BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

 Complaint No.217 of 2019

      Date of Instt. 28.06.2019

      Date of Decision: 19.05.2023

Sarabjit Singh aged about 57 years S/o Sh. Bhola Singh R/o H. No.66 Narayan Nagar Basti Sheikh Jalandhar.

..........Complainant

Versus

1.       The Oriental Insurance Company Ltd. SCO 50 Puda Complex          Tehsil Road Jalandhar through its Manager.

2.       M/s Raksha Health Insurance TPA Pvt. Ltd. SCO 359-360, First       Floor, Sector 44D, Chandigarh.

3.       Punjab National Bank Guru Nanak Nagar Branch Jalandhar    through its Manager.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Sh. Jaswant Singh Dhillon       (Member)   

Present:       Sh. Gurwinder Arora, Adv. Counsel for the Complainant.

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

                   OP No.2 exparte.

                   Smt. Harleen Kaur, Adv. Counsel for OP No.3.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the OP No.1 approached the complainant and made representation to him to have a medical insurance policy for himself and his family members. The OP No.1 also made representation to complainant that the complainant had to open an account with OP No.3 before issuance of medical insurance policy. The complainant then got open his saving bank account bearing no.1463000103183572 with OP No.3 on 18.5.2016. The complainant thereafter took medical insurance claim policy from OP No.1 on 25.5.2018 which was effective from 26.5.2018 to 25.5.2019. The OP No.1 also made representation to the complainant that OP No.1 has tie-up with OP No.2 and also made representation that all of OPs are jointly and severally liable to pay claim to the complainant in the event of any eventuality. The said policy was for a sum of Rs.3,00,000/-. Unfortunately, the complainant had got a heart problem and was taken to All India Institute of Medical Science Delhi on 13.2.2019 and later on he was remained admitted on 16.2.2019 to 21.2.2019 and he was undergone stunt implantation. The complainant paid a sum of Rs.3,21013/- during his treatment at AIIMS Delhi. After the discharge of complainant, he made several request to opposite parties to reimburse Rs.3 Lacs to complainant. However OPs put off the matter on one pretext or the other and did not pay back the amount to the complainant causing utmost harassment, mental agony, inconvenience and financial loss to the complainant 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 pay Rs.3,00,000/- which is the amount of insurance policy alongwith compensation to the tune of Rs.10,00,000/- with interest @ 12% per annum from the date of filing of the complaint till the realization.

2.                Notice of the complaint was given to the OPs, but notice sent to OP No.2 not received back despite elapsing of more than thirty days and ultimately, OP No.2 was proceeded against exparte, whereas OP No.1 appeared through its counsel and filed written reply and contested the complaint by taking preliminary objections that the above noted complaint is not maintainable under the law against the respondents. It is further averred that the complainant is barred by his own act, conduct, laches and negligence from filing the present complaint and claiming the relief as prayed in the present complaint. It is further averred that the complainant is guilty of concealment of material facts and has not approached the Forum with clean hands and as such is not entitled to any relief from this Commission. It is further averred that the complainant has got no cause of action to file the present complaint against the OPs. There has been no default or undue delay in processing the claim of the complainant and even otherwise, the claim has been dealt promptly and the same has remained unsettled only on account of complainant himself on account of his noncompliance of the requests of the OP to provide document for proper settlement of the matter. The fact of the matter is that the complainant did not disclose any ailment or disease and upon account opening with Punjab National Bank got the PNB Royal Mediclaim Policy subject to terms and conditions thereof from the OPs. The First Insurance Policy bearing Policy No.233108/48/2017/672 was from 26.05.2016 to 25.05.2017 and then policy No.233108/48/2018/739 for the period 26.05.2017 to 25.05.2018. Thereafter, the Insurance Policy no.233108/48/2019/416 was for the period 26.05.2018 to 25.05.2019. Whereas the complainant has concealed the above all facts from the Commission and tried to manipulate and mislead the Commission for getting undue relief from the Commission by representing as if the third policy was only the first one and that the heart problem suddenly happened. In fact during the Policy period 26.05.2018 to 25.05.2019 i.e. third year of the policy for the Insured Sum of Rs.3,00,000/- the complainant raised a claim of Rs.3,21,013/- for reimbursement of Medical Expenses on account of Aortic Stent Graft. The case was sent to the TPA RAKSHA for further processing after the receipt of Claim Form on 01.03.2019 from the complainant. The documents submitted by the complainant were duly considered and found insufficient to settle the claim and thus a query letter was issued to the complainant on 06.03.2019 to provide 1) Treating Doctor's certificate mentioning Complete Medical History, Type - 2 Aortic Disseaction Alongwith All Previous Treatment Record clearly specifying duration. (2) Purchase Invoice and Sticker for Implant used in Surgery. Thereafter another final reminder was issued by the TPA on 05.04.2019 to provide aforesaid requisites but the insured/ complainant failed to comply with the same. Although it is mandatory under the policy terms and conditions for the insured to provide all requisite documents sought by TPA for processing the claim otherwise the claim is liable to be closed/ repudiated. Now, what necessitated the requirement of the medical history and duration etc as demanded at point 1 was that as per the Short Discharge Notes of the Doctor/ Treating Hospital supplied by the complainant Post DTA stent graft (2016) for Type B Aortic Dissection had already been got done by the complainant regarding the heart ailment. The recorded impression - K/C/O Type B Aortic disseaction - post stent graft, Patent Thoracic aortic stent graft. Pseudoaneurysm at the distal landing zone of stent graft as described requires urgent management in the form of repeat endovascular stenting. Thus, it implied that in the year 2016 he was already suffering from Heart Ailment and got stent and further complication thereof the preexisting heart disease/ ailment but had concealed the said fact and took policy from the company. Thus claim would have been non-payable, all the more so, he couldn't get any claim or reimbursement and even otherwise he chose to remain silent regarding the previous stent implantation as during first year and on account of pre-existing disease the claim was not maintainable. Now, on raising the present claim the above point was observed and it is pertinent to note that as per the policy terms and conditions clause 4.1 the claim evidently and conclusively was liable to be rejected and was not maintainable. The complainant had entered the mediclaim policy with preexisting disease meaning thereby that the claim pertaining to the present ailment could only be raised in the 4th continuous period of term of insurance and not third or within three years. It is pertinent to mention here that as per Clause 4.1 of the Policy - 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: Pre-existing health condition or disease or ailment/injuries: Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person up to 3 years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability condition. This exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries. Such complications shall be considered as a part of the pre-existing health condition or disease. Still in order to clarify and to give an opportunity to the complainant to produce the medical history answering respondent vide its office letters dated 26.04.2019 and 10.05.2019 asked for the same. But the complainant/insured failed to comply and rather got issued a misconceived and misdirected notice and then filed the instant complaint by concealment of material facts and purposeful misstatement. In the face of the facts and documents on file the claim is not maintainable and liable to be repudiated.      On merits, the factum with regard to taking medical insurance claim policy by the complainant from the OP is admitted and the facts regarding admission of the complainant from 16.02.2019 to 21.02.2019 is also 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.                OP No.3 filed its separate written reply and contested the complaint by taking preliminary objections that the complaint is not maintainable as the same is knowingly false and purposely vexatious to the knowledge of the complainant. It is further averred that the complainant has not approached this Commission with clean hands and has not revealed the actual facts and suppressed the material facts from this Commission. It is further averred that the complaint has been filed with malafide intention and with some ulterior motive. The complaint is vague and indefinite besides being malicious. It is further averred that the complainant is barred, estopped and precluded from filing the present complaint due to their own acts of admission, commission and omission. It is further averred that the complaint is vague and the complainant has not approached this Forum with clean hand and had suppressed the material facts from the Forum. Even otherwise the complaint is misconceived and is bad in intent content and form. The present complaint is not maintainable in as much as there is no negligence nor any deficiency of service nor any unfair trade practice on part of the OP No.3. The complaint is neither maintainable in law nor on facts and the same is liable to be dismissed on this score alone. The allegations as leveled in the instant complaint are wrong, false and vehemently denied and specifically, save and except which are matter of record and admitted herein. Thus, it is submitted that the proceedings before this Forum are essentially summary in nature and adjudication of issues espoused in the complaint involve disputed factual question which cannot be adjudicated before this Forum as it requires examination and cross-examination in view of the disputed facts. It is pertinent to mention here that the complainant admittedly has been holding a bank account bearing no.1463000103183572 with the answering OP which was opened on 18/05/2016. The said Medical Insurance Claim was taken on 25/05/2018. The said Medical Insurance Policy was from OP No.1 i.e. The Oriental Insurance Co. which has the exclusive right to accept and reject medical insurance claims depending on the circumstances of the case and all the consideration in respect of the said policy goes to OP No.1. On merits, it is admitted that the complainant has been holding a bank account bearing no.1463000103183572 with the answering OP which was opened on 18/05/2016, 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.

4.                Rejoinder not filed by the complainant.

5.                In order to prove their respective versions, both the parties have produced on the file their respective 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 counsel for the OP No.1 very minutely.

7.                It is admitted that the complainant took medical insurance claim from the OP No.1 on 25.05.2018, which was effective from 26.05.2018 to 25.05.2019. The OP has alleged that the complainant had taken the policy from the OP No.1. in the year 2016 and the copy of the same has been proved as Ex.O-1, which was effective from 26.05.2017 to 25.05.2018 and then the same continued for the period from 26.05.2017 to 25.05.2018, which has been proved as Ex.O-2. The OP has also proved on record the policy effective from 26.05.2018 to 25.05.2019 Ex.O-3/C-1. So, this fact is proved that the complainant had purchased the mediclaim policy from the OP No.1.

8.                The complainant has alleged that he got a heart problem and was taken to AIMS, Delhi on 13.02.2019 and he remained admitted from 16.02.2019 to 21.02.2019 and undergone stunt implantation. He paid a sum of Rs.3,21,013/-. The allegations of the complainant is that he had sent all the documents of the treatment, bills to the OPs, but his claim has not been settled by the OP No.1 and the claim has not been given to the complainant for the amount spent by him on his treatment. The OP has relied upon the letters written by the OP to the complainant asking the complainant to send the documents which include the medical history of the complainant and the treatment got by the complainant from the AIMS. These letters have been proved by the OP Ex.OP-5 and Ex.OP-6, whereas the complainant has alleged that he had provided all the documents and treatment record to the OP.

9.                The complainant has not produced on record any letter written to the OP showing that he had given the medical treatment record or the documents to the OP for his claim. Perusal of Ex.OP-5 shows that the letter was written by the OP on 06.03.2019 asking the complainant to provide treating doctor certificate, mentioning history of complete medical history, Type-2 Aortic Disseaction alongwith all previous treatment record clearly specifying duration and provide purchase invoice and sticker for implant used in the surgery. Similarly, the letter was written by the OP Ex.OP-6 to the complainant asking the complainant to provide treating doctor certificate, mentioning history of complete medical history, Type-2 Aortic Disseaction alongwith all previous treatment record clearly specifying duration and provide purchase invoice and sticker for implant used in the surgery. The complainant has relied upon the document Ex.C-2, which is the bill provided by the Accounts Officer of AIMS. Perusal of this document Ex.C-2 shows that this is just a certificate showing that this much amount i.e. Rs.3,21,013/- was received by the AIMS from the complainant as package charges for PTA + Used Items excluding the hospital charges. This document nowhere shows the certificate of any treating doctor nor the medical history of the complainant nor the detail of the diagnoses or discharge summary. The documents sought for by the OP vide Ex.OP-5 and Ex.OP-6 have not been produced by the complainant. The document sought for in the column no.1 i.e. treating doctor certificate, mentioning history of complete medical history, Type-2 Aortic Disseaction alongwith all previous treatment record clearly specifying duration, is necessary for the settlement of the claim. However, the purchase invoice and sticker for implant used in the surgery is not required for the settlement of the claim. In such circumstances, the complainant is directed to supply the necessary required information/documents, to the OPs, within 15 days from the date of receipt of the copy of the order and then the OPs will settle the claim of the complainant within 15 days from the date of receipt of the necessary documents/information, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then he is at liberty to file a fresh complaint. Original documents submitted alongwith the complaint be returned to the complainant for onward submission of the same to OPs for the settlement of the claim. Thus, this complaint is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.

10.              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                    Dr. Harveen Bhardwaj     

19.05.2023                              Member                                President