Punjab

Faridkot

CC/16/204

Pardeep Bansal - Complainant(s)

Versus

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

Jatinder Bansal

06 Feb 2017

ORDER

      DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

Complaint No. :      204

Date of Institution:  25.07.2016

Date of Decision :   6.02.2017

 

1. Pardeep Bansal s/o Sh Mahesh Chander Bansal,
2. Geetika alias Sarika w/o Pardeep Bansal s/o Sh Mahesh Chander Bansal.

Both residents of Kotkapura, Tehsil Kotkapura, District Faridkot.

...Complainants

Versus

1. The Oriental Insurance Company Ltd, Regd & Head Office at A-25/27, Asaf Ali road, New Delhi-110 002 through its authorized signatory/ Managing Director.
2. The Oriental Insurance Company Ltd, Branch Office, Near Old Grain Market, Kotkapura, Tehsil Kotkapura, District Faridkot through its Branch Manager.
3. M/s Park Mediclaim TPA Pvt Ltd, B-15/179/1 Sona Complex Room No. 11, 2^nd Floor, GT Road Miller Ganj, Ludhiana, District Ludhiana through its Managing Director/authorized representative.                                         

 .....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Sh P Singla, Member.

 

Present: Sh  Jatinder Bansal, Ld Counsel for complainant,

              Sh Vinod Monga, Ld Counsel for OPs.

 

(Ajit Aggarwal, President)

                                      Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment on account of Mediclaim of complainants and for further directing OPs to pay Rs. 01 lac as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.25,000/-.

2                               Briefly stated, the case of the complainant is that complainants purchased a Mediclaim insurance policy bearing no.233702/48/2015/1010 valid for period from 15.06.2014 to 14.06.2015 and paid a sum of Rs.6,189/-as premium to OPs and complainants and their children were also covered under said Mediclaim insurance policy to the tune of Rs. 3 lacs. It is submitted that on 31.01.2015, complainant no. 2 suffered from fever and due to vomiting and severe pain in her abdomen, she was got admitted in Dr Pirthi Pal Memorial Hospital, Satta Bazar, Kotkapura, where she was diagnosed as Calculus Cholecystitis, she remained admitted there from 4.02.2015 to 5.02.2015 and after conducting medical test and MRI Test upon her , she was advised by Dr Manvir Gupta for urgent ERCP i.e Endoscopic Sphincterotomy from Dayanand Medical College & Hospital Ludhiana and after discharge from Pirthi Pal Hospital, she was got admitted in DMC, Ludhiana. It is further submitted that complainant paid Rs.31,676/- to hospital authorities after getting discharged from Pirthi Pal Hospital, Kotkapura. In DMC, Ludhiana, she was medically examined and surgical treatment of Endoscopic Sphincterotomy (ERCP) was done upon her by Dr. Ajit Sood, DM, Head of Gastroenterology, DMC, Ludhiana and husband of complainant paid Rs.16,155.95 to hospital authorities for treatment of his wife/complainant no. 2, but complainant no. 2 still suffered from severe abdomen pain and was immediately got admitted in Satguru Partap Apollo Hospital, Ludhiana on 12.02.2015, where after  examination, doctor concerned removed her gall bladder and conducted surgical operation of Lap Cholecystectomy upon her on 13.02.2015 and then, she was discharged from said hospital on 14.02.2015 and complainant no. 1 paid Rs.54,413/-to hospital authorities for surgical operation and treatment of his wife. It is further submitted that complainant spent total amount of Rs.1,02,244/-as hospital charges on treatment of complainant no. 2, who was also covered under the policy in question. Thereafter, complainant no.1 submitted all the relevant documents alongwith bills to OPs for obtaining Mediclaim on account of treatment of complainant no. 2., but instead of making payment of Mediclaim, OP-3 issued letter dt 16.06.2015 to complainant requiring him to submit the inpatient record of hospital relating to complainant no. 2 for the period from 31.01.2015 to 5.02.2015 and in compliance of letter of OPs, complainant submitted indoor patient sheets, drug sheets, discharge summary, medicine prescription, receipt of bill payment receipts etc for desired period to OPs, but OPs again issued letter dt 17.08.2015 vide which they withheld the claim of complainant on the ground that  indoor case paper and drug sheet  are in single hand writing during 5 days of hospitalization and asked him to give reason for the same. Thereafter, complainant sent certificate dt 29.08.2015 duly issued by Dr Manvir Gupta stating that all the said noting and papers are written by him, but despite this, OPs did not make payment of genuine claim of complainant. It is further submitted that complainant completed all the formalities to obtain insurance claim and paid several visits to the office of Ops, but all in vain. Due to non payment of insurance claim by OPs, complainant has been suffering great economic loss and hardships. Complainant made many requests to Ops to settle his claim, but all in vain. This act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. Hence, the present complaint.

3                                       The counsel for complainant was heard with regard to admission of the complaint and vide order dated 29.07.2016, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                On receipt of the notice, OPs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        filed written statement taking preliminary objections that complainants have no cause of action to file the present complaint as they themselves did not supply the requisite information and therefore, Ops were compelled to close the claim of complainant as no claim vide letter dt 18.03.2016 and asserted that there is no deficiency in service on the part of OPs as they have duly processed the claim of complainants, but they did not give required information despite issuance of letter dt 11.03.2015, 24.03.20145, 11.04.2015, 16.06.2015, 17.08.2015, 16.09.2015 and 5.12.2015 and therefore, complaint in hand is not maintainable. However, on merits, they have denied all the allegations levelled by complainant being wrong and incorrect and asserted that vide letter dt 16.06.2015, complainant was asked to produce inpatient record, which was reported to be misplaced by Hospital Authority and complainant furnished the same. It is further averred that after careful Scruitinization of inpatient record, it was revealed that it was in single handwriting during the entire course of hospitalization and appeared to have been prepared in one go and therefore, Ops asked complainants to send clarification for all record in same handwriting, but despite repeated letters, complainant did not furnish any clarification and therefore, claim of complainants was declared as No Claim by OP-3 vide letter dt 16.01.2016 and same was conveyed to complainants vide letter dt 18.03.2016. It is further averred that as the complainants did not furnish the required explanation and did not clarified the query of OPs, therefore, claim of complainant was closed as No Claim and there is no deficiency in service on the part of answering OPs. All the other allegations and allegations with regard to relief sought too were refuted with prayer to dismiss the complaint with costs.

5                         Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to 34 and then, closed his evidence.

6                               In order to rebut the evidence given by complainant, the ld Counsel for OPs tendered in evidence, affidavit of Vikas Kataria as Ex OP-1 and documents Ex OP-2 to 9 and then, closed the same on behalf of OPs.

7                                We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

8                         Ld Counsel for complainant has vehementally argued that complainants purchased a Mediclaim insurance policy valid from 15.06.2014 to 14.06.2015 and paid a sum of Rs.6,189/-as premium to OPs and complainants and their children were also covered under said Mediclaim insurance policy for sum of Rs. 3 lacs. It is submitted that on 31.01.2015, complainant no. 2 suffered from fever and due to vomiting and severe pain in her abdomen, she was got admitted in Dr Pirthi Pal Memorial Hospital, Kotkapura, where she was diagnosed as Calculus Cholecystitis and she remained admitted there from 4.02.2015 to 5.02.2015 and after conducting medical test and MRI Test upon her, she was advised by Dr Manvir Gupta for urgent ERCP i.e Endoscopic Sphincterotomy from Dayanand Medical College & Hospital Ludhiana and after discharge from Pirthi Pal Hospital, she was got admitted in DMC, Ludhiana. It is further submitted that complainant paid Rs.31,676/- to hospital authorities of Pirthi Pal Hospital, Kotkapura as treatment charges. In DMC, Ludhiana, she was medically examined and surgical treatment of Endoscopic Sphincterotomy (ERCP) was done upon her by Dr. Ajit Sood, DM, Head of Gastroenterology, DMC, Ludhiana and husband of complainant paid Rs.16,155.95 to hospital authorities for treatment of his wife/complainant no. 2, but complainant no. 2 still suffered from severe abdomen pain and then, she was immediately got admitted in Satguru Partap Apollo Hospital, Ludhiana on 12.02.2015, where after  examination, doctor concerned removed her gall bladder and conducted surgical operation of Lap Cholecystectomy upon her on 13.02.2015 and thereafter, she was discharged from said hospital on 14.02.2015 and complainant no. 1 paid Rs.54,413/-to hospital for surgical operation and treatment of his wife. It is further submitted that complainant spent total amount of Rs.1,02,244/-as hospital charges on treatment of complainant no. 2, who was also insured and covered under the policy in question. Complainant no.1 submitted all the relevant documents alongwith bills to OPs for obtaining Mediclaim on account of treatment of complainant no. 2., but instead of making payment of Mediclaim, OP-3 issued letter dt 16.06.2015 to complainant requiring him to submit the inpatient record of hospital relating to complainant no. 2 for the period from 31.01.2015 to 5.02.2015 and in compliance thereof, complainant submitted indoor patient sheets, drug sheets, discharge summary, medicine prescription, receipt of bill payment receipts etc for desired period to OPs, but OPs again issued letter dt 17.08.2015 vide which they withheld the claim of complainant on the ground that  indoor case paper and drug sheet are in single hand writing during 5 days of hospitalization and asked him to give reason for the same. Thereafter, complainant sent certificate dt 29.08.2015 duly issued by Dr Manvir Gupta stating that all the said noting and papers are written by him, but despite this, OPs did not make payment of genuine claim of complainant. Though complainant completed all the formalities and paid several visits to the office of Ops, but all in vain. Due to non payment of insurance claim by OPs, complainant has been suffering great economic loss and hardships. Complainant made many requests to Ops to settle his claim, but all in vain. All this act of OPs amounts to deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. He has stressed on documents Ex C-1 to 34.

9                              To controvert the allegations of complainant, ld counsel for Ops argued that complainants have no cause of action to file the present complaint as they themselves did not supply the requisite information and therefore, Ops were compelled to close the claim of complainant as no claim vide letter dt 18.03.2016 and there is no deficiency in service on their part as they have duly processed the claim of complainants, but complainants did not give required information despite issuance of letter dt 11.03.2015, 24.03.20145, 11.04.2015, 16.06.2015, 17.08.2015, 16.09.2015 and 5.12.2015 and therefore, complaint in hand is not maintainable. OPs have denied all the allegations levelled by complainant being wrong and incorrect and asserted that vide letter dt 16.06.2015, complainant was asked to produce inpatient record, which was reported to be misplaced by Hospital Authority and complainant furnished the same, but from careful scruitinization of said inpatient record, it was revealed that it was in single handwriting during the entire course of hospitalization and appeared to have been prepared in one go and therefore, Ops asked complainants to send clarification and give reason for all record in same handwriting, but despite repeated letters, complainants did not furnish any clarification and therefore, claim of complainants was declared as No Claim byOP-3 vide letter dt 16.01.2016 and same was duly conveyed to complainants vide letter dt 18.03.2016. It is further averred that as the complainants did not furnish the required explanation and did not clarified the query of OPs, therefore, claim of complainant was closed as No Claim and there is no deficiency in service on the part of answering OPs. Ops have prayed for dismissal of complaint and stressed on documents Ex OP-1 to 9.

10                      The case of complainant is that they were insured with OPs for Rs. 3 lacs vide policy issued by OP-1 and 2 and during the period of insurance, wife of complainant no. 1 i.e complainant no. 2 suffered from some problem and she was hospitalized in various hospitals at Kotkapura and Ludhiana for her treatment, where after medical examination and surgical operation was conducted upon her and her gall bladder was removed. Complainant no. 1 spent total hospitalization charges of Rs1,02,244/-for treatment of his wife and after getting discharged from hospital, he submitted all requisite documents alongwith relevant bills, drug sheets, indoor patient sheets etc as required by OPs to them for obtaining the insurance claim. But  OPs repudiated the claim of complainants on false ground that all indoor patient sheets and drug sheets are in same handwriting and thereupon, complainant also furnished certificate issued by concerned doctor that it was written by him, but OPs did not pass the claim of complainant and withheld the payment of insurance claim. All this  amounts to deficiency in service. In reply, OPs asserted that careful scruitinization of said inpatient record furnished by complainants revealed that it was in single handwriting during the entire course of hospitalization and appeared to have been prepared in one go and therefore, Ops asked complainants to send clarification and give reason for all record in same handwriting, but despite repeated letters, complainants did not furnish any clarification and therefore, claim of complainants was declared as No Claim vide letter dt 16.01.2016 and same was duly conveyed to complainants vide letter dt 18.03.2016 and there is no deficiency in service on their part.

11                     To prove his case complainant has relied upon documents Ex C-1 to 34 and from document Ex C-2/ copy of insurance policy, it is clear that both the complainants were insured with OPs and covered for treatment upto Rs.3 lacs during the validity of insurance period. Documents Ex C-9 to C-32, which are copies of bills and reports of ultrasound or other medical tests conducted upon complainant no. 2 clearly prove that complainant no. 2 suffered from Calculus Cholecystitis and she was advised by Dr Manvir Gupta for urgent ERCP i.e Endoscopic Sphincterotomy from Dayanand Medical College & Hospital Ludhiana and surgical treatment of Endoscopic Sphincterotomy (ERCP) was done upon her in DMC Ludhiana by Dr Sood, but when even after said operation, she did not get relief from severe abdomen pain, surgical operation of Lap Cholecystectomy was also conducted upon her on 13.02.2015 and her gall bladder was removed. Ex C-33 is the certificate issued by Dr Manvir Gupta stating that all indoor notes including TRP notes etc are done by doctor only in their hospital and Ex C-34 is the affidavit given by Dr Manvir Gupta, which clears the point that all the indoor patient record is written by him. 

12                            After careful perusal of the record available on file and going through the evidence led by parties, it is observed that in the light of certificate Ex C-33 and Ex C-34 i.e affidavit given by Dr Manvir Gupta, there remains no iota of doubt that all reports and indoor patient sheets are written by him and therein concerned doctor has given sufficient reason and explanation to the queries of OPs. Complainants have produced sufficient evidence to prove their pleadings and these documents can not be doubted. Documents Ex C-9 to 32, are copies of bills and reports the authenticity of which can not be ignored. Plea taken by Ops that all indoor patient sheets are in single hand has no legs to stand upon as affidavit given by concerned doctor is enough to contradict the same.

13                                    From the above discussion and evidence produced by the complainant, we are of considered opinion that OPs have not made payment on account of Mediclaim of insured complainant no. 2 on false grounds and it amounts to deficiency in service on the part of OPs. Complainants have succeeded in proving their case and hence, complaint case in hand is hereby allowed. OPs are directed to make payment of genuine insurance claim of complainants to the tune of Rs.1,02,244/- i.e amount spent by complainants on treatment of complainant no. 2 at various hospitals and Ops are further directed to pay Rs. 8000/- to complainants as compensation for harassment and mental agony suffered by them besides Rs.3000/-as litigation expenses. Compliance of this order be made within one month of receipt of the copy of the order, failing which, complainants shall be entitled to initiate proceedings under Section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 6.02.2017

                                             Member                          President

               (P Singla)                      (Ajit Aggarwal)