BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.167 of 2018
Date of Instt. 17.04.2018
Date of Decision:05.07.2022
Mrs. Amita Joshi aged 58 years wife of Anil Joshi, R/O 29/30 Central Town, Jalandhar-144001.
..........Complainant
Versus
1. The Oriental Insurance Company Ltd. Branch Office-CBO III, 1st Floor, Rattan Tower, Namdev Chowk, Jalandhar City through its Branch Manager.
2. E-Meditak (TPA), Services Ltd., Corporate Office, Plot No.577, Udyog Vihar, Phase V, Gorgon (Haryana)-1220016 through its Authorized Officer.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Complainant in Person.
Sh. Brijesh Bakshi, Adv. Counsel for OP No.1.
OP No.2 exparte.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant had taken policy from OP No.1 through its authorized agent for the period 17.12.2016 to 16.12.2017 and allotted policy No.233102/48/2017/968 as per Policy Schedule dated 22.12.2016. The complainant has been continuously and uninterruptedly insured herself and her husband for mediclaim insurance policy since year 2013, without any gap/brake and strings by OP No.1. The policy schedule of mediclaim insurance policy was issued in the name of the complainant insured. The total amount of renewal premium inclusive of all taxes of Rs.15,613/- as consideration was paid to the OP No.1 through its agent/representative which was accepted after fully satisfying the continue insurability and without questioning the credentials of the insured person without any demur. The OP No.1 issued to the complainant Happy Family Floater policy schedule only from the inception of the risk coverage under Mediclaim insurance policy and on its renewal. The policy document was not ever issued to the complainant by OP No.1, during the whole period of the policy. It was mandatory and obligatory upon op No.1 to have issued policy document which expresses the contract of insurance between the insurer i.e. OP No.1 and the insured complaint. There is no ground or reason or occasion for not issuing the policy bond. Normally cover note is only interregnum during which policy is prepared and issued. The terms and conditions including exclusion clauses were not ever communicated and explained nor made known to the complainant and were not part of insurance. The OP No.1 has agreed and undertaken to indemnify for medical and surgical expenses or illness/sickness, accident and surgical operation etc. contracted within the period of insurance to the full extent without any limitation and deduction. Accordingly, the complainant has got the right of indemnification/reimbursement for the whole amount of mediclaim insurance policy expenses incurred against peril covered under mediclaim insurance policy. The complainant insured with OP No.1, sustained accidental injuries on upper lips and nose (afresh) lacerated cut wound (on upper lip and deep cut wound on nose, bleeding freshly) was immediately taken to nearby Dr. Tarun Aggarwal, Physician, Jalandhar for emergency treatment who gave emergency first aid treatment and advised and referred for surgery. There upon the husband of the injured complainant and insured had taken, her to Dr. B. P. Singh, M.S.FACCS, FIAMS, FIACS Centre for Laser Cosmetics Surgery, Mota Singh Nagar, Jalandhar where the complainant was operated under Anthesia on the same day. Cut upper lip surgery was done in layers, Nose Deep cut was also operated. The complainant was admitted on 16-05-2017 and discharged on 17-05-2017 with advice to remain on rest and come for check up on 22-05-2017. The reason for admission was also given in certificate dated 17-05-2017. After discharge from the Hospital, the complainant lodged a claim in the sum of Rs.36,000/- for Medical Treatment and expenses incurred for clinical and laboratory test reimbursement of expenses to OPs. Duly completed prescribed claim form, bills, receipts discharge certificate along with clinical test were submitted to OPs. All the formalities were completed and complied with for settlement and reimbursement of mediclaim for full amount of Rs.36,000/-. To utter surprise and dismay of the complainant, the OP No.1 vide No.EMSL/REJ/146539 dated 02.02.2018 repudiated mediclaim of the complainant on flimsy and strange purported reason. The repudiation and denial of genuine and bonafide claim was made on lame excuses in mechanical and routine manner and wrongly assumed and presumed and misconceived that the treatment fall in releam of clause 3.23 of the policy. The OPs are guilty of rendering deficient service, negligent and adopted unfair trade practice in unilateral arbitrary and malafide rejection of mediclaim of the complainant as fully described ante and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse amount of Rs.36,000/- alongwith interest @ 12% per annum from the date lodgment mediclaim till date of actual payment to the complainant. Further, OPs be directed to pay Rs.10,000/- as compensation for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, but despite service OP No.2 failed to appear and ultimately, OP No.2 was proceeded against exparte, whereas OP No.1 appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that the complaint is not maintainable under the law in the present form against the OP No.1. It is further averred that the OP NO.1 has been dragged into unnecessary litigation hence they are entitled for special compensatory costs of Rs.20,000/-. There is complicated question of law and facts involved in the matter and the same cannot be adjudicated in summary proceedings, therefore this Commission has got no jurisdiction to entertain, try and decide the present complaint. The complainant has got no cause of action to file the present complaint against the answering OP. There has been no default or undue delay on the part of the answering OPs in processing the claim of the complainant and even otherwise, the claim has been repudiated as per the policy terms and conditions. The fact of the matter is that the complainant held a policy having validity from 17.12.2016 to 16.12.2017. The complainant after a delay of about 34 days raised a claim for medical reimbursement and filed application for condonation of delay and consideration of the claim as raised by her and the OP No.1 in good faith condoned the delay and the complainant was asked to provide the details of the claim. The complainant vide letter dated 12.11.2017 requested for deduction of medicine charges Rs.3500/- from the amount claimed by her. On perusal and scrutiny of the claim it was observed that the complainant was admitted in Dr. B. P. Singh Centre for Laser Cosmetic Surgery with complaint of injury upper lip and nose due to accident. The complainant underwent suturing of upper lip. Patient/complainant allegedly stayed for 24 hours in Hospital for the procedure which is day care. Hence 24 hours of hospitalization is not justified and thus the case was repudiated under the clause 3.23 of the policy terms and conditions. The claim was duly repudiated as per law and the intimation thereof was duly given to the complainant. Thus, the present complaint is not maintainable and deserves to be dismissed. On merits, the factum with regard to taking mediclaim insurance policy by the complainant is admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder not filed by the complainant.
4. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA & Ex.CB alongwith some documents Ex.C-1 to Ex.C-9 and closed the evidence.
5. In order to rebut the evidence of the complainant, the counsel for the OPs tendered into evidence affidavit Ex.OA alongwith documents Ex.O-1 to Ex.O-6 and closed the evidence.
6. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by the counsel for the OP No.1 very minutely.
7. The complainant has taken the mediclaim insurance policy from the OP No.1 which was valid upto 16.12.2017. She and her husband have got themselves insured for mediclaim insurance policy since 2013 without any gap and strings by the OP No.1. It has been alleged that the renewal premium inclusive of all taxes of Rs.15,613/- was paid to the OP No.1. The policy schedule has been proved as Ex.C-5 to Ex.C-9 showing the same to be valid from 20.12.2013 to 16.12.2018 without any break. The complainant has alleged that she sustained accidental injuries on upper lips and nose (afresh) lacerated cut wound (on upper lip and deep cut wound on nose, bleeding freshly. She was taken to Dr. Tarun Aggarwal, for emergency treatment and she was referred for surgery. She was taken to Dr. B. P. Singh for Laser Cosmetic Surgery and she was admitted on 16.05.2017 and was discharged on 17.05.2017 with advice to remain on rest. She spent Rs.36,000/- on her treatment and clinical and laboratory test expenses. The claim was filed for reimbursement of the above said amount, but her claim was repudiated as per Ex.C-1. Perusal of Ex.C-1 shows that the OPs have repudiated the claim of the complainant on the ground that the patient stays for 24 hours in hospital for the procedure, which is day care. Her hospitalization is not justified, therefore the case is repudiated under Clause 3.23. Perusal of Ex.O-6 shows that there is no such clause 3.23 as alleged by the OPs. Ex.O-1 and Ex.C-1 are the repudiation letters, which read as under:-
“We are in receipt of the claim form and associated documents of Mrs. Amita Joshi. On scrutiny of the same, we observed that he/she was admitted in Dr. B. P. Singh Hospital. Patient 56 yr female was admitted in hospital with c/o injury upper lip and nose due to accident. Patient underwent suturing of upper lip. Patient stays for 24 hours in hospital for the procedure which is day care. Hence 24 hours of hospitalization is not justified and thus case is repudiated under the clause 3.23.
In this regard, we wish to inform you that the claim is not payable as per-
1. Definitions 3.23 IN-Patient: means an insured Person who is admitted to Hospital and stays for at least 24 hours for the sole purpose of receiving the treatment for suffered ailment/illness/disease/injury/accident during the currency of the Policy.”
The day care treatment as per clause 3.8 of Ex.O-6 means, refers to medical treatment, and/or surgical procedure which is:
i. undertaken under General or Local Anaesthesia in a hospital/day care centre in less than 24 hours because of technological advancement, and
ii. which would have otherwise required a hospitalization of more than 24 hours.
The repudiation has been made on the ground that the admission for 24 hours is not justified as per the injury. There is a certificate of the Dr. B. P. Singh Ex.C-2/O-3, wherein he has certified that the complainant was admitted on 16.05.2017 at 10:30AM with alleged to have sustained accidental injuries on upper lips and nose. She was operated under Anaesthesia on the same day. Cut upper lip surgery was done in layers. Nose deep cut was also operated and she was advised to remain on rest at the time of discharge on 17.05.2017 at 11:30 AM. The complainant has written letters to the Branch Manager of Insurance Company to get information about her claim vide Ex.O-2 and Ex.O-4. The complainant has also proved on record the receipt showing that she had paid Rs.36,000/- on account of her surgery on 16.05.2017.
8. The contention of the OP is that the certificate of the doctor clearly shows the 24 hours of hospitalization is not justified, but this contention is not tenable. From the certificate of the doctor Ex.O-3/C-2, it no where transpires that the 24 hours of hospitalization was not justified nor the doctor has stated anywhere that her stay in the hospital for 24 hours was not required. Surgery was done under the Anesthesia and the doctor is the best judge to see as to when the patient is to be discharged. More so, there is no opinion of any expert doctor to show that 24 hours of hospitalization of the complainant was not justified. It has further been alleged by the OPs that the procedure/treatment usually done in outpatient department are not payable under the policy, even if converted as stay in the hospital for more than 24 hours, but the OP has failed to prove that the stay in the hospital for more than 24 hours has been converted by the complainant willingly. The exclusion clause as alleged by the OPs i.e. 3.23 is no where shown in the policy terms and conditions Ex.O-6. There is no definition of In-Patient in Ex.O-6 in clause-3 on the basis of which the claim has been repudiated. The OPs have not sought any opinion of the expert doctor to the effect that the Anesthesia given to the complainant was local Anesthesia and there was no such follow up and line of treatment requiring any further hospitalization as alleged.
9. The contention of the OPs that the plea of the complainant regarding the non-supply of policy or the policy conditions or the complainant not being aware of the policy exclusion and condition, is not tenable as the OPs themselves are not aware as to under which clause, the claim has been repudiated. The terms and conditions filed on the record as Ex.O-6 are different terms and conditions. The OPs have not led any evidence to show that the actual terms and conditions including the exclusion clause 3.23 were ever supplied to the complainant as Ex.O-6 nowhere is consisting of clause 3.23. Thus, there is a deficiency in service and unfair trade practice on the part of the OPs and accordingly, the complainant is entitled for the relief as claimed.
10. In the light of above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to pay an amount of Rs.36,000/- with interest @ 9% per annum from the date of lodgment mediclaim till realization. Further, the OPs are directed to pay Rs.10,000/- as compensation for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr.Harveen Bhardwaj
05.07.2022 Member Member President
