Haryana

Karnal

CC/246/2019

Mahinder Kumar - Complainant(s)

Versus

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

Amandeeo Singh

12 Sep 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 246 of 2019

                                                        Date of instt.03.05.2019

                                                        Date of Decision:12.09.2022

 

Mahinder Kumar son of Shri Ram Kishan resident of VPO Johar Majra Tehsil Indri District Karnal through his wife Smt. Seema as the claimant Mahinder Kumar advised bed rest (copy of medical is attached herewith), age 51 years. Mobile no.9466325654.

       

                                               …….Complainant.

                                              Versus

 

1.     The Oriental Insurance Co. Ltd. through its Manager, above OBC Bank, Meera Ghati Chowk, Karnal.

 

2.     Raksha Health Insurance TPA Pvt. Ltd. SCO 39, 1^st floor, Sector-26, Madhya Marg, above Barbeque Nation, Chandigarh-160019.

 

                                                                      …..Opposite Parties.

 

Complaint under Section 12 of the Consumer Protection Act, 1986 as amended under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary….Member

 

 Argued by: Sh. Amandeep Singh, counsel for the complainant.

                   Shri Naveen Khetarpal, counsel for OP no.1

                    OP no.2 exparte.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased an Oriental Royal Mediclaim Policy bearing no.261301/48/2018/2543, valid from 01.11.2017 to 31.10.2018. OP no.1 tie up with the OP no.2 and insurance policy issued by OP no.2 through OP no.1. In that policy, the complainant, her wife Seema, two sons namely Hemang and Shivam are insured. The said policy is cashless policy. Suddenly, complainant was suffering from swelling Umbilical Region disease and accordingly on 26.07.2018 (wrongly typed as 26.07.2017) he was admitted in Miglani Nursing Home, Karnal where the complainant remained indoor patent and then due to critical condition he was shifted to Fortis Hospital, Mohali and remained indoor patient from 03.08.2018 to 20.08.2018 where surgery/operation of the complainant was conducted. It is further averred that in Miglani Hospital, Karnal, complainant spent an amount of Rs.10000/- on his treatment, medicines etc. and also paid Rs.8,15,000/- at Fortis Hospital, Mohali, thus total amount is Rs.825000/- paid by the complainant on his treatment. Thereafter, complainant lodged claim against the said policy and also submitted all relevant documents as per the demand of the OPs within time but OPs always postponed the matter on one pretext or the other and till date did not release the claim amount.

2.             It is further averred that thereafter, OPs automatically renewed the said policy and issued another policy bearing no.261301/48/2019/1915, valid from 09.11.2018 to 08.11.2019. Thereafter, complainant was again admitted in Fortis Hospital, Mohali and remained indoor patient from 12.11.2018 to 21.11.2018 where surgery of the complainant was conducted and also spent Rs.2,42,286/- on his treatment. Thereafter, complainant lodged the claim against the said policy and submitted all the relevant documents as per demand of the OPs within time but OPs did not release the claim and refused to pay the same. In this way there is deficiency in service on the part of the OPs. Hence complainant filed the present complaint seeking directions to the OPs to pay Rs.1067286/- to the complainant alongwith interest, to pay Rs.1,00,000/- as compensation for mental pain, agony and harassment and Rs.21,000/- towards litigation expenses.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that the sum insured of both the policies in question is Rs.5,00,000/- but complainant is not entitled for any claim as alleged in the complaint. It is further pleaded that the case of the complainant falls under the exclusion clause 4.2 of the policy. The claim of the complainant under the policy no.261301/48/2018/2543 and policy no.261301/48/ 2019/1915 has been rightly repudiated it is the case of Anastmotic Leak, Strangulated Umblical Hernia. Hernia Umblical Hernioplasty & Resection Anastomo Done. Expenses related to Harnia are payable after two years as per policy terms and conditions. This policy is in 1^st and second year. So, the claim is not payable as per clause 4.2. Clause 4.2 reproduced as under:-

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

If these diseases are pre-existing at the time of proposal the exclusion clause no.4.1 for pre-existing conditions shall be applicable in such cases. In 1^st year, Benign ENT disorders and surgeries i.e. Tonsillectomy, adenoidectomy, Mastoibectomy, Tympanoplasty etc. polycystic ovarian diseases.

For two years:- Surgery of Hernia, Surgery of Hydrocele, non-infective Arthritis, Undescendent tests, cataract, surgery of Benign Prostatic hypertrophy, Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapsed of Uterous, fissure/fistula, piles Sinusitis and related disorders, surgery of gall bladder and bileduct excluding Malignancy, Surgery of Genitu Urinary System exclusing Maligancy, Pilonidal sinus, Gout and rheumatism, Hypertension, Diabets, Calculus diseases, surgery of varicose veins and varicose ulcers.

For three years- Joint replacement due to degenerative condition age related osteoarthritis and osteoporosis.

There is no deficiency in service on the part of the OP while repudiating the claim of the complainant. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

3.             OP no.2 did not appear despite service and proceeded against exparte, vide order dated 03.07.2019 of the Commission.

4.             Parties then led their respective evidence.

5.             Learned counsel for complainant has tendered into evidence copy of Aadhar card Ex.C1, copy of Fortis Bill dated 17.9.2019 Ex.C2 to Ex.C5, copy of fitness certificate Ex.C6, copy of bill dated 31.07.2018 Ex.C7, copy of query regarding mediclaim Ex.C8, copy of insurance policy Ex.C9, copy of premium receipt Ex.C10, copy of TPA policy Ex.C11, copy of Royal Mediclaim dated 31.10.2017 Ex.C12, copy of Aadhar card of Seema Rani Ex.C13 and closed the evidence on 13.01.2020 by suffering separate statement.

6.             On the other hand, learned counsel for OP no.1 has tendered into evidence affidavit of Dinesh Jain, Senior Divisional Manager Ex.RW1/A, copy of insurance policy Ex.OP1, copy of repudiation letter Ex.OP2, copy of medical bill Ex.OP3, copy of claim form Ex.OP4, copy of discharge summary Ex.OP5, copy of second insurance policy Ex.OP6, copy of repudiation letter Ex.OP7, copy of claim form Ex.OP8, copy of medical bill Ex.OP9, copy of treatment record Ex.OP10, copy of terms and conditions of the insurance policy Ex.OP11 and closed the evidence on 23.12.2021 by suffering separate statement.

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

8.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that the complainant purchased an Oriental Royal Mediclaim Policy from the OP no.2 through OP no.1. The said policy is cashless policy. On 26.07.2018, complainant was suffering from swelling Umbilical Region disease and accordingly he was admitted in Miglani Nursing Home, Karnal where the complainant remained indoor patent and then due to critical condition he was shifted to Fortis Hospital, Mohali and remained indoor patient from 03.08.2018 to 20.08.2018 where surgery/operation of the complainant was conducted. Complainant spent an total amount of Rs.825000/- on his treatment. Thereafter, complainant lodged claim against the said policy and also submitted all relevant documents. He further argued that complainant was again admitted in Fortis Hospital, Mohali and remained indoor patient from 12.11.2018 to 21.11.2018 where surgery of the complainant was conducted and also spent Rs.2,42,286/- on his treatment. Thereafter, complainant lodged the claim against the said policy and submitted all the relevant documents but OPs did not release the claim and refused to pay the same and lastly prayed for allowing the complaint.

9.             Per contra, learned counsel for OPs, while reiterating the contents of written version has vehemently argued that the case of the complainant falls under the exclusion clause 4.2 of the policy. The claim of the complainant under the policy has been rightly repudiated it is the case of Anastmotic Leak, Strangulated Umblical Hernia. Expenses related to Harnia are payable after two years as per policy terms and conditions. This policy is in 1^st and second year. So, the claim is not payable as per clause 4.2 and lastly prayed for dismissal of the complaint.

10.           We have duly considered the rival contentions of the parties.

11.           Admittedly, insured has availed the health insurance policy from the OPs. It is also admitted that during the subsistence of the insurance policy complainant was admitted in Miglani Nursing Home, Karnal and thereafter in Fortis Hospital, Mohali from 03.08.2018 to 20.08.2018 and again admitted in Fortis Hospital, Mohali on 12.11.2018 and was discharged on 21.11.2018.

12.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.OP7 dated 06.05.2019 on the grounds that expenses related to Hernia are payable after two years as per policy terms and conditions. This policy is in 1^st and second year. So, the claim is not payable as per clause 4.2 of the policy.

13.           The onus to prove his case lies upon the complainant, but complainant has miserably failed to prove his version by leading any cogent and convincing evidence. On the other hand, to prove its version, OPs have placed on record discharge summary of the complainant Ex.OP5, on perusal of discharge summary, complainant diagnosis for Anastomotic Leak with Faecal Fistula Following Umbilical Hernioplasty and Resection Anastomosis (28.07.2018) for Strangulated Umbilcal Hernia. Underwent Exploratory Laparotomy+ Drainage of Pyoperitoneum-Dismantling of previous on 04.8.2018.

14.           In the present case, complainant purchased the policy in question on 01.11.2017 and as per terms and conditions of policy, the expenses for surgery of Hernia are payable after two years. Complainant admitted in the hospital on 28.07.2018 for Hernia disease in the first year of the policy and second time in the second year of the policy. So, the claim is not payable as per clause 4.2 of the policy. It is not a case of the complainant that OP did not explain and supplied the terms and conditions of the policy. Thus, complainant is not entitled for claim under the policy in question. Hence, there is no deficiency in service on the part of the OP.

14.           In view of the above, present complaint is devoid of any merits and same deserves to be dismissed and same is hereby dismissed. No order as to costs. The parties concerned be communicated the order accordingly, and the file be consigned to the record room, after due compliance.

Announced

Dated:12.09.2022.                                                                      

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

       

                (Vineet Kauhik)                 (Dr. Rekha Chaudhary)      

                      Member                               Member