Haryana

Panchkula

CC/428/2021

DR.KRISHAN KUMAR BANSAL. - Complainant(s)

Versus

THE ORIENTAL INSURANCE COMPANY LTD. - Opp.Party(s)

NARESH TUNDWAL.

08 May 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  PANCHKULA

                                               

Consumer Complaint No	:	428 of 2021
Date of Institution	:	14.10.2021
Date of Decision	:	08.05.2023

 

 

 

Dr.Krishan Kumar Bansal aged 53 years resident of House No.65, Sector-12-A, Panchkula.

 

                                                                           ….Complainant

Versus

1.     The Oriental Insurance Company Ltd. A-25/27, Asaf Ali Road, New Delhi-110002 through its Authorised Signatory.

2.     The Oriental Insurance Company Ltd. BC Manimajra, Shop No.2366/11, First Floor, Mariwala Town, Manimajra, Chandigarh-160101 through its Authorised Signatory.

3.     M/s Raksha Health Insurance TPA Private Ltd. 15/15, Mathura Road, Faridabad.

4.     The Oriental Insurance Company Ltd. BO Pinjore, Laljeet Complex, 2^nd Floor, Chandigarh Shimla Highway, Opposite Bus stand Pinjore, Haryana-134102, through its Authorised Signatory.

                                                                                      ….Opposite Parties

COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019.

 

Before:              Sh. Satpal, President.

Dr. Sushma Garg, Member.

                        Dr.Barhm Parkash Yadav, Member

 

 

For the Parties:   Sh.Mohinder Singh, Advocate for the complainant. 

                        Sh.Krishna Kant, Advocate for OPs No.1 to 4.

 

ORDER

(Satpal, President)

1.             Briefly stated, the facts as alleged in the present complaint, are that the complainant obtained the PNB Oriental Mediclaim Policy 2017: Group Health Insurance Protect/Policy for Bank Account Holders of PNB only UIN:07CHLGP18074V011718, from OPs No.1 & 2, for the complainant, his wife Mrs. Meena Rani Bansal, daughter Ms.Mehak Bansal and his son Mr. Harshit Bansal in the year 2016, which was renewed from time to time as per details given below:

Policy No.	Period from	Period to	Policy issued by	Amount (Rs.)
231290/48/2016/2125	18.02.2016	17.02.2017	B.C. Manimajra	500000
231290/48/2017/2239	18.02.2017	17.20.2018	Oriental Insurance Company Ltd.	500000
231290/48/2018/2377	18.02.2018	17.02.2019	-do-	500000
231290/48/2019/1979	18.02.2019	17.02.2020	-do-	1000000
231290/48/2020/1796	18.02.2020	17.02.2021	-do-	1000000

 

        As per clause 2A(viii) of the policy, the pre and post hospitalization expenses(Medical expenses incurred 30 days prior to hospitalization and upto 60 days post hospitalization) incurred  by the policy holder are also payable by the OPs. On 15.04.2021 Mr.Harshit Bansal, son of the complainant was found unconscious, lying on floor with vomitious nearby, at home and admitted for further observations and management in Alchemist Hospital. He was immediately incubated in view of poor GCS, Antiepileptic drug(loading dose) were given and patient  was put on mechanical ventilator support. NCCT HEAD was done which was s/o left basal ganglia bleed with midline shift and intravetricular extension of bleed. After informed consents and relevant investigational, Mr.Harshit Bansal, son of the complainant was taken up for Surgery i.e. left Decompressive Craniotomy +Evacuation of Hematoma on 16.04.2021. The post operatively patient was shifted to ICU various type of tests and treatment have been conducted by the hospital. It is alleged that the son of the complainant was given trial of weaning off ventilator support but he could not be weaned off ventilator support in view of the persistent fever and poor GCS. After informed consents, Tracheotomy was done on 22.04.2021 and post procedure of Mr.Harshit Bansal, son of the complainant was continued on mechanical ventilation. On 23.04.2021, CSF examination was done in view of persisting fever, which was within normal limits. Antibiotics were revised accordingly. Mr.Harshit Bansal, son of the complainant was given weaning off trial and was weaned off ventilator on 27.04.2021 and his condition got improved. After discussing with family regarding need of general nursing car at home, Mr.Harshit Bansal, son of the complainant was discharged for home on 01.06.2021. For the above said period, the Alchemist Hospital raised the bill for the treatment of Mr.Harshit Bansal, son of the complainant as under:-

a.     Total bill amount         Rs.1573724.91

b.     Discount amount(-)      Rs.125821.96

c.      Net Bill amount           Rs.1447903.00

b.     Amount received(-)     Rs.210000.00

e.     Amount to be received         Rs.1237903.00

        The complainant got Rs.10,00,000/- from the Ops against  the base policy i.e.231290/48/2021/1803 dated 14.2.2021. The complainant paid Rs.2,10,000/- and the amount of Rs.2,37,903/- is to be paid to the hospital. He has also incurred an expenses of amount of Rs.1,73,914/- on the purchase of medicine from 01.06.2021 to 31.08.2021. The total amount is to be paid by the Ops was Rs.6,21,817/- on 04.05.2021. It is stated that the complainant had also obtained the Oriental Super Health Top-Up-Family Floater Plan Policy for his and his family from OP No.1. The period of insurance was 15.10.2020 to 15.10.2021. As per clause 1.2 of the terms and conditions of the policy, the company indemnify the insured and under the said policy, the Ops are liable to pay, over and above Rs.10 lacs insured under the base policy, under the Super Top up policy.  As per the clause 2 B of the terms and conditions of the policy(top up), the policy would trigger when the aggregate of actual admissible expenses incurred in respect of any one or more claims in a policy period exceeds the Deductible under the policy. In no case shall the liability of the company exceed the sum insured for one or all claims in aggregate during the policy period. The complainant requested the Ops to make the payment over and above Rs.10.0 lacs under the top-up policy from 15.04.2021 to 01.06.2021 and from 01.06.2021 to 31.07.2021(60 days of post hospitalization) for an amount of Rs.6,21,817/- but the Ops had replied that there no amount was payable under the top up policy as disease was pre-existing as mentioned in the policy. At the time of issuance of the Oriental Super Health Top up Family Floater Plan Family no.231304/48/2021/144 dated 04.05.2021, the pre-existing disease i.e. Brain Hemorrhage, has been mentioned. The complainant sent the another email dated 03.06.2021 but no action has been taken till date by the Ops. Due to the act and conduct of Ops, the complainant has suffered a great deal of financial loss and mental agony, harassment; hence the present complaint.

2.             Upon notice, the OPs No.1 to 4 appeared through counsel and filed written statement, raising preliminary objections. It is stated that the health insurance policy was issued to the complainant by the OP No.2 from the year 2016 and the same was renewed through subsequent policies. It is submitted that the complainant obtained a Oriental Super Health Top-up –Family Floater Plan Policy 231304/48/2021/144 from the OP No.4 for the sum insured of Rs.10,00,000/-, valid from 16.10.2020 to 15.10.2021 subject to the terms and conditions of the said insurance policy. It is submitted that the terms and conditions of the Top-up insurance policy were explained and supplied to the complainant. It is stated that the complainant was paid Rs.10,00,000/- as per the basic policy, but the expenses claimed by the complainant to the extent of Rs.6,21,817/- are not admissible as the maximum liability of the company was of Rs.10,00,000/-, which included the post hospitalization expenses for a period of 60 days from the date of discharge from the hospital. It is further submitted that no amount of Rs.6,21,817/- is payable to the complainant. It is submitted that the Super Health Top up Family Floater Policy was obtained but that was subject to the terms and conditions of the policy and it will come into effect after 48 months as per Exclusion Clause No.4.01, which is reproduced as under:-

          “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:

          Pre-existing Diseases-Code-Excl01

1. Expenses related to the treatment of a pre-existing diseases(PED) and its       direct  complications shall be excluded until the expiry of 48 months of continuous  coverage after the date of inception of the first policy with      the insurer or its reinstatement”.

The complainant has himself declared in the proposal form that his son, Harshit is having a pre-existing disease of brain Hemorrhage and therefore, any expenses incurred for treatment of brain Hemorrhage or any complications arising of it are not payable upto 48 months. Since the insurance coverage under the Top up policy is in the first year only so the claim is not admissible under the Oriental Super Health Top-up- Family Floater Plan. It is stated that the clause 2B of the terms of Top Up policy would trigger only if the mandatory period of 48 months had expired.The admissible claim as per basic policy has been paid and the amount under the Top-up policy is not admissible as the mandatory period of 48 months have not elapsed and the amount under Top-up policy would be admissible only after 48 months from the inception of the policy. It is stated that the email was received from the complainant and the same was replied vide email dated 20.05.2021 mentioning that the Top up policy was in the first year of inception starting from 16.10.2020 and therefore, no amount was payable under the policy as the disease is pre-existing. It is further submitted that the policy is issued not only for one person but it is for four persons and the policy has been issued as per terms and conditions, which are duly explained to the complainant; so there is no deficiency in service on the part of the OPs No.1 to 4 and as such, the complaint of the complainant is liable to be dismissed.

3.             The learned counsel for the complainant has tendered the affidavit as Annexure C-A along with documents Annexure C-1 to C-8 in evidence and closed the evidence by making a separate statement. On the other hand, the learned counsel for the OPs tendered affidavit Annexure R-A alongwith documents as Annexure R-1 & R-2 and closed the evidence.

4.             We have heard the learned counsels for the complainant and OPs No.1 to 4 and gone through the entire record available on the file including written arguments filed by the complainant as well as OPs No.1 to 4, minutely and carefully.

5.             Admittedly, the expenses amounting to Rs.10,00,000/- as incurred by the complainant on account of hospitalization of his son, namely, Harshit Bansal, w.e.f. 15.04.2021 to 01.06.2021 and thereafter, within 60 days of the hospitalization, have already been indemnified by the OPs, out of the total expenses, amounting to Rs.16,21,821/-. The aforesaid expenses have been indemnified under the basic policy namely, Group Health Insurance Protect/Policy for Bank Account Holders of PNB only. The OPs have denied the reimbursement of the additional/ extra expenses amounting to Rs.6,21,821/-, which has been incurred over and above/beyond the sum insured of Rs.10,00,000/- under the base policy. Though, the OPs have not raised any kind of objection qua the expenses as incurred by the complainant on account of hospitalization of his son but indemnification of the expenses qua the balance amount of Rs.6,21,821/- under the top up policy has been declined vide email dated 22.08.2021(Annexure C-6) taking  the plea of pre-existing disease as envisaged vide exclusion clause 4.01 of the top up policy (Annexure C-5), wherein, the claim, in case of any pre-existing disease, is admissible after the expiry of 4 years from the inception of the policy.

6.             The learned counsel on behalf of the complainant reiterating the averments as made in the complaint contended that his son, namely, Harshit Bansal, was hospitalized during the relevant period on account of aliment of hypertension and in this regard, he has placed reliance upon  certificate(Annexure C-8) issued by Alchemist Hospital as well as discharge summary(Annexure C-2). It is contended that the waiting period of 90 days is provided in case of aliment of hypertension, as per table given in the clause ‘F’ of the exclusion clause 02 of the top up policy(Annexure C-5) and thus, it is claimed that the denial of the reimbursement claim by the OPs  under the top-up policy was wrong, invalid and illegal.

7.             On the other hand, the learned counsel on behalf of the OPs, while reiterating the averments as made in the written statement, contended that a sum of Rs. 10,00,000/- had already been reimbursed to the complainant under the basic health policy and that no claim under the top-up family Floater policy(Annexure C-5) is admissible,  in  case of any pre-existing disease, until of the expiry of 48 months from the inception of the policy. It is contended that the complainant’s son, namely, Harshit Bansal, was, admittedly, suffering from pre-existing disease i.e. the disease of brain Hemorrhage as the same was admitted vide proposal form(Annexure R-2), prior to the inception of the policy. It is contended that the reimbursement claim has been lodged within the Ist year of the policy, which has rightly been denied as per exclusion clause contained in the top up policy. It is further contended that the terms and condition of the policy were duly explained  to the complainant prior to providing  of the top-up policy to him and that both the parties are bound by the terms and condition of the insurance contract. Reliance has been placed upon the following case laws:-

1. Vikram Greentech Vs. New India Assurance Co. Ltd.  ll(2009) CPJ 34(SC).
2. Life Insurance Corporation of India Vs. Sunita(SLP Civil no.13686 of 2019) decided on 29.10.2021(SC).

Concluding the arguments, the learned counsel asserted that reimbursement claim has validly been denied as per the terms and condition of the top up policy and thus, the complaint is liable to be dismissed being frivolous and baseless.

8.             After hearing the rival contentions of both the parties, it is found that the certificate(Annexure C-8) as well as the discharge summary(Annexure-2) issued by the Alchemist Hospital, wherein the insured Harshit Bansal was hospitized and obtained treatment, is of utmost relevance and importance. Evidently, as per discharge summary (Annexure C-2), the insured Harshit Bansal was having a history of hypertension. The treatment provided to the insured Harshit Bansal during hospitalization also speaks volumes about the problem of hypertension being suffered by him. The certificate issued by the Alchemist Hospital, in the shape of Annexure C-8, speaks unambiguously in specific and clear terms that Harshit Bansal, son of the complainant was an old case of Hypertension and several medicines for controlling the same were administered to him during his hospitalization. The OPs have not disputed the observations made in the said certificate(Annexure C-8), wherein Harshit Bansal, son of the complainant has been shown afflicted with the aliment of the hypertension. In the light of clear, specific and unambiguous opinion given by Dr. Manish Budhiraja vide his certificate(Annexure C-8) qua the aliment of Harshit Bansal i.e. hypertension, we are of the considered view that the case of the complainant falls under the clause ‘F’ exclusion clause 02 of the top up insurance policy of Annexure C-5, wherein a waiting period of 90 days has been provided to claim the reimbursement. Admittedly,  the period of 90 days had already expired before lodging the present claim by the complainant under the top-up policy(Annexure C-5); therefore, the denial by the Ops vide email dated 22.08.2021(Annexure C-6) of the reimbursement claim as lodged by the complainant seeking indemnification of the expenses amounting to Rs.6,21,821/-, over and above the amount of Rs.10,00,000/-, as covered under the basic health policy, is neither fair nor justified and accordingly, the Ops are held deficient, while rendering services to the complainant for which they are liable to compensate to the complainant, jointly and severally.

9.             As per bill(Annexure C-3)  an expenses of Rs.14,47,903.91 were incurred and an expenses amounting to Rs.1,73,914/- were incurred vide Essentiality certificate (Annexure C-4(colly)); thus, total expenses comes to Rs.16,21,817.91(14,47,903.91+1,73,914) out of which Rs.10,00,000/- have already been reimbursed to the complainant. So, the complainant is entitled to the reimbursement of the Rs.6,21,817.91.

10.            As a sequel to the above discussion, we partly allow the present complaint with the following directions to the OPs No.1 to 4:-

1. To make the reimbursement of the expenses amounting to Rs.6,21,817.91 to the complainant along with interest @ 9%      per annum(S.I.) w.e.f  filing of the present complaint till its realization. 

 

2. To pay an amount of Rs.15,000/- to the complainant on account of mental agony and harassment.

 

3. To pay an amount of Rs.5,500/- as cost of litigation charges.

               

11.            The OPs No.1 to 4 shall comply with the order within a period of 45 days from the date of communication of copy of this order failing which the complainant shall be at liberty to approach this Commission for initiation of proceedings under Section 71/72 of CP Act, 2019 against the OPs No.1 to 4. A copy of this order shall be forwarded, free of cost, to the parties to the complaint and file be consigned to record room after due compliance.

Announced: 08.05.2023

 

 

 

Dr.Barhm Parkash Yadav      Dr.Sushma Garg             Satpal              

                   Member                          Member               President

 

Note: Each and every page of this order has been duly signed by me.

                                         Satpal                                        

President