BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.448 of 2018
Date of Instt. 29.10.2018
Date of Decision: 14.03.2022
Harmail Singh Malhi s/o Joginder Singh resident of Vill. Atta, PO Goraya, Tehsil Phillaur, Distt. Jalandhar.
..........Complainant
Versus
1. The Oriental Insurance Co. Ltd., A-25/27, Asaf Ali Road, New Delhi-110002 through its Authorized Officer
2. The Oriental Insurance Co. Ltd, Branch Office II, SCO-50 Jeevan Raksha, PUDA Complex, Opposite Tehsil Complex, Jalandhar through its Branch Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. R. K. Bhardwaj, Adv. Counsel for the Complainant.
Sh. A. K. Arora, Adv. Counsel for the OPs No.1 and 2.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein he has alleged that the OP No.1 is an insurance company duly incorporated and registered under Companies Act and is offering insurance services throughout India including the State of Punjab and have different branches throughout India and OP No.2 is its branch at Jalandhar, Punjab and the complainants are the consumer of the OPs No.1 and 2 having been availed a Family Health Insurance Plan bearing Policy No.233108/48/2019/76. The above said policy has been valid from 12.04.2018 to 11.04.2019. Prior to the issuance of policy, the complainant had policy No.233108/48/2018/15 in the previous year and the agents of the OPs approached the complainant for the purpose of health insurance policy. The executives of the OP told the complainant that the health policy provided by the company is comprehensive and includes almost all the ailments. Being lured by deceptive assurances of the agents of OPs, the complainant No.1 agreed for purchasing a health insurance policy for his family and consequently the above mentioned policy was issued after receiving the premium amount by the OPs. It is noteworthy to add here that the policy had been issued after the agents and executives of the OPs assured themselves that the complainants are hale and hearty and they are not suffering from any pre-existing disease nor they had any such pre-existing disease. That in the month of May 2018, the complainant started feeling pain in abdomen, so the complainants got medical tests from Gandhi Hospital and Uttam Diagnostic Center and it was told that the complainant was suffering from Pancreatita. That thereafter on 24.05.2018 the complainant was admitted in Gandhi Hospital and after operation and other medical treatment discharge from hospital on 06.06.2018. That though, at the time of issuance of health claim policy, it was assured to the complainants by the OPs that cashless medical facility will be available at Gandhi Hospital, alongwith other hospitals as per their empanelment however, the OPs did not provide cashless facility and the complainants had to pay the entire hospital bills from their own pocket, though all the documents and bills have been submitted to the OPs. That after being discharged from the hospital, the complainant alongwith medical bills of the hospital and other documents followed up the claim with the OPs, however the OPs refused to entertain the claim of the complainant and repudiated the same without any legal and valid reason on the false and frivolous ground vide letter dated 14.09.2018. This clearly amounts to deficiency in service and negligence in duties towards the customers. That after the repudiation of claim, the claimant also contacted the OP through customer care as well as by visiting the office of OP No.2, but every time OPs refused to listen to the complainant on one pretext or the other. That the act and conduct of the OP amounts to deficiency in service and unfair trade practice and due to this the complainant has suffered a lot of mental tension, agony and harassment and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to entertain the claim of the complainant as per the medical bills to the tune of Rs.1,36,453/- already submitted with OPs. Further OPs be directed to pay Rs.50,000/- as compensation for causing mental tension, agony, inconvenience, harassment etc to the complainant and Rs.10,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, who filed joint written reply, whereby contested the complaint by taking preliminary objections that the complainant has taken PNB-Oriental Mediclaim Policy 2017- Group Health Insurance Product from the OP No.2 for the period 12.04.2018 to 11.04.2019. The complainant lodged a claim with the OP for the treatment taken by the complainant for the period 24.05.2018 to 06.06.2018 from Gandhi Hospital, Patel Nagar, Phagwara. As per discharge slip issued by the said hospital to the complainant, the complainant was admitted in the hospital as a case of Gall Stone with Pancreatitis, treated conservately. The policy of insurance issued to the complainant is in the 2nd year, since the complainant was insured by the OP from 04.04.2017 to 03.04.2018. As per clause 4.2 of the policy of insurance, the expenses on the treatment Gall Bladder Stone and Bile Duct are payable after two years as per policy terms and conditions. The policy is in second year. So, the claim of the complainant was repudiated as per clause 4.2 of the policy. Clause 4.2 of the policy of insurance reads as under:-
“The expenses on treatment of such ailment/diseases/surgeries for the specified period are not payable if contracted and/or manifested during the currency of the policy.”
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 filed by the complainant is liable to be dismissed. On merits, the factum in regard to taking Family Health Insurance Plan by the complainant is admitted, but the other allegations 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.
3. Rejoinder not filed by the complainant.
4. In order to prove their respective versions, both the parties produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for both the parties very minutely.
6. The complainant has claimed the amount of Rs.1,36,453/- spent by him on the treatment taken by him on the basis of health insurance alongwith compensation and litigation expenses.
7. It has been alleged by the complainant that the complainant took the health insurance policy from OPs No.1 & 2 and this health insurance policy was stated to be valid from 12.04.2018 to 11.04.2019. It has been further alleged that he was admitted in Gandhi Hospital on 24.05.2018 due to pain in abdomen and got medical tests from Gandhi Hospital and Uttam Diagnostic Center and the complainant was suffering from Pancreatita and after operation and other medical treatment, he was discharged from hospital on 06.06.2018 and spent Rs.1,36,453/- on his treatment on different dates, which is evident from Ex.C-1 i.e. Detail of Expenditure on Treatment. He has proved on record the receipts including tests reports and discharge summary Ex.C-8 to Ex.C-58. It has been alleged by the complainant that the OPs repudiated the claim on false and frivolous ground. Request has been made to allow the complaint.
8. The case of the OPs No.1 & 2 is that the complainant has taken Group Health Insurance Product from the OP No.2 for the period 12.04.2018 to 11.04.2019 and the complainant lodged a claim with the OP for the treatment taken by him for the period 24.05.2018 to 06.06.2018 from Gandhi Hospital, Phagwara. As per discharge slip, the complainant was admitted in the hospital due to Gall Stone with Pancreatitis, treated conservately. The policy of insurance issued to the complainant is in the 2nd year, since the complainant was insured by the OP from 04.04.2017 to 03.04.2018. As per clause 4.2 of the policy of insurance, the expenses on the treatment Gall Bladder Stone and Bile Duct are payable after two years as per policy terms and conditions. The policy is in second year. So, the claim of the complainant was repudiated as per clause 4.2 of the policy. Request has been made to dismiss the complaint.
9. As per Ex.C-2, the claim of the complainant was repudiated by the OPs as per Clause 4.2 of the policy. As per Ex.C-50, the complainant was admitted in the hospital on 24.05.2018 and discharged on 06.06.2018. As per Ex.C-50 i.e. Discharge Slip, the case history is that the patient admitted as a case of Gall stone Pancreatita. Patient was kept in ICU, treated conservately and recovered. Clause 4.2 (xiii), the exclusion is in case of surgery of gallbladder and bile duct excluding malignancy and the period required is 2 years. In the present case, if we see the discharge slip Ex.C-50, then it is crystal clear that there is no mentioning of any surgery rather it is only treatment. So, the Clause 4.2 is not applicable and the claim of the complainant has wrongly and illegally been repudiated by the OPs and thus, the repudiation letter is hereby set-aside and further held that the complainant is entitled for the relief claimed.
10. In the light of above detailed discussion, the complaint of the complainant is partly allowed and OPs are jointly and severally directed to pay medical insurance claim amount of Rs.1,36,453/- alongwith interest @ 6% per annum from the date of repudiation the claim i.e. 14.09.2018, till realization. Further, OPs are directed to pay compensation of Rs.15,000/-, to the complainant for causing mental harassment and agony to the complainant and further, OPs are directed to pay litigation expenses of Rs.5000/-. The entire compliance be made within 45 days 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.
11. 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
14.03.2022 Member Member President
