Punjab

Moga

CC/16/159

Davinder Goyal - Complainant(s)

Versus

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

Sh. Ashok Goyal

08 Feb 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                      CC No. 159 of 2016

                                                                                      Instituted on: 08.11.2016

                                                                                      Decided on: 08.02.2017

 

1.       Davinder Goyal aged 42 years son of Sh. Parshotam Lal Goyal,

2.       Malka Rani aged 38 years wife of Sh. Davinder Goyal son of Parshotam Lal Goyal, both resident of House no.859, Ward no.29, Gali Dev Samaj, Arya School Road, Moga District Moga.

                                                                                ……… Complainants

 

Versus

1.       The Oriental Insurance Company Ltd, through its Authorized Signatory, having registered and Head Office: A-25/27, Asaf Ali Road, New Delhi-110002.

 

2.       The Oriental Insurance Company Ltd, Branch Office at G.T.Road, Moga District Moga, through its Branch Manager.

 

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Vinod Bala, Member

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Ashok Kumar Goyal, Advocate Cl. for complainant.

                   Sh. Pawan Kumar Sharma, Advocate Cl. for opposite parties.

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against The Oriental Insurance Company Ltd, through its Authorised Signatory, having registered and Head Office: A-25/27, Asaf Ali Road, New Delhi and others (hereinafter referred to as the opposite parties) directing them to make payment of Rs.3,00,000/- (medical bills) expenses incurred by complainant no.1 on the treatment of complainant no.2 against mediclaim policy no.233904/48/2015/1040 purchased by the complainants from opposite parties. Further opposite parties may be directed to pay Rs.1,00,000/- as compensation for mental tension, harassment and agony suffered by complainants without any reason and logic and for deficient services on the part of opposite parties and to pay litigation expenses to the complainant or any other relief which this Forum may deem fit and proper be granted.

2.                Briefly stated the facts of the case are that the complainants availed insurance policy from opposite party's office at Moga under the title i.e. "Happy Family Floater Policy' having policy no.233904/48/2015/1040 for the period from 16.01.2015 to 15.01.2016 with basic insurance cover of Rs.4,00,000/- and paid the premium of Rs.7472/-. The complainants had been getting this policy from the opposite parties since 2009. Unfortunately, due to some sinuses/allergy/congenital heart disease, complainant no.2 had to go medical treatment for Medanta, The Medicity, Gurgaon (now Gurugram) and she got admitted in the hospital on 08.02.2016 and discharged on 18.02.2016. Prior to get treatment from Medanta The Medicity Gurgaon, complainant no.2 got medical diagnosis and treatment from Moga, Fortis Hospital Noida, Max Healthcare, New Delhi and some other hospital and during this treatment complainant spent a lot of money. Actually the complainant no.1 had spent Rs.7/8 lakhs for the treatment of complainant no.2. Complainant no.1 policy holder has submitted mediclaim policy- Claim form with opposite party on 26.02.2016. Complainant no.1 submitted medical bill of Rs.3,00,000/- approximately with opposite parties. All the details regarding the expenses incurred by complainant no.1 on medical treatment of complainant no.2 was already submitted with the branch office of opposite parties at Moga. Despite providing all the details regarding the medical treatment and bills of different hospital, opposite parties failed to pay the claim to the complainants. Legal notice dated 10.10.2016 was also dispatched at the head office and branch office of opposite parties, but they did not give any reply to the same. The complainants visited the local office of opposite party's at Moga for a number of times regarding payment of claim, but to no effect. Hence this complaint.

3.                Upon notice, opposite parties appeared through counsel and filed their written reply taking preliminary objections that the complaint is not maintainable; that the complainant is estopped by his own act and conduct; that the complainant has not complied with the terms and conditions of the insurance policy; that the complaint is premature; that no cause of action arose to the complainant against the answering opposite parties; that there is no deficiency in service on the part of opposite parties; that the complainant has not come to the Forum with clean hands. He has concealed, suppressed and misstated the material facts from this Forum. Further submitted that Sh. Devinder Goyal/complainant has purchased a Happy Family Floater Policy, vide policy no.233904/48/2015/1040 for the period 16.01.2015 to 15.01.2016 for Rs.4 lac and as per claim form submitted by the complainant, he has stated in the claim form that complainant no.2 Malka Rani was admitted in Medanta Hospital on 08.02.2016 and discharged on 18.02.2016. After receiving the information, the opposite parties investigated the claim and observed that Mrs. Malka Rani was hospitalized at Medanta Global Health Ltd. Gurgaon from 08.02.2016 to 18.02.2016 with diagnosis Congenital heart disease, Ostium Secundum ASD (Atrial Septal Defect) (Left Right Shunt), Dilated RA/RV, Right ovarian Cyst, normal Coronaries underwent Coronary Angiography and ASD Closure surgery. As per the available information patient was insured under Happy Family Floater Policy and policy does not cover the impugned expenses. Moreover, the policy does not cover the expenses incurred for the treatment of congenital internal & external disease vide exclusion clause no.4.8. Hence the claim is not admissible. On merits, it is admitted to the extent that the complainants have availed the insurance policy i.e. Happy Family Floater Policy vide policy no.233904/48/2015/1040 for the period 16.01.2015 to 15.01.2016. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with special costs has been made.

4.                In order to prove the case, complainant no.1 tendered in evidence his duly sworn affidavit Ex.C-1 alongwith copies of documents Ex.C-2 to Ex.C-18 and closed the evidence. 

5.                On the other hand, opposite parties tendered in evidence duly sworn affidavit of Sh. Muneesh Nagpal, Branch Manager, Oriental Insurance Co. Ex.OPs-1 alongwith copies of documents Ex.OPs-2 and Ex.OPs-3 and closed the evidence.

6.                We have heard ld. counsel for the parties and have very carefully gone through record placed on file.

7.                Ld. counsel for the complainants argued that complainants availed insurance policy for the period from 16.01.2015 to 15.01.2016 with basic insurance cover of Rs.4,00,000/- and paid the premium of Rs.7472/-. The complainants had been getting the policy from the opposite parties since 2009. Unfortunately, due to some sinuses/allergy/congenital heart disease, complainant no.2 had to go medical treatment for Medanta, The Medicity, Gurgaon (now Gurugram) and she got admitted in the hospital on 08.02.2016 and discharged on 18.02.2016. Prior to get treatment from Medanta The Medicity, complainant no.2 got medical diagnosis and treatment from Moga, Fortis Hospital Noida, Max Healthcare, New Delhi and some other hospital and during this treatment complainant spent a lot of money. Actually the complainant no.1 had spent Rs.7/8 lakhs for the treatment of complainant no.2. Complainant no.1 submitted mediclaim policy- Claim form with opposite parties on 26.02.2016 alongwith medical bills of approximately Rs.3,00,000/- with opposite parties. Despite providing all the details regarding the medical treatment and bills of different hospital, opposite parties failed to pay the claim to the complainants. The complainants visited the local office of opposite parties a number of times regarding payment of claim, but all in vain. Complainants also served a legal notice dated 10.10.2016 upon opposite parties, but they failed to reply to the said notice. The present complaint may be accepted and opposite parties may be directed to pay the medical claim to the complainant alongwith compensation and litigation costs.

8.                On the other hand, ld. counsel for opposite parties argued that Devinder Goyal/complainant no.1 had purchased a Happy Family Floater Policy for the period 16.01.2015 to 15.01.2016 for Rs.4 lacs and as per claim form submitted by the complainant, he stated in the claim form that complainant no.2 Malka Rani was admitted in Medanta Hospital on 08.02.2016 and discharged on 18.02.2016. After receiving the information, the opposite parties investigated the claim and observed that Mrs. Malka Rani was hospitalized at Medanta Global Health Ltd. Gurgaon from 08.02.2016 to 18.02.2016 with diagnosis Congenital heart disease, Ostium Secundum ASD (Atrial Septal Defect) (Left Right Shunt), Dilated RA/RV, Right ovarian Cyst, normal Coronaries underwent Coronary Angiography and ASD Closure surgery. As per the available information patient was insured under Happy Family Floater Policy and policy does not cover the expenses incurred for the treatment of congenital internal & external disease vide exclusion clause no.4.8. Hence the claim is not admissible. They rightly repudiated the claim of the complainant and there is no deficiency in service on their part. Hence the present complaint may be dismissed with costs.

9.                We have thoroughly gone through the file, evidence and arguments lead by ld. counsel for the parties. The case of the complainant is that he purchased mediclaim insurance policy i.e. Happy Family Floater policy having policy no.233904/48/2015/1040 valid for the period from 16.01.2015 to 15.01.2016 with insurance cover of Rs.4 lacs covering himself and his family members. He had been purchasing the insurance polices from the opposite parties continuously since 2009. Due to some sinues/allergy/congenital heart disease, complainant no.2 got medical treatment from Medanta, The Medicity, Gurgaon and remained hospitalized from 08.02.2016 to 18.02.2016. The complainant lodged the claim for reimbursement of medical bills with opposite parties, but they did not pay any amount towards the mediclaim of complainant no.2. On the other hand, ld. counsel for opposite parties admitted that the complainant purchased the medical insurance policy in question from opposite parties, which was valid from 16.01.2015 to 15.01.2016. They further admitted that the complainant lodged the claim for reimbursement of medical expenses borne by him on the treatment of complainant no.2 from 08.02.2016 to 18.02.2016. He argued that the disease for which the complainant no.2 got her treatment is not covered under the policy in question and she is not entitled for any claim of her treatment. He further argued that the policy in question was valid only from 16.01.2015 to 15.01.2016, whereas the complainants claimed reimbursement for the treatment taken by her from 08.02.2016 to 18.02.2016 i.e. beyond the policy period, as the policy in question expired on 15.01.2016 and the treatment taken after this day is not covered under the policy and complainants are not entitled for any claim regarding the treatment taken by them after 15.01.2016 under the policy in question.

10.              Now, it is admitted case of the parties that the complainants purchased the medical insurance policy in question from opposite parties, which was valid for the period from 16.01.2015 to 15.01.2016. It is further admitted that the complainant no.2 hospitalized in hospital from 08.02.2016 to 18.02.2016 and lodged the claim for the reimbursement of medical expenses borne by the complainant no.1 for the treatment of complainant no.2. Now, the question is that whether the period for which, the complainant remained hospitalized i.e. from 08.02.2016 to 18.02.2016 is covered under the policy in question or not. Admittedly the policy in question was valid from 16.01.2015 to 15.01.2016 and after 15.01.2016, the policy in question has been expired, whereas, the complainant lodged the claim for the period from 08.02.2016 to 18.02.2016, which is beyond the policy period. As such, this period is not covered under the policy in question, as it was already expired on 15.01.2016. The opposite parties are not liable to pay the any medical claim for this period, after the expiry of policy in question. So, in these circumstances, we found no merit in the present complaint and the same is hereby dismissed. Parties are left to bear their own costs. Copy of the order be supplied to the parties, free of costs. File be consigned to record room.

Announced in Open Forum.

Dated: 08.02.2017.

 

                               (Bhupinder Kaur)                 (Vinod Bala)         (Ajit Aggarwal)

                                              Member                           Member                President