BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.460 of 2014

Date of Instt. 30.12.2014

Date of Decision :07.10.2015

Vishwa Mittar Kohli son of late Dr.Dharam Pal Kohli, R/o 47 First Floor, Sarswati Vihar, Kapurthala Road, Jalandhar.

..........Complainant Versus

1. The Oriental Insurance Company Ltd., Divisional Office, 32, GT Road, Jalandhar through its Senior Divisional Manager, Jalandhar.

2. E-Meditek (TPA), Services Ltd, Carpet Office, Plot No.577, Udyog Vihar, Phase-V, Gurgaon (Haryana)-1220016.

.........Opposite parties.

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.KC Malhotra Adv., counsel for complainant.

Sh.Brijesh Bakshi Adv., counsel for OP No.1.

Opposite party No.2 exparte.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that the law abiding citizen/complainant above named obtained mediclaim insurance policy (individuals) for himself. The policy was taken from opposite party No.1, through its authorized agent for the period stated in the policy schedule by renewal effective from 6.1.2014 to 5.1.2015. The complainant has been continuously and uninterruptedly insured himself for mediclaim insurance policy since year 2009, without any gap/break and strings by opposite party No.1. The policy schedule of mediclaim insurance policy was issued in the name of the complainant/insured. Opposite party No.1, issued/delivered to the complainant policy schedule and cover note only from the inception of the risk coverage under mediclaim insurance policy and on its renewal. The policy document was not ever issued/delivered to the complainant by opposite party No.1, during the whole period of the policy. The complainant insured with opposite party No.1, suddenly developed weakness in UL i.e upper limb and became aphasic and diagnosis was stroke and associated diagnosis HT (Hypertonic) by Dr.Sandeep Goel of NASA Neuro Care Hospital, Jalandhar. The complainant was advised and was admitted in NASA Neuro Care Hospital, Jalandhar on 14.4.2014 and discharged on 15.4.2014 for further management and treatment. After discharge from hospital, the complainant made a claim in the sum of Rs.17,416/- for medical treatment and clinical and laboratory test expenses incurred for reimbursement of hospitalization to opposite parties. Duly completed claim from prescribed, bills, receipts, discharge certificates alongwith clinical tests were submitted to opposite parties. All the formalities were completed and complied with for settlement of mediclaim for an amount of Rs.17,416/-. The claim was numbered 103041400286. Opposite party No.2 vide its letter dated 8.5.2014, provided draft letter (to be dispatched by insurance on concurrence only), to opposite party No.1. In the said draft letter, it was mentioned that the claim is not payable as per-1)section 4 exclusion-'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 (4.10) expenses incurred at hospital or nursing home primarily for a evaluation/diagnostic purposes which is not followed by any active treatment for the ailment during the hospitalized period'. On such like averments, the complainant has prayed for directing the opposite parties to pay him medical expenses of Rs.17,416/- alongwith interest. He has also claimed compensation and litigation expenses.

2. Upon notice, opposite party No.1 appeared and filed a written reply pleading that the complainant has got no cause of action to file the present complaint against the opposite party No.1. There has been no default or undue delay, on the part of the opposite party No.1 in processing the claim of the complainant and even otherwise, the claim has been repudiated as per the policy terms and conditions. The complainant had submitted the claim for Rs.17,416/- on account of expenses incurred for evaluation/diagnostic purposes which was not followed by active treatment for the ailment during the hospitalized period. The same is not payable on account of exclusion clause in the individual mediclaim policy opted by the complainant. The bills were raised on account of 2D ECHO, MRI Brain, MRI Brain with Neck Angio and other tests and room charges etc for the tests period of 14.4.2014 to 15.4.2014. The same is not payable as per section 4.Exclusion- 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 (Sec4.10) expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period. Thus, the claim was duly considered and repudiated as per law/policy conditions. They denied other material averments of the complainant.

3. Opposite party No.2 did not appear inspite of notice and as such it was proceeded against exparte.

4. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavits Ex.CA and Ex.C/B alongwith copies of documents Ex.C1 to Ex.C24 and closed evidence.

5. On the other hand, learned counsel for the opposite party No.1 has tendered affidavit Ex.OP-A alongwith copies of documents Ex.O1 to Ex.O10 and closed evidence.

6. We have carefully gone through the record and also heard the learned counsels for the parties.

7. The facts involved in the present case are not much disputed. It is not disputed that complainant had obtained mediclaim policy from opposite party No.1 insurance company. According to the complainant he suddenly developed weakness in UL and he was admitted in NASA Neuro Care Hospital, Jalandhar where certain diagnostic tests were performed and was diagnosed to be suffering from stroke and was discharged on the next date after prescribing certain medicines and diet chart. He lodged claim with opposite party No.1 insurance company but opposite party No.1 insurance company repudiated his claim vide letter dated 6.5.2014 Ex.C2 on the ground that he was admitted in the hospital primarily for diagnostic purpose which was not followed by active treatment for the ailment during the hospitalized period and as such his case falls under said exclusion clause. Counsel for the opposite party No.1 insurance company contended that the claim of the complainant has been repudiated as per above said exclusion clause contained in the terms and conditions of the mediclaim policy. We have carefully considered this contention advanced by learned counsel for the opposite party No.1. Ex.C19 is discharge summary issued by NASA Neuro Care Hospital, Jalandhar. In the discharge summary, the diagnosis is mentioned as stroke and associated diagnosis as HTN and procedure adopted is mentioned as conservative treatment. In the discharge summary it is specifically mentioned that yesterday suddenly patient had developed weakness in UL i.e upper limb and became aphasic for some time. So from the discharge summary it is evident that the complainant had suffered from stroke and was given conservative treatment and thereafter was discharged on next day after prescribing medicine vide Ex.C18. In the hospital, certain diagnostic tests were performed on the patient. For proper diagnosis certain diagnostic tests are required. Since the complainant had suffered stroke as such it can not be said that he was admitted in the hospital simply for diagnostic purpose followed by no active treatment. The complainant has also produced medical certificate issued by the above said hospital wherein it is mentioned that the patient was admitted in their hospital on 14.4.2014 with complaint of right side weakness, Aphasia and patient was diagnosed of (PCA infarct), stroke, HTN. It is further mentioned in the certificate that patient was discharged on 15.4.2014 and hospitalization was essential and after discharge he is on the prescribed treatment. So in the above circumstances, the opposite party No.1 insurance company was not justified in repudiating the claim of the complainant on the above said ground.

8. In view of above discussion, the present complaint is accepted and opposite party No.1 insurance company is directed to pay him Rs.17,416/- alongwith 9% interest per annum from the date of repudiation of his claim till the date of payment. The complainant is also awarded Rs.3000/- on account of litigation expenses. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

07.10.2015 Member Member President