s/o Shri Bihari Lal Bhatia, aged 75 years, R/o 65, Old Jail Road, Amritsar.    …Complainant

Versus

1. The Oriental Insurance Company Limited, Branch Office Tarn Taran, Near Satkar Palace, Amritsar Road, District Tarn Taran through its Manager.

2. Oriental Insurance Company Limited, Oriental House, Asif Ali Road, New Delhi-110002 through its General Manager.

…Opposite Parties

 

Complaint U/S 11 and 12 of The Consumer Protection Act 1986 as amended up to date

Present: Sh. Munish Kohli Adv counsel for the complainant.

Sh. Neeraj Brahmi Adv counsel for opposite parties No. 1 and 2.

 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Smt. Urmila Kumari : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 11 and 12 of the Consumer Protection Act against The Oriental Insurance Company Limited, Tarn Taran and another. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that on the request of the complainant the opposite parties issued an Mediclaim Policy No. 233308/48/2016/1429 on payment of premium. The complainant was admitted to Sukh Sagar Hospital, Amritsar on 15.12.2016 at 8.05 AM and discharged on 16.12.2016 on 1.00 Pm for treatment of Lipoma of Right Food advised by Dr. Rohit Sharma. He was admitted to the hospital on the recommendation of the doctor vide his prescription dated 15.12.2016. The policy was a cashless policy but to the utter surprise of the complainant the cashless claim was denied vide email dated 6.3.2018 with the remarks that the claim is not payable as per .-

Definitions: 2.11 Day Care Treatment: refers to medical treatment and/or surgical procedure which is 1) undertaken under General or Local Anaesthesia in a hospital/day care centre is less than 24 hours because of technological advancement and 2) which would have otherwise required a hospitalization of more than 24 hours. Procedures/ treatments usually done in out patient department are not payable under the policy even if converted to Day Care Surgery/procedure or taken as an patient in a hospital for more than 24 hours. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to settle the claim of the complainant for Rs. 11,500/- as a cost of medical expenses incurred.     

2) To pay Rs. 25,000/- on account of harassment and mental agony.

3) To pay cost of legal expenses.

4) Any other relief to which the complainant is found entitled. 

3. Upon notice of this complaint, the opposite parties filed written version taking preliminary objections on the grounds that the present complaint is not maintainable and complainant has not come to this Commission with clean hands and suppressed the true facts. The complainant has got no cause of action to file the present complaint. The complaint is bad for mis joinder and non joinder of necessary parties. The complainant obtained the insurance policy for a period from 23.1.2016 to mid night of 22.1.2017 from the opposite party. It is admitted that during the currency period of policy the insured/complainant was admitted at Sukh Sagar Hospital, Amritsar for disease lipoma right foot and was advised surgery. He was admitted in hospital on 15.1.2016 at 8.05 AM and was discharged from the hospital on 16.12.2016 at 1.00 PM as per certificate of treating hospital. The complainant applied for cashless claim which was denied at relevant time vide email dated 6.3.2017 and not 6.3.2018 as per definition 2.11 Day Care Treatment of the policy. However, after discharge from hospital the complainant lodged the claim and submitted claim bill alongwith claim form and claim was preferred to E-Meditek Insurance TPA Limited who after scrutiny of the claim from issued letter dated 13.1.2017 to the complainant asking him for submission of certain documents for processing the claim which were later on submitted and considered by TPA and TPA after scrutiny of the entire medical record and documents opined that the claim is not payable and same was repudiated and complainant was duly informed in this regard vide letter dated 30.1.2017. 

4. On merits, it is not denied that the complainant obtained the policy from the opposite parties. Rest of the submissions are already submitted in the preliminary objections so there is no need to repeat the same. However, lastly the opposite parties  prayed for the dismissal of the present complaint with costs. 

5. In support of his complaint, the complainant tendered into evidence his affidavit Ex.CW-1/A, copy of repudiation letter Ex.C-1, prescription slip Ex.C-2, certificate from doctor Ex.C-3, copy of bill Ex.C-4 and closed the evidence. 

6. To rebut the case of the complainant, the opposite parties  tendered in evidence affidavit of Naresh Singla Senior Divisional Manager Ex.OP-1, documents Ex.OP-2 to Ex.OP-8 and closed the evidence. 

7. We have heard the learned counsel for the parties and have gone through the record on the file carefully. Written arguments also filed by the opposite parties.

8. The opposite parties admitted all the contents regarding purchase of policy, validity of policy, sum insured and treatment taken by the complainant from Sukh Sagar Hospital, Amritsar. The only dispute between the parties is regarding the stay of the complainant in the hospital. The learned counsel for the opposite parties argued that the as the stay of the complainant in the hospital is less than 24 hours so the claim is not payable and repudiated by the opposite parties. On the other hand, the learned counsel for the complainant argued that the complainant admitted in the hospital on 15.12.2016 at 8.05 AM and discharged from the said hospital on 16.12.2016 on 1.00 PM for treatment of Lipoma of Right Foot, so his stay in the hospital is more than 24 hours and opposite parties repudiated the claim of the complainant on unreasonable and baseless ground. 

9. To prove his case the complainant tendered in evidence original certificate from his treating doctor Dr. Rohit Sharma of Sukh Sagar Hospital, Amritsar Ex.C-3 in which he certified that Vinod Bhatia s/o BL Bhatia was admitted in the said hospital on 15.1.2016 at 8.05 AM and discharged on 16.12.2016 at 1.00 PM vide registered No. 9068. So, from this document the complainant successfully proved on the file that he stayed in the hospital for more than 24 hours. On the other hand, the opposite parties have not filed any document to rebut this most important document on the file and failed to prove that the complainant stayed in the hospital less than 24 hours. In this way, the repudiation of the claim of the complainant on baseless ground is clear cut deficiency in service and unfair trade practice on their part. 

10. In view of the above discussion, present complaint is partly allowed and opposite parties are directed to pay the amount of Rs. 11,500/- to the complainant on account of insurance claim alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite parties are also directed to pay Rs. 3,300/- to the complainant as compensation for mental tension and harassment and Rs. 2,200/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Both the opposite parties  jointly and severally liable to comply with the above mentioned order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        21st Day of July 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member