BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR.
Complaint No.204 of 2020 Date of Instt.26.07.2020 Date of Decision:-28.09.2021
Bharat Bhushan Handa, aged about 68 years son of Sh. Faqir Chand Handa, R/o Flat No. 402, Block-I, Silver Palm Apartments, Jalandhar Kunj, Kapurthala Road, Jalandhar City.
….. Complainant
Versus
1. The Oriental Insurance Company Limited, through its the Divisional Manager, SCO 18-19, Scheme No. II, Chandigarh Road, Hoshiarpur, Punjab.
2. The In-charge, Regd. Office Oriental House, A/26-27, Asif Ali Road, New Delhi 110001
3. The In-charge, Raksha Health Insurance, TPA, Mathura Road, Faridabad Haryana.
……Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Kuljit Singh (President) Smt. Jyotsna (Member) Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Ashish Bhandari, Adv. Counsel for the Complainant. Sh. A. K. Arora, Adv. Counsel for OPs No.1 and 2. OP No.3 exparte.
Order
Kuljit Singh (President)
The present complaint has been filed by complainant against the OPs on the averments that he has suffered seizure on 20.01.2018 and had consulted PGI on 24.01.2018 wherein he was advised to get MRI Brain. He got his MRI done in PGI same day and it was diagnosed as parasagittal MENINGIOMA and surgery was advised. He thereafter consulted Neurosurgeon in NHS (NASA & HUB Superspeciality) Hospital Kapurthala Road, Jalandhar and got operated for removal of the tumor MENINGIOMA. The operation was done on 20.03.2018. He has been charged Rs.1,04,000/- as operation charges by the Hospital as cost of surgery. The medi-claim with all the documents and bill was submitted with OPs no.1 and 3. He was then went abroad and there was no communication from the OPs as wrongly mentioned in the repudiation letter, except a letter dated 03.10.2018, which was received by the complainant, when he returned India. In compliance of the notice dated 03.10.2018 and email dated 04.01.2019 was sent to OP no.3 and original documents were also sent by registered post on 05.01.2019 to OP no.3. The complainant was in hope that the claim would be settled and amount would be deposited in his account. The details of account were provided by the complainant in letter dated 12.04.2019. The complainant again went abroad and returned to India on 17.02.2020. No communication regarding settlement of claim was received by complainant. The complainant was shocked when the complainant got the reply dated 28.02.2020 through registered post from OP no.1 informing that claim has been repudiated. The repudiation of the complainant is illegal and deficiency of service to complainant has been caused by OPs. Due to act and conduct of OPs, the complainant has filed the present complaint and prayed that the OPs be directed to pay Rs.1,04,000/- as compensation and Rs.90,000/- for mental torture and harassment.
Upon notice, OPs no.1 and 2 appeared and filed joint written reply and contested the complaint of the complainant by raising preliminary objections that this Commission has got no jurisdiction to entertain and try the complaint. There is no deficiency of service or unfair trade practice. On merits, it was averred that on receipt of claim documents regarding reimbursement of medical expenses incurred by the complainant for treatment taken by him for the period 20.03.2018 to 25.03.2018 from NASA Brain Spine Centre, claim was registered by OP no.1. OP no.1 asking the complainant to comply with the requirements for settlement of claim vide letter dated 12.04.2018, but complainant filed to submit documents within stipulated period. As such, his claim was repudiated by OPs. Rest of the averments made by the complainant was denied by OPs no.1 and 2 and they prayed for dismissal of the complaint.
Notice sent to OP no.3 has not been received back. Sufficient period from service has been lapsed. As such, OP no.3 was proceeded against exparte by this Commission, vide order dated 02.02.2021.
4. We have heard learned counsel for the parties and have gone through the record very carefully as well as written arguments filed by complainant.
5. The glance of evidence is required for settlement of the case in hand. The complainant has tendered in evidence his affidavit
6. The glance of evidence is required for settlement of case. The complainant has tendered in evidence Ex.C-1 is copy of MRI Report dated 24.01.2018. Ex.C-2 and Ex.C-3 are copies of Out Patient Card of complainant. Ex.C-4 is copy of legal notice served upon OPs. Ex.C-5 is postal stamp thereof. Ex.C-6 is copy of reply addressed to Divisional Manager/OIC to repudiation letter of OPs. Ex.C-7 is letter dated 28.02.2020. Ex.C-8 is copy of certificate. Ex.C-9 is copy of Aadhar Card of the complainant. Ex.C-10 is copy of list of diseases which are pre-existing diseases at the time of proposal under Exclusion Clause no. 4.1 of the policy. Ex.C-11 is copy of card of Oriental Insurance Co. Ltd Mediclaim Policy. Ex.C-12 is copy of email.
7. To refute this evidence of the complainant, OPs no.1 and 2 tendered in evidence affidavit of Sunita Rani Senior Divisional Manager as Ex.OP-1-2/ in support the case of OPs. This witness stated that treatment taken by complainant for the period 20.03.2018 to 25.03.2018 from NASA Brain Spine Centre claim was registered by OP no.1. The complainant has failed to comply with the requirements of the OPs as called vide letter dated 12.04.2018. Ex.OP-1-2/1 is copy of query letter for claim no.5562217188468051. Ex.OP-1/2 is reminder regarding submission of documents. Ex.OP-1/3 is coy of final reminder regarding submission of documents from complainant. Ex.OP-1/2/4 is copy of non pay letter for claim. Ex.OP-1/2/5 is copy of non-pay letter for claim. Ex.OP1-2/6 is copy of letter dated 23.06.2018. Ex.OP-1/2/7 is letter dated 03.10.2018. Ex.OP-1/2/8 is letter regarding status of claim of the complainant. Ex.OP-1-2/10 is copy of letter addressed from the complainant to OPs, in this letter complainant stated that he had submitted all the required documents demanded by OPs. Ex.OP-1-2/11 is copy of repudiation letter dated 28.02.2020. Ex.OP-1/2/12 is copy of policy , which is valid from 28.12.2017 to 27.12.2018.
8. It is an established fact that the complainant had consulted PGI on 24.01.2018 wherein he was advised to get MRI Brain. He got his MRI done in PGI on the same day. It was diagnosed as parasagittal MENINGIOMA. Thereafter, he consulted Neurosurgeon in NHS (NASA & HUB Superspeciality) Hospital Kapurthala Road, Jalandhar and got operated for removal of the tumor MENINGIOMA. The operation was done on 23.03.2016 and he has been charged Rs.1,04,000/- as operation charges by the hospital as cost of surgery. Then the complainant went abroad and there was no communication from OPs as wrongly mentioned in repudiation letter, except dated 03.10.2018, which was received by the complainant. In compliance of the notice dated 03.10.2018 and email dated 04.01.2019, original documents were sent by the complainant to OPs through registered post on 05.01.2019, this fact is clear from copy of postal receipt Ex.C-13 on the record. The complainant contacted OPs on phone and they informed him that they sent the case file including documents (received by registered post) to OP no.1. In letter dated 03.10.2018 the OP no.1 demanded Original Investigation Report for dated 20.03.2018. On the other hand, NHS Hospital given certificate that “No MRI was done at their hospital on 20.03.2018.”, OP no.1 repudiated the claim of the complainant vide letter dated 28.02.2020 due to non-submission of documents but on the other hand complainant stated that he supplied all the required documents to OPs. He also stated that this fact is clear from copy of postal receipt Ex.C-13 on the record. Ex.C-1 is copy of MRI Report of complainant which is placed on the record. In this report, it is clear in Impression: Left frontal extra-axial mass lesion as described, likely parasagittal meningloma.”. Ex.C-6 is copy of letter addressed to OP no.1 by complainant, in this letter complainant specifically mentioned that all the documents supplied to OPs. The policy period is 28.12.2017 to 27.12.2018. The diagnosis given to complainant as LT FRONTAL PARASAGITTAL MENINGIOMA. In letter dated Ex.C-6 the complainant mentioned that he supplied all the document to OPs.
9. From perusal of entire record, it has transpired that the complainant has not supplied the all required documents to OP no.1 for settlement of the claim. As per terms and conditions of Oriental Insurance Company Limited –PNB ORIENTAL ROYAL MEDICLAIM -2017 POLICY ,
v. Claim Documents u
a. Original bills, all receipts and discharge certificate /card from the Hospital.
b. All documents pertaining to the illness, starting from the date it was first detected, i.e. Doctors consultations reports/medical history.
c. Medial history of the patient recorded by the hospital.
d. Original cash memo from the Hospital (d)/ chemist s) supported by proper prescription.
e. Original receipt, pathological and other test reports from a pathologist/radiologist/radiologist including film etc supported by the note from attending Medical Practitioner/Surgeon demanding such tests.
f. Original attending consultants/ Anesthetists/Specialist certificates regarding diagnosis and bills receipts etc.
g. Surgeon original certificate stating diagnosis and nature of operation performed along with bills /receipts etc.
h. MLC/FIR/Post Mortem report, (if required)
I Death certificate (if required)
j. Documents in respect of organ donation claim, shall be in accordance with the extant Act, Central /State Rules/ regulations, as applicable , in respect of transplantation of human organs.
k. Details of previous policies, if the details are already not with TPA.
As per terms and conditions of the policy, the above documents are required for settlement of the case of the complainant but complainant has failed to submit the same. The complainant submitted some documents but he has failed to submit the remaining documents to OPs, that is why OP no.1 repudiated the claim of the complainant, vide letter dated 28.02.2020. We have gone through the all record on the file, the complainant has not placed on record discharge summary, bill/payments receipts and other relevant documents. There is no prescription slips of doctor on the record. The complainant has not produced valid documents on record to prove his case. Raksha Health Insurance TPA sent the case of the complainant to OP no.1 for settlement of his case but OP no.1 demanded required documents from complainant vide letters Ex.OP-1-2/1 dated 12.04.2018, letter Ex.OP-1-2/2 is dated 01.05.2018, letter Ex.OP-1-2/3 dated 19.05.2018, letter Ex.OP-1-2/4 is dated 14.06.2018, letter Ex.OP-1-2/5 is dated 21.06.2018, Ex.OP-2/6 is letter dated 23.06.2018. letter Ex.OP-1-2/7 is dated 03.10.2018. OP no.1 sent various letters to complainant time and again but complainant has failed to supply requisite documents to OP no.1. As per condition no.5 of the terms and condition of the insurance policy, documents are necessary for settlement of case but complainant has failed to do so, that is why OP no.1 repudiated the claim of the complainant.
10. Keeping in view the totality of the facts and circumstances of the case, we dispose the complaint of the complainant with direction to complainant to submit all the required documents to OP no.1 for settlement of his case within 45 days from receipt of copy of this order and OP no.1 is directed to settle the claim of the complainant on receipt of required documents from him.
11. Copies of the order be sent to the parties, as permissible, under the rules. This complaint could not be decided within stipulated time frame due to rush of work.
12. File be indexed and consigned to the record room after due compliance.
Announced in open Commission
28th of September 2021
Kuljit Singh
(President)
Jyotsna
(Member)
Jaswant Singh Dhillon
(Member)
