Haryana

Ambala

CC/14/2012

PUSHPINDER SAXENA S/O SH S.K SAXENA - Complainant(s)

Versus

THE ORIENTAL INSURANCE CO. LTD - Opp.Party(s)

SUDHIR SEHGAL

25 Jan 2017

ORDER

             BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA.

                                                           Complaint case no.        : 14 of 2012

                                                           Date of Institution         : 11.01.2012

                                                           Date of decision            : 25.01.2017

Pushpinder Saxena son of Sh. S.K. Saxena resident of house No. 172,     Sector-10, HUDA Ambala City.  

              ……. Complainant.

1.       The oriental Insurance Co. Ltd; LIC Building Ambala City through its     Branch Manager.

2.       Vipul Med Corp TPA (P) Ltd., 515-Udyog Vihar, Phase –V Gurgoan.

           ….…. Opposite Parties

BEFORE:   SH. D.N. ARORA, PRESIDENT.

                   SH. PUSHPENDER KUMAR, MEMBER.                          

 

Present:       Sh. Sudhir Sehgal, Adv. for complainant.

                   Sh. Anita Sharma, Adv. for Ops.    

ORDER:

                   In nutshell, brief facts of the present complaint is that the complainant had obtained Happy Family Floater Policy vide No. 261101/48/2011/1346 dated 04.12.2010 for family members named Pushpindra Saxena- Self, Rashmi Saxena –wife, Unnati Saxena-minor daughter and Mr. Vansh Saxena minor son of complainant for the period from 16.12.2010 to 15.12.2011 for Rs. 5,50,000/- and paid a sum of Rs.7870/- as premium vide cheque from OP No. 1 and OP NO. 2 is T.P.A. of OP No. 1 as mentioned in the policy schedule. Further submitted that the minor son of complainant named Vansh Saxena suddenly fell ill and was having swear pain in Rt. Torsion testis on 3^rd of October 2011 and was got admitted in hospital and was treated by Dr. Sanjay Aggarwal and her remained admitted in the hospital for four day, for which permission was sought to get him treated in M.M. Hospital, Ambala City due to ailment or urgent nature and after the treatment, the complainant submitted his claim for the expenses incurred by him but the same was wrongly and illegally rejected with the observation that Torsion of Testis does not fall within the claim, which is totally false and against the policy obtained by the complainant. Further submitted that as per clause 4.3 torsion of testis does not fall within the claim and it is pertinent to mention that clause 4.3 covered undiscended testis and the same is by birth but not Torsion of testis which can fall/rise at any time, but rejection of the claim of the complainant for the treatment of his son during the currency of the policy is deficiency in service on the party of the Ops and Ops are liable to pay the same alongwith harassment and compensation. Hence, the present complaint.

2.                Upon notice, OPs appeared and filed written statement submitting that there is no deficiency in service on the part of the respondent as the present disease namely “Torsion of testis” for which the insured underwent surgery is the Surgery of URO Genital System and as the policy was running in the Second year (From 16.12.2009) and the claim merits repudiation under clause 4.3/mediclaim because the current illness is not payable in the First two years of the policy. Hence, the present claim is liable to be dismissed with costs.

3.                Op No.2 also tendered their Witten statement on the same footings as that of OP No.1 and prayed for dismissal of complaint with costs.

4                 To prove his version, counsel for complainant tendered his affidavit as Annexure C-X along with documents as annexure C-1 to C-18 and close his evidence. On the other hand, counsel for Ops tendered affidavit Annexure RX alongwith documents as Annexures  R-1 to R-5 and closed their evidence.

5.                We have heard learned counsels for the parties and carefully gone through the case file. The arguments of counsel for complainant is that  on 03.10.2011 his son Vansh Saxena  got severe pain in Right Torsion Testis and  he was brought to M.M. Hospital, Ambala City and remained admitted there for four days.  Counsel for complainant further argued that permission to get the patient treated from M.M. Hospital was sought due to ailment of urgent nature.  But the claim submitted by the complainant with the Op Insurance company rejected by them on the ground that “since the policy is second Yr.(16.12.2009), current illness is not payable in first two years of policy hence the claim is not admissible under exclusion 4.3.” which as per complainant is deficiency in service as well as unfair trade practice on the part of Ops.  He further clarified that Torsion Testis is not a congenital disorder/ by birth rather it is a surgical emergency and it is to be dealt by a surgeon at the earliest by way of surgical procedure. In the present case, patient had underwent  Orchidectomy Rt. Testis with Orchidopexy Lt. Testis and  Right Testis was removed as per treatment record (Annexures C-4 to C-6) and  his case does not fall under clause (vi) of 4.3 as it is  not a congenital disease/by birth. So, the complainant is entitled for the expenses incurred on the treatment of his Vansh Saxena.

6.                On the other hand, counsel for Ops has argued that disease namely “Torsion of testis” for which the insured underwent surgery- the Surgery of URO Genital System and Torsion of Testis  is a part of genito-urinary system  as mentioned in clause 4.3 (xiv) of the policy and the above said disease occurred to the patient within two years after taking the policy i.e. on 16.12.2009 and the patient was operated on 03.10.2011 so, the claim of complainant under clause 4.3/mediclaim was rightly repudiated by them. As such, there is no deficiency in service on their part and sought for dismissal of the complaint with exemplary costs.

7.                It is admitted fact on record that the OP has issued a policy to complainant (Annexure C-1) wherein complainant alongwith his family member including his son Vansh Saxena are covered under the policy. But the moot question for consideration before us is that whether repudiation of claim of complainant was violation of terms & conditions of the policy by the OPs?

                   To resolve this controversy, we have gone through the terms conditions of the policy Annexure R-3, clause 4.3 which is reproduced as under:-

“The expenses on treatment of following ailment/diseases/surgeries for the specified period are not payable if contracted and /or manifested during the currency of the policy.

If these diseases are pre-existing at the time of proposal  the exclusion no.4.1 for pre-existing conditions SHALL be applicable in such cases.”

8.                 After perusing the policy document, it  has come out that insured person is not entitled for claim whether the disease has occurred within two years from commencement of the policy or the disease is pre-existing i.e. before obtaining the policy.  In the present case, policy of complainant starts from  16.12.2009 and the complainant had undergone surgery on 03.10.2011 for ailment of Torsion of Testis. Meaning thereby that the disease has occurred to the complainant within limit of two years from commencement of the policy. As such, we do not find any illegality in repudiating  of claim of complainant by Ops. Accordingly, the complaint is dismissed with no order as to costs.  Copies of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room.

Announced on :25.01.2017                                             Sd/-

                                                                                 (D.N. ARORA)

                                                                                       President

                           Sd/-

     (PUSHPENDER KUMAR)

                                                                                       Member