Haryana

Yamunanagar

CC/58/2013

Luxmi devi Goenka W/o Jayanti Parkash Goenka - Complainant(s)

Versus

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

R.K.Sharma

10 Aug 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

                                                               Complaint No. 58 of 2013.

                                                               Date of institution: 22.01.2013.

                                                               Date of decision: 10.08.2017.

 

Smt. Luxmi Devi Goenka wife of Sh. Jayanti Parkash Goenka, R/o H. No., 777, Old Hamida, Tehsil Jagadhri, Distt. Yamunanagar.                                                                                                        

                                                                                                        …Complainant.

                                        Versus

1. The Oriental Insurance Co. Ltd. Oriental House, Asaf Ali Road, New Delhi through its Managing Director/ Chairman.
2. The Oriental Insurance Co. Ltd., 2^nd Floor, Jeevan Jyoti Building, Jagadhri Road, Ambala Cantt. through its Regional Manager.
3. The Oriental Insurance Co. Ltd. Opposite Madhu Cinema, Jagadhri road, Yamunanagar through its Divisional Manager.  

      

       …. Respondents.

                  

BEFORE     SH. DHARAMPAL, PRESIDENT

                    SH. S.C.SHARMA, MEMBER.

                    SMT. VEENA RANI SHEOKAND, MEMBER.          

 

Present:        Sh. Raj Kumar Sharma, Advocate, counsel for complainant.   

                    Sh. Parmod Gupta, Advocate, counsel for OPs. 

 

ORDER      (DHARAMPAL PRESIDENT)

 

1.                Complainant Luxmi Devi has filed this complaint under section 12 of the Consumer Protection Act 1986 as amended up to date. 

2.                Brief facts of the complaint, as alleged by the complainant, are that the complainant’s husband had taken a joint medical claim policy from the OP No. 3 in the names of the complainant and his own name vide policy No. 261700/48/2010/2698 dated 04-12-2009 (Cover Note date) and this policy is continuing since 20-11-1996 in respect of which due payments of the premium have been made. It has submitted that the complainant along with her husband met with an accident on 11-01-2010 due to which the complainant got an injury in the right knee joint. The complainant got treatment from Shalby Hospitals At Ahmedbad and the complainant remained admitted there from 11-01-2010 to 16-01-2010. During the treatment, the complainant was operated for right total knee joint replacement surgery and the complainant’s husband also had to undergo treatment due to the injury suffered by him at the time of accident. The complainant applied for the medical claim from the OP No. 3 and claimed Rs. 1,68,083.45/- as total expenditure made on the treatment of the complainant at Shalby Hospitals. The complainant’s husband had also applied for a medical claim for his own treatment due to the joint accident under the same policy which was passed by the OPs and due payment of Rs. 1,54,291.00 /- was made to the complainant’s husband against his own claim on 02-08-2010. But to the utter surprise of the complainant, the respondent NO. 3 did not pass the claim of the complainant and finally intimated it to be rejected on 27-01-2011. As such, the complainant prayed that his complaint may kindly be accepted and OPs be directed to pay Rs. 1,68,083.45/- i.e. total expenditure made on the treatment of the complainant along with interest, to pay Rs. 90,000/- as compensation on account of deficiency in service on the part of the OPs, mental agony, harassment and Rs. 11,000/- as litigation expenses to the complainant.    

3.                Upon notice, OPs appeared and filed their written statement by taking some preliminary objections such as complaint is not maintainable, complainant has no locus-standi, no cause of action and there is concealment of the facts. It is submitted that Mr. Jaiyanti Parkash Goenka R/o H. No. 777, Old Hamida, Yamuna Nagar has taken a Medi-claim Policy No. 261700/48/2010/2698 w.e.f. 05-12-2009 to 04-12-2010 for medical coverage of himself i.e. Mr. Jaiyanti Parkash Goenka and the complainant for Rs. 2,00,000/- each from the OP company. It is submitted that the matter was referred to TPA M/s Vipul Medicorp TPA Pvt. Ltd., who has observed that “As per our record patient is covered in first year policy. So osteoarthritis related ailments are not payable upto first four years. Hence, as per clause No. 4.3 the claim is not payable which please note”. It is submitted that though the complainant’s husband had previously taken the policy No. 261700/48/2009/2114 w.e.f 28-11-2008 to 27-11-2009, but neither the complainant nor her husband had taken steps to renew the policy within proper period and there was gap of seven days between the two policies. Therefore, the present coverage under policy no. 261700/48/2010/2698 was treated as first year policy. Lastly, prayed for dismissal of complaint.

4.                To prove his case, counsel for the complainant tendered into evidence complainant’s affidavit as Annexure CW1/A and documents such as photocopy of discharge summary as Annexure C1, photocopy of treatment record as Annexure C-2, photocopy of Policy as Annexure C3, photocopy of claim form as Annexure C-4 and C-5, photocopy of insurance record as Annexure C-6,  photocopy of letter vide which claim has been passed and a cheque amounting to Rs. 1,54,291/- has been sent to Mr. Jayanti Parkash Goenka as Annexure C-7, photocopy of RTI application as Annexure C-8 and C9, photocopy regarding policy as Annexure C-10,  and closed the evidence on behalf of complainant.

                   Lateron, the counsel for the complainant moved an application for producing evidence and counsel for the opposite parties endorsed no objection on the aforesaid application and in the interest of justice, the same was allowed. Accordingly counsel for the complainant has tendered further documents such as photocopy of cover note as Annexure C-11 to C14, photocopy of statement of account as Annexure C-15, photocopies of cover note as Annexure C-16 and C-17, photocopy of mediclaim policy schedule as Annexure C-18, photocopy of account summary as Annexure C-19 and closed additional evidence on behalf of the complainant.  

5.                On the other hand, counsel for the OPs Insurance Company tendered into evidence affidavit of Sh. Abhas, Asstt. Manager, Official Oriental Insurance Co. Yamuna Nagar as Annexure RW/A and documents such as photocopies of insurance policy as Annexure R1 and R2, photocopy of terms and condition as Annexure R-3, photocopy of Physiotherapy advice certificate as Annexure R-4, photocopy of treatment record as Annexure R-5, photocopy of consultation as Annexure R-6, photocopy of query regarding policy number 261700/48/2010/2698 as Annexure R-7 and R-8, photocopy of claim processing sheet as Annexure R-9 and photocopy of letter regarding query vide policy No. 261700/48/2010/2698 as Annexure R-10, photocopy of fitness certificate as Annexure R-11, photocopy of medical certificate as Annexure R-12, photocopy of discharge card as Annexure R-13, photocopy of discharge summary as Annexure R-14 and closed the evidence on behalf of OPs. 

6.                We have heard the learned counsel for both the parties and have gone through the pleadings as well as written arguments on behalf of the complainant and documents placed on file very minutely & carefully.

7.                 Counsel for the complainant has argued that the complainant’s husband had taken a joint medical claim policy from the OP No. 3 vide policy No. 261700/48/2010/2698 dated 04-12-2009 and this policy is continuing since 20-11-1996. It is further argued that the complainant along with her husband met with an accident on 11-01-2010 due to which the complainant got an injury in the right knee joint and operated for right total knee joint replacement surgery from Shalby Hospitals at Ahmedbad. The complainant’s husband also had to undergo treatment due to the injury suffered by him at the time of accident. It is further argued that the complainant applied for the medical claim from the OP No. 3 to the tune of Rs. 1,68,083.45/- as total expenditure made on her own treatment at Shalby Hospital. The complainant’s husband had also applied for a medical claim for his own treatment, which was passed by the OPs and payment of Rs. 1,54,291.00 /- was made to the complainant’s husband. But the OP No. 3 did not pass the claim of the complainant and finally intimated it to be rejected on 27-01-2011.

8.                 Counsel for the OPs has argued that Mr. Jaiyanti Parkash Goenka had taken a Medi-claim Policy No. 261700/48/2010/2698 w.e.f. 05-12-2009 to 04-12-2010 for medical coverage of himself and the complainant for Rs. 2,00,000/- each. It is further argued that the matter regarding above said claim was referred to TPA M/s Vipul Medicorp TPA Pvt. Ltd., who has observed that “As per our record patient is covered in first year policy. So osteoarthritis related ailments are not payable upto first four years. Hence, as per clause No. 4.3 the claim is not payable which please note”. It is further argued that through the complainant’s husband had previously taken the policy No. 261700/48/2009/2114 w.e.f 28-11-2008 to 27-11-2009, but neither the complainant nor her husband had taken steps to renew the policy within proper period and there was gap of seven days between the two policies as per Annexure R-1 and R-2. Therefore, the present coverage under policy no. 261700/48/2010/2698 was treated as first year policy.

9.                We have gone through the clause 4.3 of the policy in question, which is reproduced is as under:-

                   “During the period of insurance cover, the expenses on treatment of following ailment/disease/surgeries for specified periods are not payable if contracted and/ or manifested during the currency of the policy”.            

xxiii	Joint replacement due to degenerative condition	4 years
Xxiv	Age related osteoarthritis and osteoporosis	4 years

         

10.              In view of the above said discussion, we are of the considered view that, the complainant has failed to renew the policy in question, in time. So in view of the above said facts as well as clause 4.3 of the policy, the complainant is not entitled for the claim as prayed for. Accordingly, the complaint is, hereby, dismissed with no order as to costs. Copies of this order be sent to the parties concerned as per rules. File be consigned to the record room after due compliance.

Announced in open court. 10.08.2017

 

 

                                                     ( DHARAMPAL)

                                                     PRESIDENT

                                                     D.C.D.R.F.YAMUNA NAGAR

                                                     AT JAGADHRI

 

 

(VEENA RANI SHEOKAND)      (S.C.SHARMA)

 MEMBER                                       MEMBER

 

Note: Each and every page of this order has been duly signed by me.

 

( DHARAMPAL)

                                                             PRESIDENT

                                                             D.C.D.R.F.YAMUNA NAGAR

                                                             AT JAGADHRI