Haryana

Ambala

CC/324/2022

RAVI KUMAR. - Complainant(s)

Versus

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

MAHINDER KAMAR.

16 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	324 of 2022
Date of Institution	:	08.08.2022
Date of decision	:	16.08.2024

Ravi Kumar aged about 32 years s/o Shri Bhushan Sharma, R/o Village Rao Majra. Post Office-Tandwal, Tehsil Barara. District Ambala

          ……. Complainant.

                                                Versus

1. The Oriental Insurance Company Limited, Regional Office-Second Floor, LIC Building, Jagadhri Road, Ambala Cantt (Haryana), Pincode- 133 001, through its Manager/Authorized Signatory
2. The Oriental Insurance Company Limited, Head Office-A-25/27, Asaf Ali Road, New Delhi-110002, through its Authorized Signatory.

                                                                                   ….….  Opposite parties

Before:         Smt. Neena Sandhu, President.

                      Smt. Ruby Sharma, Member.           

 

Present:       Shri Mahinder Kumar, Advocate, counsel for the complainant.

                     Shri Dev Batra, Advocate, counsel for the OPs.

                  

 Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

(i) To pay the amount of Rs.1,13,087/-, on account of medical expenses incurred by the complainant for the treatment of his wife taken under the policy in question;

(ii) To grant interest at the rate of 18% per annum on the abovesaid amount from 08.03.2022 till realization;

(iii) To pay a sum of Rs.2,00,000/- on account of compensation for causing deficiency in services and unfair trade-practice, harassment, mental torture and agony to the complainant by the OPs by denying genuine and legal medical claim.

(iv) To pay costs of litigation.

(v) Grant any other relief, which this Hon'ble Commission may deems fit.

2.             Brief facts of the case are that the complainant was employed by D Mart, Avenue Supermarts Limited, Plot No B-72A, Wagle, Industrial Estate, Thane (West)-400604, Maharashtra (India). He joined the company on 17.12.2020 at a monthly salary of Rs.25,300/- and was kept by the employer-company in their Warehouse as a Senior Officer on Billing at Avenue Supermarts Limited, Khasra No. 104-113, Village Shambhu Khurd, H.D. No 133. NH1, Taluka, Ghanour, Tehsil Rajpura, District Patiala (Pb)-140 417, having Employee Code No. 10017073. The complainant kept his job continuing since beginning in a very careful manner and presently the salary of the complainant is Rs.28,059/- At the time of  joining the company, the complainant was specifically told that he has to get his mandatory insurance done with the  OPs  through the employer of the complainant i.e.D-Mart Avenue Supermarts Limited and was got insured by his employer with the  OPs  vide Policy No. 112300/48/2022/992 for the family sum assured Rs.1,00,000/- valid for the period from 01.08.2021 to 31.07.2022 with the beneficiaries covered such as the complainant-Ravi Kumar-himself, Father-Shri Bhushan Sharma, mother-Smt.Reena Rani and wife -Smt.Ritu Rani. Unfortunately the wife of the complainant, Smt.Ritu Rani complained for pain in lower portion of her stomach and as such was taken to VCare Hospital, Plot No.04, Raksha Enclave, VIP Road, Zirakpur (Punjab)-140 063, as this hospital is on the empanelment of the company. After conducting thorough investigation of the wife of the complainant, she was advised to undergo for some medical tests. Accordingly the wife of the complainant got her medical tests conducted, whereafter, the doctor advised that she has to undergo for operation; as she is having Tumor in the lower portion of her stomach. OP No.1 had given an initial approval of Rs.29,750/- on 08.03.2022 for this cashless case that enabled the doctor to start the treatment of his wife. The OPs further disclosed to the doctor that the final amount upto Rs.1,00,000/- will only be paid at the time of discharge of the patient being covered under the aforesaid Policy. After taking approval from the OPs, the doctor concerned from VCare Hospital treated the wife of the complainant during the period 08.03.2022 to 12.03.2022. Total amount of Rs.1,13,087/- was incurred on her treatment. The VCare Hospital raised bill No.2022/03/IP/5246 to the tune of Rs 75,587/-. However, OP No.1 refused to pay the said bill amount. OP No.1 refused the payment of bill on the ground that the wife of the complainant had got conducted her past IVF treatment. Though the treating doctor through email as well as through certificate conveyed that the procedure is not done for infertility and the operation conducted is nowhere connected with IVF treatment and the operation is conducted only to remove the tumor from the lower portion of stomach but the OPs ignored the same. Legal notice dated 16.05.2022, served upon the OPs, calling upon them to pay the amount of Rs.1,13,087/- but to no avail. Hence, the present complaint.
3.           Upon notice, OPs appeared and filed written version wherein they raised preliminary objections to the effect that this Commission has no jurisdiction to entertain & try the present complaint; the complaint has been filed by the complainant on false, frivolous and vague grounds and no cause of action either arose in favour of the complainant or against the OPs and therefore instant complaint is liable to be dismissed in limine; the complainant has attempted to gravely flout the terms and condition of the Medi- Claim Insurance Policy which was issued to him etc. On merits, it has been stated that infact the Insured/Claimant, Mr. Ravi Kumar is having group medicliam policy through The Oriental Insurance Co Ltd Group Policy-Tailor Made vide policy no 112300/48/2022/992 valid from 01.08.2021 to 31.07.2022 for sum insured of Rs 1,00,000/-. During the validity of policy no.112300/48/2022/992, cashless claim for Beneficiary, Ms Reetu (Wife) for expenses incurred on treatment of ailment which proximately related to Endometriosis, unspecified was raised. On receipt of documents the claim was processed by the team of panel doctors as per policy terms & conditions. During the policy period, the OPs had received cashless claim request (Estimate) for a sum of Rs.75000/- and the same was processed vide Pre-Authorisation claim No 27702388, incurred on treatment of Beneficiary, Ms Reetu (Wife). She was admitted at V Care Hospital (GIPSA), Mohalli (Punjab) on 08.03.2022 for Endometriosis, unspecified and discharged on 10.03.2022. On scrutinizing the cashless claim documents by the team of the OPs, the panel doctors vide query letter dated 08.03.2022, raised the query for the requirement of documents i.e. the GPLA Status (Number of living children and Gravida and also the Doctor Certificate detailing about the etiology (Cause) of ailment. After receipt of above documents the claim was reviewed wherein it was found that a 29 years old female patient admitted with complaint of nulligravida MF-10YRS IVF done on 2019 dysmenorrheal is known case of endometriosis underwent lap removal of endometriosis cyst adhesiolysis with chrompertubatian. Ailment related to infertility is not payable as per policy terms & conditions. With regard to above, the initial approval was wrongly given for Rs.29,750/- vide pre-authorization claim no 27702388 and the same was denied on above grounds. Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with costs.
4.           Learned counsel for the complainant tendered affidavit of complainant as Annexure CA alongwith documents as Annexure C-1 to C-37 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OPs tendered affidavit of Renu Dhingra, Authorized Signatory of the OPs Company-Oriental Insurance Company Ltd. as Annexure OP-1/A alongwith documents Annexure OP-1/1 to OP-1/7 and closed the evidence on behalf of the OPs
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that by repudiating the genuine claim of the complainant, filed for the reimbursement of the amount incurred on the treatment of his wife, on flimsy ground that ailment related to infertility is not payable as per policy terms & conditions, through no such treatment of infertility was taken by her, the OPs have committed deficiency in providing service and also adopted unfair trade practice. 
7.           On the contrary, the learned counsel for the OPs submitted that since the wife of the complainant has taken treatment for infertility, as such, the claim lodged by the complainant under the policy in question was rightly rejected by the insurance company, strictly as per terms and conditions of the insurance policy.
8.           Neither the issuance of the policy in question in favour of the complainant and his family members nor the fact that the wife of the complainant took treatment in the said hospital but her claim was repudiated by the OPs  are in  dispute, therefore, the only question which needs to be adjudicated is whether, the said claim was rightly repudiated or not. Admittedly, the claim of the complainant was repudiated by the insurance company vide letter dated 26.05.2022, Annexure OP-1/6 on the ground that ailment related to infertility is not payable as per policy terms and conditions. It is also coming out from the letter dated 08.03.2022, Annexure OP-1/3 that when the OPs demanded some documents especially doctor certificate detailing about the etiology, (cause of ailment), the complainant had admittedly supplied those documents i.e. Annexure C-29 (Doctor Certificate) and also Annexure C-30. A bare perusal of the treating Doctor Certificate issued by the V-Care Hospital reveals that it has been clearly certified by Dr.Liza Gupta (Treating Doctor) that “The surgery is not done for infertility”. It is not the case of the OPs that they have not received the demanded documents from the complainant, whereas, perusal of the repudiation letter, Annexure OP-1/6 reveals that it has been mentioned therein that they have reviewed the received documents meaning thereby that all the documents including (Doctor Certificate) Annexure C-29 and also Annexure C-30 had been provided to the OPs by the complainant. However even after clear-cut certificate issued by Dr. Liza Gupta (Treating Doctor) that “The surgery is not done for infertility” the OPs repudiated the claim holding to the contrary.  The refusal to honor a claim that clearly does not fall within the excluded category, constitutes a deficiency in providing service. The OPs are thus liable to pay the amount which the complainant had incurred on the treatment of his wife but not more than the sum insured amount permissible under the policy in question. They are also liable to compensate the complainant for the mental agony and physical harassment suffered by him alongwith litigation expenses.  
9.           In view of aforesaid discussion, we hereby partly allow the present complaint and direct the OPs, in the following manner:-
   1. To pay the amount which the complainant had incurred on the treatment of his wife but not more than the sum insured amount permissible under the policy in question, alongwith interest @6% p.a. from the date of repudiation of the claim i.e. 26.05.2022, till realization.
   2. To pay Rs.5,000/-, as compensation for the mental agony and physical harassment suffered by the complainant.
   3. To pay Rs.3,000/-, as litigation expenses.   

The OPs is further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OPs shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

 Announced:- 16.08.2024

	(Ruby Sharma)	(Neena Sandhu)
	Member	President