Haryana

Karnal

CC/276/2017

Romy Sagar - Complainant(s)

Versus

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

Davinder Singh Chaudhary

11 Feb 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No.276 of 2017

                                                         Date of instt. 21.08.2017

                                                         Date of decision:11.02.2019

Romy Sagar sona of Shri Prem Sagar resident of House no.828, Chaura Bazar, Karnal.

                                                                        …….Complainant

                                        Versus

1. The Oriental Insurance Company Limited, Meera Ghati Chowk, Above OBC Bank, Karnal through its Branch Manager.

2. Raksha Health Insurance TPA Pvt. Ltd. SCO 359-360 1^st floor, Sector 44-D, Chandigarh through its Divisional 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 Davinder Singh Advocate for complainant.

                Shri Rohit Gupta Advocate 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 purchased a Medi Claim policy from OP no.1 in the year 2014 by paying a premium of Rs.1749/- and the said policy was renewed every year with different policy numbers i.e. 261301/48/2014/1950 valid from 09.01.2014 to 08.01.2015, 261301/48/2015/2447 valid from 9.1.2015 to 8.1.2016, 261301/48/2016/2797 valid from 9.1.2016 to 8.1.2017 and 261301/48/2017/3082 valid from 9.1.2017 to 8.1.2018. On 3.4.2017 the complainant started suffering from a disease in left eye, in which straight lines/words appeared away to the complainant. The complainant got tested his eyes from Kalpana Chawla Govt. Medical College Hospital, Karnal on 3.4.2017 and the attending doctor asked the complainant to undergo a test namely ‘O.C.T’ which was got conducted by the complainant by paying a sum of Rs.1100/- and after getting the abovesaid test, the attending doctor told that because of accumulation of blood in the backside of retina in his eye, the straight words appears away to him and for the treatment of said disease, an injection namely ‘Lucentis’ will have to be administered and the complainant purchased the said injection for Rs.23,623.36, vide invoice dated 4.4.2017 and the complainant remained admitted in the hospital from 4.4.2017 to 6.4.2017, vide CR no.025606 for the treatment and the said injection was administered to him, as a result of which, the complainant noticed improvement in his eye sight. That since the abovesaid disease was not fully cured so, the complainant was again administered the abovesaid injection which he purchased on 04.05.2017 for Rs.23,623.36 for which complainant remained admitted in the abovesaid hospital from 04.05.2017 to 06.05.2017. After recovering from abovesaid illness, the complainant lodged his claim with the OPs and submitted all the requisite documents with them. However, OPs vide letter dated 16.06.2017 repudiated the claim of the complainant on the ground that the treatment which was given to the complainant do not come under the Day Care List of Treatment/Procedures, therefore, this claim is not payable CNVM and one another ground for repudiating the claim of the complainant was taken by the OP was that the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of clause 4.5: surgery for correction of eye sight, cost of Spectacles, Contact Lenses, Hearing Aids etc. The said ground of OPs to repudiate the claim of the complainant are false, flimsy and baseless as no surgery was performed upon the complainant and only abovesaid injection was administered to him twice on two different days and administered the injection does not come within the purview of surgery. Complainant requested the OPs many times to pay the claim amount of Rs.48346/- to him 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 concealment of true and material facts; cause of action; locus standi and jurisdiction. On merits, it is pleaded that the reimbursement of the claim of the complainant for hospitalization expenses was duly processed by the OPs through OP no.2 and the same stands denied, vide letter dated 18.06.2017 since on scrutiny of the claim documents, it has been observed that the claim is not admissible in view of the following:

        “Patient suffered from Choroidal Neovascularisation Membrance. Patient was given Intra Viteral Injection. This treatment do not comes under the Day care list of Treatment/procedures. Therefore, this claim is not payable CVNM.”

This type of treatment falls under the policy exclusion clause and the claim of the complainant was rightly repudiated. Moreover, this type of treatment falls under policy exclusion clause 4.5. Hence there is no deficiency in service on the part of the OP no.1 and prayed for dismissal of the complaint.

3.             OP no.2 did not appear and proceeded against exparte, vide order dated 20.11.2017.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C17 and closed the evidence on 19.03.2018.

5.             On the other hand, OP no.1 tendered into evidence affidavit of Manraj Virk Ex.RW1/A and documents Ex.O1 to Ex.O4 and closed the evidence on 21.12.2018.

6.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.             The case of the complainant is that the complainant purchased a Mediclaim policy from OP no.1 in the year 2014 by paying a premium of Rs.1749/- and the said policy was later on renewed every year. On 03.04.2017, the complainant started suffering from a disease in the left eye, in which straight lines/words appeared away to the complainant. The complainant got tested his eye from Kalpana Chawla Government Medical College and Hospital, Karnal on 03.04.2017 and the attending doctor asked the complainant to undergo a test namely O.C.T. which was got conducted by the complainant by paying a sum of Rs.1100/-. After getting the abovesaid test done, the attending doctor told the complainant that because of accumulation of the blood in the backside of retina in his eye, the straight words appears away to him and for the treatment of said disease, an injection namely “Lucentis” will have to be administered and the complainant purchased the said injection for Rs.23,623.36/-. Complainant remained admitted in the said hospital from 04.04.2017 to 06.04.2017.

8.             Further, since the abovesaid disease was not fully cured, so the complainant was again administered the abovesaid injection, which he purchased on 04.05.2017 for Rs.23,623.36/-, for which the complainant remained admitted in the abovesaid hospital from 04.05.2017 to 06.05.2017. The complainant lodged his claim with OPs and same was repudiated on 16.06.2017 on the ground that the treatment which was given to the complainant do not comes under the Day Care List of the treatment/procedures, therefore, this claim is not payable CVNM.

9.             On the other hand, the case of the OP no.1 is that the reimbursement claim of the complainant for hospitalization expenses was duly proceeded by the OPs and during the scrutiny of the claim documents, it has been observed that the claim is not admissible in view of the following:

        “Patient suffered from Choroidal Neovascularisation Membrance. Patient was given Intra Viteral Injection. This treatment do not comes under the Day care list of Treatment/procedures. Therefore, this claim is not payable CVNM.”

Further, this type of treatment falls under the policy exclusion clause and the claim of the complainant was rightly repudiated.

10.           Admittedly, the complainant purchased a Mediclaim policy from OP no.1 and premium was paid for the same by him. It is also admitted that the complainant was admitted in the hospital for eye problem. As per the advice of the attending doctor, complainant undergone a test namely O.C.T. which was got duly conducted. As per the test, accumulation of the blood in the backside of retina of his eye was found and for the cure of the said disease, an injection namely lucentis was administered twice and the cost of the one injection was Rs.23,632.36/-. Complainant got admitted in the hospital from 04.04.2017 to 06.04.2017 and again from 04.05.2017 to 06.05.2017 and an amount of Rs.48346.72/- was paid by complainant for testing and injections.

11.           During the course of argument, the counsel for the OP produced the copy of “Oriental Bank Mediclaim Policy” (running 20 pages). The claim of the complainant was repudiated on the ground that the treatment which was given to the complainant do not comes under the Day Care List of the treatment/procedures, therefore, this claim is not payable CVNM. Moreover, this type of treatment falls under the policy exclusion clause 4.5 i.e. surgery for correction of the eyesight, cost of the spectacles, contact lenses, hearing aids etc.

12.           We have gone through the exclusion clause 4.5 and according to the said clause, the treatment taken by the complainant does not fall under the said clause, as the treatment taken was not surgery for correction of the eyesight, cost of the spectacles, contact lenses, hearing aids etc. Complainant taken the treatment for the disease of accumulation of blood at backside of retina of his eye. The complainant got admitted in the hospital twice for a period of more than 24 hours. As per discharge and follow-up card (Ex.C13 & Ex.C14), complainant got admitted in hospital on 04.04.2017 to 06.04.2017 and 04.05.2017 to 06.05.2017 respectively. Meaning thereby, complainant remained admitted in the hospital for more than 24 hours for both the times of getting treatment. As per the “Oriental Bank Mediclaim Policy,” if any patient stays in hospital for more than 24 hours, he/she is covered under the mediclaim policy. In view of the above, we are of the considered view that the act of the OP is amounts to deficiency in service.

13.           Thus, as a sequel to above discussion, we allow the present complaint and direct the OPs to pay Rs.48346/-i.e. is cost of injections and testing with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.11,000/-to the complainant for mental agony, harassment and towards litigation expenses. This order shall be complied with within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 11.02.2019

                                                                        President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

 

                     (Vineet Kaushik)     (Dr. Rekha Chaudhary) 

                        Member                       Member