Chandigarh

DF-II

CC/485/2017

Sh. Adarsh Pal Singh - Complainant(s)

Versus

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

Kunal Garg Adv. & Shama Adv.

08 Dec 2017

ORDER

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

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Consumer Complaint  No	:	485 of 2017
Date  of  Institution	:	21.06.2017
Date   of   Decision	:	08.12.2017

 

 

 

 

Adarsh Pal Singh, aged 62 years, R/o H.No.347, Sector 9-D, Chandigarh.     

             …..Complainant

Versus

1]  The Oriental Insurance Company Limited, through its Divisional Officer/Authorised Signatory, The Oriental Insurance Company Limited, SCO 48-49, Sector 17-A, Chandigarh 160017

2]  M/s Medi Assist India, through its Incharge/authorised signatory, Cabin No.207, SCO 19, Sector 7-C, Chandigarh 160017

….. Opposite Parties

 

3]   Fortis Hospital, through its Incharge, Sector 62, Phase-VIII, SAS Nagar, Mohali 160062 (Pb.)

     [Deleted vide order dated 4.10.2017]

 

4]   Medanta The Medicity, through its Incharge, Sector 38, Gurugram 122018 (Haryana) [Deleted vide order dated 4.10.2017]

 

5]   Max Super Speciality Hospital, through its Incharge, Near Civil Hospital, Phase-VI, SAS Nagar. Mohali 160055 (Pb.) [Deleted vide order dated 4.10.2017]

 

….. Performa Opposite Parties 

 

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH              MEMBER

 

 

For complainant(s)      : Sh.Kunal Garg, Advocate.  

 

For Opposite Party(s)   : Sh.J.P.Nahar, Adv. for OPs No.1 & 2

  OPs NO.3,4 & 5 deleted.

 

 

PER PRITI MALHOTRA, MEMBER

 

          As per the case, the complainant purchased Mediclaim insurance policy from Opposite Party No.1 valid from 24.3.2015 to 23.3.2016, which was renewed from 24.3.2016 to 23.3.2017 insuring the complainant and his wife for a sum assured of Rs.5 Lacs.  It is averred that the complainant on 22.2.2016 approached Fortis Hospital/OP No.3, Mohali with problem of decreased appetite and general weakness. After colonoscopy, various other investigations were conducted by OP No.3 and the complainant was diagnosed to be suggestive of Adenocarcinoma by OP No.3. Complainant paid Rs.29,499/- to Opposite Party NO.3 towards treatment and medications. Thereafter, the complainant got admitted in Medanta Institute/OP No.4, Gurugram, on 14.3.2016 with complaints of pain in abdomen and circumferential growth in ascending colon/caecum and after investigation, the complainant was diagnosed to be suffering from carcinoma of ascending colon (Adenocarcinoma) (pT3 p N1, LVI+) (Stage III) and was operated for Right Hemicolectomy surgery. The complainant was discharged on 24.3.2016 in stable condition by Opposite Party NO.4. It is averred that from the date of admission till discharge, the complainant has paid Rs.2,88,207/- to Opposite Party NO.4 for the treatment and medication. On 13.4.2016, the complainant was again admitted in Medanta Institute, Gurugram and was given first cycle of chemotherapy before being discharged on 16.4.2016 after the payment of Rs.84,079/- for treatment.  Thereafter, the complainant decided to get the treatment from OP No.5 and as such admitted there on 28.4.2016 and was given second cycle of chemotherapy  before being discharged on 30.4.2016.  It is averred that from the discharge summary dated 27.8.2016, it is evident that the complainant got admitted various times in Max Super Specialty Hospital/OP No.5, Mohali for Chemotherapy and spent a huge amount of Rs.3,32,963/- on the treatment.  It is submitted that the complainant lodged claim with OP Insurance Company for reimbursement of the claim on 26.9.2016, submitting all requisite documents and apprise them about the whole matter/issue, but the OP No.2 on 7.3.2017 intimated the complainant that the competent authority has repudiated his claim on the basis that the complainant is a chronic alcoholic person and the disease is usual complication of Alcoholism. Alleging the said repudiation as illegal and deficiency in service, hence this complaint has been filed. 

 

2]       The Opposite Parties NO.1 & 2 have filed joint reply and while admitting the factual matrix of the case, stated that the OPs were not intimated before hospitalization at various dates though the complainant was required to approach TPA for cashless facility and prior information was needed to be given to OPs. It is stated that the Opposite Parties have reconsidered the matter and the claim was approved and the approval was conveyed vide letter dated 1.8.2017 asking the complainant for the cancelled cheque of the OBC.  The cancelled cheque and copy of passbook was received on 23.8.2017 by OP No.1 and the same was sent to TPA on 24.8.2017.  It is also stated that the payment of the claim for Rs.5,00,000/- being the sum insured is likely to be credited in two/three days and hence it is requested that the complaint be dismissed.   

         Opposite Parties NO.3 to 5 have been deleted vide order dated 04.10.2017.

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions made in the complaint and controverting that of OPs No.1 & 2 made in their reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the OPs and have also perused the entire record.

 

6]       Without burdening the record and avoiding reiteration of the admitted facts, it is apt to mention that during the pendency of the present complaint, the complainant duly received the amount for which he is entitled as per the policy in question.  The complainant filed a claim of Rs.8,33,475/- whereas he was rightly entitled for Rs.5.00 lacs as was insured for the similar amount.

 

7]       The record, especially, written statement filed by Opposite Parties NO.1 & 2 reflects that the claim lodged by the complainant for reimbursement of the expenditure incurred in his treatment, was initially rejected (verbally conveyed to the complainant) and after filing of the present complaint, the claim was approved and the amount was paid to the complainant. It is observed that the OPs rendered a deficient services towards the complainant, who had already suffered immense trauma, pain during the course of treatment for Adenocarcinoma. Complainant struggled hard to win the battle of his life with such courage, but could not succeed to get his rightful claim from the OPs No.1 Insurance Company.  The struggle for life becomes more hard for the patient of a deadly disease when his genuine claim for reimbursement of medical bills is declined and he is forced to knock the doors of the Court to get his genuine claim.  If the genuine claim are to be rejected with such casual approach without considering the pain undergone by the claimant, then what to talk about the other claims.  This reflects the deceitful working of the insurance companies.

         In our opinion, the complainant deserves to be suitably compensated for such harassment caused due to inefficiency of the Opposite Party No.1 Insurance Company. As such, the compliant is allowed against Opposite Party No.1 with direction to pay Rs.50,000/- as compensation for the harassment suffered by him due to its deficient services and also to pay litigation cost of Rs.10,000/- within a period of 30 days from the date of receipt of copy of this order, failing which it shall also be liable to pay additional cost of Rs.10,000/-, apart from the above awarded relief.

8]       However, the complaint qua Opposite Party NO.2 to 5 stands dismissed.

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

8^th December, 2017                                                                                                                                                                 Sd/-  

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER