Haryana

Karnal

CC/329/2017

Dharamvir Lather - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

Balvinder Singh

04 Dec 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                             Complaint No.329 of 2017

                                                         Date of instt. 06.10.2017

                                                         Date of decision:04.12.2018

                                                                                       

1. Dharamvir Lather son of Shri Arjun Singh.

2. Jarnallo wife of Shri Dharamvir Lather.

Both residents of village Phoosgarh, Tehsil and District Karnal.

                                                                                                …….Complainants.

                                        Versus

 

1. The Oriental Insurance Company Limited, Meera Ghati Chowk, Karnal through its Manager/Authorized Officer.

2.  M/s Raksha Health Insurance TPA Pvt. Ltd. SCO no.359-360, 1^st floor, Sector 44-D, Chandigarh through its Branch Manager.

 

  …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.    

       

Before   Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

              Dr. Rekha Chaudhary……Member

 

 Present   Shri B.S. Virk Advocate for complainants.

                 Shri Karamvir Mandhan Adv. for OP no.1

                 OP no.2 exparte.

               

                (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant no.1 having his bank account in Oriental Bank of Commerce, had obtained Oriental Bank Mediclaim Policy with family floater bearing no.261301/48/2017/2654 valid from 21.11.2016 to 20.11.2017 by paying the premium of Rs.6990/- debited from the account of complainant no.1. Complainant no.2 being spouse of complainant no.1 was also fully insured in the abovesaid policy. The policy started from the year 2015. Complainant no.2 was hale and hearty. In the month of July 2017 complainant no.2 felt some swelling in her neck and had taken treatment from Karnal. Thereafter, complainants approached Fortis Hospital at Mohali on 29.07.2017 for further treatment where certain laboratory tests and CT scan were conducted and it was reported that one Homogenously Lymch Node on the left side of the neck is causing compression over left internal Jugular vein, so there is some swelling which causing obstruction in proper breathing. As per the advice of the doctor, an investigation, the nodes which was causing obstruction in breathing and causing swelling was removed. The intimation regarding the admission of the complainant no.2 was given by the complainant through the attending doctors to the OPs by providing all the relevant details for extending cashless facility, as per the terms and conditions of the policy. The complainant spent an amount of Rs.1,50,000/- on 29.07.2017 at the time of admission of the complainant no.2 and conducting investigations to diagnose the cause of swelling and obstruction in the neck. The intimation regarding the hospitalization of the complainant no.2 was also given to the OPs. As per the intimation of the complainants, the approval was also granted by the OPs. Complainant no.2 was operated upon on 30.7.2017 and C.B.T. Excision was done. The obstruction from the neck was removed by way of operation and thereafter the complainant no.2 felt some giddiness and heaviness in the brain which was investigated through CT scan and it was found that some blood vessels passing through the neck carrying the blood from heart to brain are narrow down and due to less supply of blood, is the main cause of giddiness etc. and after taking the treatment for the said disease, the condition of the complainant no.2  was also improve and she was discharged from the hospital on 27.8.2017 but still under treatment as outdoor patient. It is further alleged that all the relevant record regarding medical tests, treatment etc. was provided to the OPs for extending the cashless facility to the tune of Rs.5,00,000/- as per the mediclaim policy, but the OPs sent a letter date nil to the Fortis Hospital, by declining the same with frivolous reason. Complainant no.2 remained admitted in the hospital from 29.07.2017 to 27.08.2017 and thus spent a sum of Rs.15,23,000/- during this period and the complainant no.2 is still under the treatment as Out Door Patient. The complainant requested the OPs to pay the amount of Rs.5,00,000/- under the abovesaid cashless policy, but OPs refused to pay the same. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs. OP no.1 appeared and filed written version raising preliminary objections with regard to maintainability; locus standi and concealment of true and material facts. On merits, it is pleaded that complainant no.2 was admitted in Fortis Hospital, Mohali as case “Carotid Body Tumour, RT Sylvain haematoma”. She had a history of same disease since March, 2012. Policy is in the first year of inception as the disease is pre-existing and falls under the exclusion of four year. It is further pleaded that the complainants had never claim the re-imbursement from the OP no.1 till date. The complainants have not provided any record regarding the treatment to the OP no.1. The complainants never requested to the OP no.1 to pay the amount of Rs.5,00,000/- so the question of refusal does not arise at all. Hence there was no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.2 did not appear and proceeded against exparte by the order of this Forum dated 30.3.2018.

4.             Complainant tendered into evidence his affidavit Ex.C1 and documents Ex.C2 to Ex.C21 and closed the evidence on 23.7.2018.

5.             On the other hand, OP no.1 tendered into evidence affidavit of Manraj Virk Ex.RW1/A and documents Ex.R1 and Ex.R2 and closed the evidence on 15.11.2018.

6.             We have heard the learned counsel for both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             The case of the complainant is that in the year 2015, the complainants have obtained mediclaim policy from OPs. In the month of July, 2007 complainant  no.2 felt some swelling in her neck and had taken treatment from a hospital, Karnal. Thereafter complainants approached Fortis Hospital, Mohali on 29.07.2017 for further treatment where the certain laboratory tests and CT scan was conducted. As per the advice of the Doctors and investigations, the nodes which were causing obstruction in breathing and causing swelling was removed. Intimation regarding admission of the complainant no.2 was given to the OPs through attending doctors.  The complainant no.2 was discharged from the hospital on 28.08.2017. The complainant no.2 remained admitted in the hospital from 29.7.2017 to 28.08.2017 and spent a sum of Rs.15,23,000/- during this period and is still under treatment as outdoor patient. The complainants are entitled for Rs.5,00,000/- as per the policy alongwith interest and compensation.

8.             On the other hand, the case of the OPs is that the complainant no.2 was admitted in Fortis Hospital, Mohali as case of “Carotid Body Tumour, RT Sylvain haematoma”. She had a history of same disease since March, 2012. Policy is in the first year of inception as the disease is pre-existing and falls under the exclusion of four years. The complainants had concealed the true facts at the time of taking the policy. Moreover, complainants had never claimed reimbursement from the OP no.1 till date. The complainant never requested the OP no.1 to pay the amount of Rs.5,00,000/- so the question of refusal does not arises. The OP no.2 has only repudiated the cashless claim of the complainants and not the claim of the reimbursement.  

9.             Admittedly, the complainants have purchased the Mediclaim policy from the OPs. It is also admitted that complainant no.2 had taken treatment from Fortis Hospital, Mohali. As per payment receipts Ex.12 to Ex.C20 and bill details Ex.C21, complainants had spent Rs.15,55,949/- for the treatment of complainant no.2. As per the version of the OPs the claim of the complainant is not repudiated till now, only cashless claim of the complainant was repudiated. Complainants never submit the claim for reimbursement till date. Hence, there was no deficiency in service on the parts of the OPs.

10.           OPs have taken plea that the disease of the complainant no.2 was pre-existing. Onus to prove his case was on the OPs that disease was pre-existing but in this regard opinion of doctors or any treatment record has not been placed by the OPs on record to establish that disease was pre-existing and complainant no.2 has taken treatment or consulted to any doctor prior to inception of the policy. Hence this plea of the OPs is untenable.

11.            Thus, as a sequel to abovesaid discussion, we dispose off the present complaint with the direction to the complainants firstly they filed the claim for reimbursement with the OPs. We direct the OPs after receipt of the claim, the claim of the complainant be reimbursed as per Mediclaim policy. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced:

Dated:04.12.2018

                                                                        President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)                (Dr. Rekha Chaudhary)

            Member                               Member