Chandigarh

DF-II

CC/324/2018

Indu Garg - Complainant(s)

Versus

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

Tribhawan Singla Adv.

10 May 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

 

Consumer Complaint  No	:	324 of 2018
Date  of  Institution	:	12.06.2018
Date   of   Decision	:	10.05.2019

 

 

 

 

 

Indu Garg wife of Jiwan Kumar, resident of House No.1593, Sector 21, Panchkula, District Panchkula.        HaryaHarHar      

             …………….Complainant

 

Versus

 

1]  The Oriental Insurance Company Limited, Division Office No.II, SCO 48-49, Sector 17-A, Chandigarh 160017 through its Branch Manager.

 

2]  The Oriental Insurance Company Limited, Regd. & Head Office A-25/27, Asaf Ali Road, New Delhi 110002 through its M.D./Chairman/Authorised Person.

 

3]  Dayanand Medical College & Hospital, Unit- Hero DMC Heart Institute, Ludhiana, District Ludhiana through its MD/Manager.

 

4]  M/s Raksha TPA Pvt. Ltd., 15/5, Mathura Road, Faridabad, Haryana 121003 through its Director/Manager/Authorised Person.

 

5]  M/s Raksha TPA Pvt. Ltd., SCO No.359-360, 1^st Floor, Sector 44-D, Chandigarh 160047 through its Director/Manager/Authorised Person.  

  

………. Opposite Parties

 

BEFORE:  MR.RAJAN DEWAN        PRESIDENT

MRS.PRITI MALHOTRA    MEMBER

                    MR.RAVINDER SINGH     MEMBER

           

Argued by :- Sh.Harsh Goyal, Adv. for complainant.

             Sh.J.P.Nahar, Adv. for OPs No.1, 2, 4 & 5.

             None for Opposite Party NO.3. 

RAVINDER SINGH, MEMBER

 

                    The case of the complainant is that she purchased a Medical Policy from OPs No.1 & 2 for the year 2014-15 vide Policy No.231200/48/2015/732 and got it renewed regularly till 3.10.2015 to 2.10.2016.  The husband of the complainant was also covered under the said policy and total sum insured amount was Rs.5 lakh each.

         It is stated that the husband of the complainant, on having complaint of pain in left arm, was admitted in Dayanand Medical College & Hospital, Ludhiana on 11.9.2016 and his CAG (Coronary Angiography) was done and thereafter he underwent Coronary Artery Bypass Grafting on 20.9.2016 and discharged on 26.9.2016.  The request of the complainant for cashless facility was denied by the OP Insurance Company.  The complainant incurred expenses to the tune of Rs.2,44,036/- on the said treatment and as such, for getting reimbursement of said amount, she lodged claim with OP Insurance Company by submitting claim form along with all requisite documents.  It is submitted that the OPs No.1,2, 4 & 5 have illegally declined the claim of the complainant on flimsy ground.  It is also submitted that the concerned doctor had already issued a certificate that the husband of the complainant is under his treatment since Sept., 2016 only and coronary artery disease was recently detected on 5.9.2019 only and he also certified that there is no Past History of Coronary Artery disease present with the husband of the complainant.  Alleging the said rejection of claim by Opposite Parties NO.1, 2, 4 & 5 as deficiency in service on their part, hence this complaint has been filed by the complainant.

 

2]       The Opposite Parties No.1, 2, 4 & 5 have filed joint reply and while admitting the factual matrix of the case, stated that the policy in question was issued subject to terms & conditions.  It is stated that the claim has been repudiated on the ground of Clause 4.3 according to which the claim is not payable for the first two year for hypertension (Ann.R-2).  It is stated that the policy is a second year policy and the insured has underwent surgery for CABG which has been caused by hypertension which is excluded for two years.  It is also stated that the certificate issued by the doctor only is of non-consequence as it confirms only that the patient had no past history of Coronary Artery Disease but the exclusion provides that expenses for treatment of hypertension are not payable for two years.  It is submitted that since the cause of coronary Artery Disease is hypertension, therefore, expenses for treatment of Coronary Artery Disease are not payable.  The Discharge Summary issued by Hospital mentions that there is history of “Angina and Hypothyroidism” (Ann.R-3).  It is also submitted that without admitting the liability, if at all, it is found that any amount is payable, the same shall be subject to the 10% co-pay as per Condition No.4.23 of the policy.  It is stated that the claim has rightly been repudiated. Denying all other allegations and pleading no deficiency in service, the Opposite Parties No.1,2, 4 & 5 have prayed for dismissal of the complaint.

 

         The Opposite Party No.3 i.e. Dayanand Medical College & Hospital, Ludhiana has also filed reply denying any liability on its part.

 

3]      Replication has been filed by the complainant thereby reiterating the assertions as made in the complaint.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the learned Counsel for the complainant as well as ld.Counsel for OPs and also carefully examined the entire evidence on record.

 

6]       The complainant took Happy Family Floater Policy bearing No.231200/48/2016/858 from the Oriental Insurance Company Limited on 2.10.2015, which was valid from 3.10.2015 2.10.2016 on payment of Rs.13,769/-.  Sh.Jiwan Kumar, the husband of the complainant was covered under the said insurance policy for a sum insured of Rs.5 lakh under Silver Plan.

 

7]       Sh.Jiwan Kumar, husband of the complainant, felt pain in his left arm and admitted in Dayanand Medical College & Hospital, Ludhiana on 11.9.2016, where he was diagnosed suffering from “Hypothyroidism, Unstable Angina CAD with Acute Coronary Syndrome, Triple Vessel Disease, LVEF=60% Normal LV Systolic Function.” (Ann.R-3). Accordingly, Coronary Artery Bypass Grafting was done on 20.9.2016 and was later discharged from the Hospital on 26.9.2016.
 

8]       The claim of the complainant for Rs.2,44,036/- spent on the treatment of her husband Sh.Jiwan Kumar, who was insured under the policy in question, was presented to the OP Insurance Company for payment, but was repudiated vide letter dated 9.11.2016 (Ann.C-8/R-2) with the following observations:-

“patient suffered from cad-tvd, htn. policy is in 1^st year of inception, hypertension is cause of cad (heart disease). treatment related htn is not covered in 1^st 2 years of the policy. therefore claim is non payable as per clause 4.3 of the policy. Cad-tvd,htn.”

 

9]       The reasons put forth by the OP Insurance Company that inception of hypertension is cause of CAD (Heart disease) and the patient/insured suffered it in first year of inception of the policy, is untenable, misconceived and based on hypothetical observations.  The medical record produced by the parties regarding treatment of Sh.Jiwan Kumar, insured, nowhere led to any conclusion that the patient Jiwan Kumar, ever suffered from hypertension.  In the Discharge Summary (Ann.C-4), the insured husband of the complainant was diagnosed suffering “Hypothyroidism, Unstable Angina CAD with Acute Coronary Syndrome, Triple Vessel Disease, LVEF=60% Normal LV Systolic Function.”

 

10]      Hypothyroidism also called underactive thyroid or low thyroid, is a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. The disease hypothyroidism and angina, CAD with acute coronary syndrome, as diagnosed in the treatment in Dayanand Medical College & Hospital, Ludhiana, was unsymptomatic and cannot be attributed to any lapse or lack of care and caution on the part of patient himself. The purpose of insurance shall stand defeated if such type of sufferings/diseases suffered by the insured during the policy period are excluded by the insurance company from the insurance cover whimsically.  A person got himself insured as a measure of safety valve in case of any sudden unforeseen exigency by ailment in his life during insurance policy period. 

 

11]      The OP Insurance Company while repudiating the genuine claim of the complainant in the present case, has indulged into a grave unfair trade practice as well as deficiency in their service which lead to miscarriage of justice.  The unfair trade practice on the part of OP Insurance Company i.e. OPs No.1 & 2 is serious on their part, which needs to be snubbed with deterrent action by way of heavy compensatory cost.

 

12]      Keeping into consideration the entire evidence on record and peculiar fact & circumstances of the case, as discussed in the preceding paragraphs, the present complaint is allowed against OPs No.1 & 2/Oriental Insurance Company Limited with direction to reimburse an amount of Rs.2,19,633/- (Rs,2,44,036/- minus Rs.24,403/- i.e. 10% co-pay by insured) to the complainant with interest @12% p.a. from 9.11.2016 (date of repudiation of claim) till payment, along with litigation cost of Rs.10,000/- and compensation cost of Rs.50,000/-, within a period of 30 days from the date of receipt of certified copy of this order.  

 

13]      The complaint qua OPs No.3, 4 & 5 stands dismissed.

        

         The copy of this order be forwarded to the parties free of cost as per rules.

Announced

10^th May, 2019                                                              

Sd/-

 (RAJAN DEWAN)

PRESIDENT

                                                                                               

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER