Chandigarh

DF-I

CC/784/2014

Mr. Rakesh Sadhu - Complainant(s)

Versus

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

Ajmer Lal Pundeer

30 Jun 2015

ORDER

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

============

Consumer Complaint  No	:	CC/784/2014
Date  of  Institution	:	27/11/2014
Date   of   Decision	:	30/06/2015

 

 

 

 

 

Rakesh Sadhu, resident of House No.186, Phase-2, Mohali (Punjab).

….Complainant

Vs.

 

 

[1]   The Oriental Insurance Company Limited, E.C. Panchkula, 2366/2, First Floor, Mariwala Town, Manimajra (U.T), Chandigarh, through its Incharge.

 

[2]   The Oriental Insurance Company Limited, Regional Office, SCO 109-110-111, Surendra Building, Sector 17-D, Chandigarh, through its Chief Regional Manager.

 

[3]   M/s Medi Assist India (P) Limited, SCO 521, Second Floor, Sector 70, SAS Nagar, Mohali – 160071.

 

…… Opposite Parties

 

 

BEFORE:   SH. P.L. AHUJA               PRESIDENT

MRS. SURJEET KAUR           MEMBER

          SH. SURESH KUMAR SARDANA     MEMBER

 

 

For Complainant	:	Sh. Ajmer Lal Pundeer, Advocate.
For OPs	:	Sh. Sukaam Gupta, Advocate

 

 

PER SURESH KUMAR SARDANA, MEMBER

 

 

 

 

          The facts which are necessary for the adjudication of the present Complaint are conceptualized hereinafter. The Complainant had purchased PNB-Oriental- Royal Mediclaim Policy from the Opposite Party No.1 through his Bankers devised for Punjab National Bank Account Holder/employees (with Family Floater) in the year 2012 taking medical insurance cover for his 03 family members (self + spouse + son). The said policy was renewed from time to time before through the Bankers and policy is now valid from 12.06.2014 to 11.06.2015. It has been averred that in the intervening night of 22-23 August 2014, Mr. Chandan Sadhu, aged 26 years (insured person) son of Complainant felt severe chest pain on left side on and off with radiation of pain to arm, high blood pressure, showing signs akin to heart attack. Complainant immediately took his son to Fortis Hospital, Mohali, where the patient was admitted and undergone various types of medical investigations including echo and angiography. After investigation, it was found that complications were due to Gastroenteritis or Acidity and the patient was discharged on 24.08.2014. The Complainant had paid Rs.30,788/- at the time of discharge on account of the treatment charges. The Complainant thereafter, informed the Opposite Party No.2 and submitted reimbursement claim form duly completed along with all original bills along with reports on 29.08.2014 with Opposite Party No.3 as advised by the Opposite Party No.2 for reimbursement of medical expenses incurred on the treatment as per policy coverage. Thereafter, the Complainant also submitted treatment certificate dated 23.08.2014 issued by the treating Medical Officer of the Hospital on the demand of Opposite Party No.3 for settlement of pending claim. However, to the utter surprise of the Complainant, the Opposite Party No.3 vide e-mail dated 08.10.2014 denied the claim under Ex.4.7 due to history of smoking. The Complainant protested the denial of his genuine claim vide e-mail dated 08.10.2014, followed by reminder dated 16.10.2014 and 28.10.2014, but to no avail. However, the Opposite Parties No.1 & 2 vide letter dated 17.11.2014 again showed their inability to admit the liability due to the reasons given in Ex.4.7 (Annexure C-10A). Eventually, the Complainant got served a legal notice dated -07.11.2014 (Annexure C-11) upon the Opposite Parties, but in vain. When all the frantic efforts made by the Complainant, failed to fructify, as a measure of last resort, alleging that the aforesaid acts of the Opposite Parties tantamount to deficiency in service the Complainant has filed the instant Complaint u/s 12 of the Consumer Protection Act, 1986, seeking various reliefs.

 

2.     Notice of the complaint was sent to Opposite Parties, seeking their version of the case.

 

3.     Opposite Parties, in their joint written version, admitted the factual matrix of the case and pleaded that after receiving intimation of claim answering Opposite Parties registered the claim of the Complainant and while scrutinizing the medical papers on records answering Opposite Parties observed that patient was admitted at Fortis Hospital for the treatment of Complaints of chest pain on 23.08.2014 and was discharged on 24.08.2014 and it came to light that son of the Complainant was smoker and smoking is major predisposing factor to the development of heart ailment and gastric ailment and as per Exclusion Clause No.4.7 of terms and conditions of the insurance policy claim was outside the scope of the said policy and hence same was repudiated and intimation to the said effect was given vide letter dated 17.11.2014. Denying all other allegations and stating that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.

 

4.     The Complainant also filed rejoinder wherein the averments as contained in the complaint have been reiterated and those as alleged in the written statement by the Opposite Parties have been controverted.

 

5.     Parties were permitted to place their respective evidence on record, in support of their contentions.

 

6.     We have heard the learned Counsel for the parties and have perused the record, along with the written arguments filed on behalf of the Complainant.

 

7.     The core question, which falls for consideration, is, as to whether, the repudiation of the claim of the Complainant by the Opposite Parties, is justified.

 

8.     Having bestowed our anxious consideration to the matter, we are of the opinion that in the light of the material on record, answer to the question posed has to be in negative.

 

9.     The Opposite Parties have expressed their inability to admit the liability of the Complainant and repudiated his claim, vide letter dated 17.11.2014, on the following grounds: -

 

Exclusion 4.7

Convalescence, general debility, “run down” condition or rest cure, congenital external and internal diseases or defects or anomalies, sterility, and fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/ suicide, all psychiatric and psychosomatic disorders and diseases/ accident due to and/ or use, misuse or abuse of drugs/ alcohol or use of intoxicating substance or such abuse or addiction etc.

 

 

10.     After giving our thoughtful consideration to the above reasoning given by the Opposite Parties for repudiating the claim of the Complainant, we are not impressed with the same, as it is not mentioned in the history as to who had told the history and further, for how much period earlier, the insured (son of the Complainant) was smoking and whether the extent and period of smoking can substantiate the exclusion clause 4.7. At any rate, there is no evidence on record to prove that because of smoking the son of the Complainant had fallen sick. Even no report of the treating doctor and the affidavit of the TPA on the basis of which the Opposite Parties have allegedly repudiated the claim of the Complainant, has been placed on record. It can thus legitimately be concluded that the Opposite Parties were not within their rights to repudiate the claim of the Complainant.

 

11.     In these set of circumstances, it will not be wrong for us to ignore the line of reasoning given by the Opposite Parties on the basis of which the genuine claim of the Complainant was repudiated, as there is no proof to substantiate the same. The Complainant is thus held to be entitled to the reimbursement by the Opposite Parties to the extent of expenses borne by him and there is no legal hitch for the same.

 

12.     In the light of above observations, we are of the concerted view that the Opposite Parties are deficient in rendering proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. The Opposite Parties are directed to:-

 

[a]  To pay the claim of Rs.30,788/- to the Complainant;

 

[b]  To pay Rs.15,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

 

[c] To pay Rs.10,000/- as cost of litigation;

 

 

13.     The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, they shall be liable for an interest @12% per annum on the amount mentioned in per sub-para [a] & [b] above, apart from cost of litigation of Rs.10,000/-, from the date of institution of this complaint, till it is paid. 

 

14.     Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

30^th June, 2015                                           Sd/-    

(P.L. AHUJA)

PRESIDENT

 

Sd/-

(SURJEET KAUR)

MEMBER

 

                         Sd/-          

(SURESH KUMAR SARDANA)

“Dutt”                                                                                            MEMBER