Chandigarh

DF-II

CC/1188/2019

Dinesh Garg - Complainant(s)

Versus

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

Adv. Aman Singla & Harshit

12 Oct 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	1188 of 2019
Date  of  Institution	:	19.12.2019
Date   of   Decision	:	12.10.2021

 

 

 

 

 

Dinesh Garg s/o Late Sh.Satpal Garg, R/o H.No.1050, Sector 12-A, Panchkula (Haryana)  

             …..Complainant

 

Versus

 

1]  The Oriental Insurance Company Ltd., SCO 37, Sector 30-C, Chandigarh 160030 through its authorized representative.

    Second Address:

A-25/27, Asaf Ali Road, New Delhi – 110002 through its authorized representative.

 

2]  M/s Raksha Health Insurance TPA Pvt. , SCO 39, First Floor, Madhya Marg, above Barbeque nation, Sector 26, Chandigarh 160019 through its authorized representative

    Second Address:

Escorts Corporate Centre, 15/5/, Mathura Road, Faridabad (Haryana ) 121003

 

3]  M/s Alchemist Hospital, Sector 21, Panchkula (Haryana) 134112, through its authorized representative

 

4]  M/s Post Graduate Institute of Medical Education and Research (PGI), Sector 12, Chandigarh 160012 through its authorized reprehensive.

 

     ….. Opposite Parties

 

 

BEFORE:  SH.RAJAN DEWAN              PRESIDENT

         SMT.PRITI MALHOTRA             MEMBER

         SH.B.M.SHARMA                      MEMBER

 

 

Argued By: Sh.Aman Singla, Adv. for complainant

           Sh.Ram Avtar, Adv. for OPs No.1 & 2

           Sh.T.S.Khera, Adv. for OP No.3.

           Sh.Anil Kumar, Adv. for OP No.4.

 

PER PRITI MALHOTRA, MEMBER

         Briefly stated, the complainant obtained medical insurance policy from OP No.1 company in the year 2009 effective from 30.4.2009 and got it renewed regularly till the year 2020 (Ann.C-1, C-2 & C-5). It is averred that in Feb., 2019, the complainant got unwell and remained admitted in Alchemist Hospital/OP No.3 from 19.2.2019 to 16.3.2019.  It is also averred that the expenses for the said treatment at Alchemist Hospital was reimbursed by the OP No.1 Company under the insurance cover. Thereafter, the medical insurance policy of the complainant was renewed for the period 2019 to 2020 and unfortunately, the complainant, due to ill health, was again admitted in PGI/OP No.4 from 1.5.2019 to 16.5.2019 and then from 29.5.2019 to 27.6.2019 ( Ann.C-6 & C-7 Colly.).  However, the OP No.1 Company repudiated claim of the complainant (Ann.C-8) on the ground that the complainant is alcoholic and smoker.  Alleging the said repudiation as illegal and amounting to deficiency in service, this complaint has been filed.

 

2]       The OP No.1 Company has filed reply and while admitting the factual matrix of the case, stated that as per the Discharge Summary issued by PGI, Chandigarh, the complainant is having history of diabetes & is on insulin and having hypertension too & is on tablets for the last 5 to 6 years and is a chronic smoker and alcoholic. It is submitted that as per Discharge Summary of PGI, Chandigarh, the complainant was admitted in PGI on 29.5.2019 for “Necrotising Pancreatitis” with history of chronic alcohol and was discharged on 27.6.2019.  It is further submitted that the claim of the complainant and documents including discharge summary of PGI were thoroughly scrutinized by Raksha TPA and it was found that the complainant is a chronic smoker and alcoholic and thus the claim fell outside the scope and ambit of insurance policy, therefore, the claim was rightly repudiated vide letter dated 15.11.2019 as per exclusion clause 4.7 & 4.8 of the terms & conditions of the policy. It is stated further that disease due to alcohol and its complications fall under exclusion clauses i.e. 4.7 and 4.8 of the insurance policy in question. Denying rest of the allegations, the OP No.1 has prayed for dismissal of the complaint. 

         The OP No.2 adopted the reply of OP No.1, per zimni order dated 31.12.2020.

         The OPs No.3 & OP No.4 in their short replies, while admitting the treatment given to the complainant, as alleged, have denied other allegations being not related to them and prayed for dismissal of the complaint qua them. 

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

4]       Parties led evidence in support of their contentions.

5]       We have heard the ld.Counsel for the parties and have thoroughly perused the entire record.

6]       It is well proved on record that the complainant obtained medical insurance policy from OP No.1 in the year 2009/30.4.2009 as first coverage period from 30.4.2009 to 29.4.2020 and got it regularly renewed till last coverage from 23.4.2019 to 22.4.2020.

7]       The issue raised in the present complaint is qua the repudiation of the claims raised by the complainant in respect of the expenses incurred on the treatment taken by him at PGIMER, Chandigarh on two occasions i.e. from 1.5.2019 to 16.5.2019 and 29.5.2019 to 27.6.2019 respectively (Annexure C-6 & C-7). 

8]       The sole ground for repudiation of the above claims of the complainant taken by the OP No.1, as mentioned in the repudiation letter dated 03.7.2019 (Ann.OP1/5), is reproduced as under:-

‘Observation and Opinion

PATIENT K/C/O ACUTE NECROTISING PANCREATITIS, MANAGED CONSERVATIVELY (H/O DM SINCE 5 TO 6 YEARS, HTN SINCE 5 TO 6 YEARS. POLICY IS IN 2^ND YEARS OF INCEPTION) PATIENT IS CHRONIC SMOKER & ALCOHOLIC. DISEASE DUE TO ALCOHOL AND ITS COMPLICATION FALLS UNDER PERMANENT EXCLUSION OF POLICY. THEREFORE CLAIM RECOMMENDED TO BE NON PAYABLE AS PER CLAUSE 4.7.

‘Clause 4.8: Claim is recommended for Non-pay as per clause 4.8 which states that Convalescence, general debility, “run-down” condition or rest cure, Congenital external disease of defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, Venereal disease, intentional self injury/suicide, all psychiatric and psychosomatic disorders and disease/accident due to, and or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addition etc. any disease or Injury as a result of committing or attempting to commit a breach of Law with criminal intent.’

9]       The complainant has challenged the repudiation of claims stating that the OP No.1 has already approved and paid similar claim in the previous policy coverage for the period from 30.4.2018 to 29.4.2019 for the expenses incurred on the treatment of the same ailment on earlier occasion when the complainant remained admitted at Alchemist Hospital Ltd. from 19.2.2019 to 16.3.2019 and being treated for acute pancreatitis, which also is well proved from Claim Settlement Voucher (Ann.C-4).

10]      In view of document, referred above, as placed on record by the complainant as Ann.C-4 (Claim Settlement Voucher), we agree with the contention of the complainant that when once the OP No.1 Company after due verification has reimbursed the earlier medical claim of the complainant for expenses incurred on the treatment taken for the same ailment, which he suffered again in the subsequent policy just after a gap of hardly 2½ months, then there is nothing new for the OP Company to repudiate the claims in question. There is no change in the circumstances in the subsequent occasion when the complainant has availed the treatment on the line of earlier treatment, so the stand of OP No.1 Company to repudiate the claims of complainant is not justified and this amounts to deficiency in service on the part of OP No.1 Company.  

11]      From the above discussion and findings, we are of the opinion that the deficiency in service on the part of OP No.1 Insurance Company is proved.  Therefore, the present complaint is allowed against the Opposite Party No.1 (The Oriental Insurance Company Ltd.) with direction to reimburse both the medical claims amounting to Rs.4,47,248/- (Rs.93,809/- + Rs.3,53,439/-) to the complainant, along with compository amount of Rs.15,000/- towards compensation for harassment and litigation expenses.

         This order shall be complied with by the Opposite Party No.1 within a period of 30 days from the date of receipt of certified copy of this order, failing which they shall also be liable to pay additional compensatory cost of Rs.10000/- to the complainant apart from the above relief.

12]      The complaint qua OPs No.2 to 4 stand dismissed. 

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

Announced

12^th October, 2021                                                                                                                                                         sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

 

Sd/-

(B.M.SHARMA)

MEMBER