Chandigarh

DF-II

CC/616/2015

Vikrant Goyal - Complainant(s)

Versus

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

Samir Rathaur Adv. & Krishan Vohra Adv.

29 Nov 2016

ORDER

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

 

Consumer Complaint  No	:	616 of 2015
Date  of  Institution	:	26.10.2015
Date   of   Decision	:	29.11.2016

 

 

 

 

 

1]  Vikrant Goyal son of Sh.Suresh Goyal, age 40 years, resident of 1001-D, Sector 21, Panchkula, at present House No.2146, Sector 21, Panchkula.

 

2]  Shikha Goyal wife of Vikrant Goyal, age 40 years, resident of 1001-D, Sector-21, Panchkula, at present House No.2146, Sector 21, Panchkula.

             ……Complainants

Versus

 

1]  The Oriental Insurance Company Lt., Divisional Office-2, SCO No.48-49, Sector 17-A, Chandigarh through its Senior Divisional Manager.

 

2]  Medi Assist India TPA Pvt. Ltd., SCO 61, IInd Floor, Phase-VII, Mohali, SAS Nagar, Punjab.

 

3]  Alchemist Hospital, Registered Office, Sector 21, Panchkula 134112, Haryana through its Medical Superintendent.

 

4]  Punjab National Bank, Saket, Chandimandir, District Panchkula, Haryana.

   

…..Opposite Parties

 

BEFORE:  SH. RAJAN DEWAN           PRESIDENT

                                MRS. PRITI MALHOTRA       MEMBER

SH.RAVINDER SINGH          MEMBER

           

 

Argued By: Sh.Sumeet Goel, Proxy counsel for Sh.Krishan Vohra, Counsel for the complainant.

Sh.Sumit Narang, Counsel for OPs NO.1 & 2.

Sh.Abhineet Taneja, Counsel for OP No.4.

None for OP No.4.

 

 

PER RAVINDER SINGH, MEMBER

 

                                 The facts in issue in the present complaint are that the complainants purchased a Medical Insurance Policy namely Oriental Royal Medi-Claim Policy which covers Shikha Goyal and her family comprising husband Vikrant Goyal and minor son Varundeep Goyal, from Opposite Party No.1 through Opposite Party No.4, for a sum assured of Rs.2.00 lacs.  The said insurance policy was initially purchased by the complainants on 1.10.2012, which was renewed time to time and was valid till 12.10.2015.  Sh.Vikrant Goyal, Complainant NO.1 suddenly fell sick on 21.11.2014 and admitted in Alchemist Hospital, Sector 21, Panchkula (OP No.3).  He was operated upon due to Obscure Overt GI bleed cause Gastro Intestinal Stromal Tumor and remained admitted in the hospital from 21.11.2014 to 05.12.2014 for the said surgery/treatment and spent Rs.2,99,056/- on medical treatment. The request of the complainants for cashless treatment was rejected and the claim for medical insurance amounting to Rs.2.00 lacs was repudiated by Oriental Insurance Company/OP No.1 vide letter dated 16.3.2015 with the following observations:-

‘Policy: PNB Oriental Royal Mediclaim insurance Policy DOA:22/11/14 DOD: 05/12/14 Diagnosis: obscure overt GI bled-small bowel Gastro intestinal stromal tumour, CAD, Schizophrenia on perusal of claim documents, it is noted that as per treating Doctor Certificate attached, the cause of GIST is unknown and most likely genetic in nature. S per terms and conditions, genetic disorders are not covered under the present Policy conditions.  Hence, the present claim is falling under exclusion clause 4.1 and is being denied.  Hence, we regret our inability to admit this liability under the present policy conditions and the claim is being repudiated under exclusion clause 4.1 of above mentioned policy.  We also reserve the right to repudiate the claim under any other ground/s available to us subsequently.’   

 

         The complainants have prayed for issue of directions to the Opposite Party NO.1 to pay the claim of Rs.2.00 lacs as medical expenses, as per the insurance policy, along with Rs.30,000/- as litigation expenses and Rs.50,000/- for harassment.

 

2]       Notice was issued to the OPs.

         The OPs NO.1 & 2 have filed their written statement opposing the claim of the complainants stating that there is suppression and concealment of material facts on the part of complainant as during the policy period of 13.10.2014 and 12.10.2015, complainant NO.1 Vikrant Goyal suffered a medical emergency on 21.11.2014 and was admitted for treatment with OP No.3. That the complainant NO.1 made a requisition for availing cashless facility through OP NO.3 and the pre-authorisation form filled by the beneficiary revealed that the patient had the history of Schizophrenia since 6 years i.e. much prior to the inception of the policy. The said fact was never disclosed by the complainants at the time of taking policy, therefore, on the ground of pre-existing illness, the pre-authorisation request for availing cashless facility was not conceded.  It is also submitted that complainant No.1 was suffering from Obscure Overt GI Bleed cause Gastro Intestinal Stromal Tumour and that etiology of the disease is unknown mostly likely genetic.  It is stated that as per the policy exclusions Clause 4.14, genetic disorders and stem cell implantation/surgery is permanent exclusion.  It is also stated that relying upon the medical certificate issued by the treating doctor and invoking exclusion clause, the claim of the complainants was rejected vide letter dated 16.3.2015.  The OPs NO.1 & 2 have alleged that the claim of the complainant No.1 falls within scope of Policy Clause 4.1 which excluded the pre-existing disease and its complications.    

         The OPs No.3 & 4 are proforma parties. The OP No.4 filed written statement but Opposite Party NO.3 has not filed any written statement in this matter. 

 

3]       Parties led evidence in support of their contentions. 

4]       We have heard ld.Counsel for the parties and have thoroughly examined the complaint and written statements filed by OPs NO.1, 2 and 4 along with evidence on record.

 

5]       The complainants have valid medical health insurance policy with effect from 1.10.2012 to 12.10.2015 for sum assured of Rs.2.00 lacs.  The complainant NO.1 suddenly fell ill on 21.11.2014 and operated upon for Obscure Overt GI bleed cause Gastro Intestinal Stromal Tumor and remained admitted in the hospital of Opposite Party No.3 from 21.11.2014 to 05.12.2014 for the said surgery/treatment.  Before claiming for his ailment from Opposite Party NO.1 for the period from 21.11.2014 to 05.12.2014, the complainant NO.1 never claimed any other insurance claim benefit from Opposite Party NO.1.  Dr.Daksh Khurana of Alchemist Hospital Ltd., who treated the complainant No.1, has given his observation in Certificate (at Page 74), the relevant portion of which reads as under:-

 

“…Vikrant Goyal is admitted in hospital on 21-11-2014 & discharged on 05-12-2014.  He is suffering from Obscure Overt GI bleed cause Gastro Intestinal Stromal Tumor & underwent surgery on 24-11-2014. Etiology for disease is unknown most likely genetic & he does not require any further management.”

 

6]      The observation of Dr.Daksh Khurana in the said certificate that origin for the disease is unknown mostly likely genetic, is totally superficial and casual in nature. If the cause or origin of the disease is unknown, as per observation of Doctor, then how can he said this to be genetic?  The observation of Dr.Daksh Khurana of Alchemist Hospital, is vague and self-contradictory too. He has casually pointed out this and observed without having any hereditary/genetic medical record of the claimant/complainant NO.1 with him.  More so, the Opposite Party NO.1 has also failed to produce any documentary proof to prove the said disease of complainant NO.1 being genetic/hereditary.  There must be something on record with reference to medical record of ascendants of the complainant NO.1.  There is no evidence on record that the Complainant No.1 had any history of suffering from Schizophrenia.  Nonetheless, the medical claim for disease/surgery on account of Gastro Intestinal Stromal Tumor cannot be denied. Therefore, the claim of complainants for medical claim of Rs.2.00 lacs under the policy in question is legally valid and maintainable.  The Opposite Party NO.1 cannot repudiate the claim merely on the observation of Dr.Daksh Khurana, which is totally untenable under the law. Therefore, the repudiation of medical claim of complainants by Opposite Party NO.1 is held to be unjustified and amounts to deficiency in service on its part.

 

7]       Keeping in view the above facts, the complaint filed by the complainants is allowed against Opposite Party NO.1/Oriental Insurance Company with direction to pay medical insurance claim of Rs.2.00 lacs to the complainants alongwith litigation expenses of Rs.5000/-, within a period of 30 days from the date of receipt of certified copy of this order. 

8]       However, the complaint qua OPs NO.2 to 4 stands dismissed.

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

Announced

29^th November, 2016                                                                     Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

 

Sd/-  

 (PRITI MALHOTRA)

MEMBER

 

 

Sd/-

(RAVINDER SINGH)

MEMBER