| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PATIALA. Complaint No. CC/15/182 of 28.8.2015 Decided on: 17.3.2016 Ashok Bansal son of Sh. Roshan Lal Bansal, resident of Thatherian St8reet, Nabha, District Patiala. …………...Complainant Versus - The Oriental Insurance Co.Ltd., Regd.& Head Office, A-25/27, Asaf Ali Road, New Delhi-110002, through its M.D.Branch Manager.
- The Oriental Insurance Co.Ltd., Sai Market, Patiala.
- The Oriental Insurance Co,.having its Branch office at Patiala Gate, Nabha, through its Branch Manager.
…………….Ops Complaint under Section 12 of the Consumer Protection Act. QUORUM Sh. A.P.S.Rajput, President Smt.Neelam Gupta, Member Smt.Sonia Bansal,Member Present: For the complainant: Sh.K.K.Batta, Advocate For Ops No.1&3: Sh.B.L.Bhardwaj,Advocate ORDER A.P.S.Rajput, PRESIDENT - Complainant Ashok Bansal s/o Sh.Roshan Lal Bansal, R/o Thatherian Street, Nabha, District Patiala has filed this complaint against the opposite parties (hereinafter referred to as to the Ops) under Sections 11 to 14 of the Consumer Protection Act,1986(for short the Act). The brief facts of the complaint are as under:
- It is the case of the complainant that he is the holder of policy bearing No.233500/48/2015/1533 got issued from the Ops for the period from 13.10.2014 to 12.10.2015 having already paid the premium of the policy.
- It is averred by the complainant that he underwent Vitred Retinal surgery of his both eyes got done from Dr.Rajiv Mirchia, M.S.OPH. Laser Eye Clinic, SCO 833-34,Sector 22-A, Chandigarh and remained admitted in the said hospital. After the surgery, the complainant submitted medical bills amounting to Rs.62,603/- for reimbursement with Op no.3 but no amount was paid. The complainant visited the office of Op no.3 and requested for the payment of the bills. He also sent e mails on 28.4.2015 and 3.6.2015 regarding the status of the claim No.11117798 to the head office but nothing has been done in this regard. On 22.7.2015, the complainant got served a regd. legal notice to Op no.2 and on 24.7.2015 , he got served the legal notice through ordinary post to Op no.1 but no reply was received by the complainant. Thus there is deficiency in service and unfair trade practice on the part of the Ops. Hence this complaint with a prayer for a direction to the Ops to make the payment of Rs.62,303/- spent by the complainant on his treatment and also to pay a sum of Rs.1,00,000/- as compensation on account of mental agony and physical harassment.
- The cognizance of the complaint was taken against Ops no.1&3 only who appeared and filed the written version. It is submitted that as per terms and conditions of the Insurance policy, expenses incurred for hospitalization/surgical treatment at any nursing home/hospital in India are admissible only as an inpatient and no medical expenses are to be paid for the medical treatment availed as an outdoor patient. It is admitted that PNB-Oriental Royal Mediclaim Policy Schedule vide policy No.233500/48/2015/1533 for the period from 13.10.2014 to 12.10.2015 was issued by the Ops alongwith the terms and conditions of the policy. It is also admitted that the complainant submitted the medical bills for an amount of Rs.62,203/ incurred on OPD treatment/tests/consultation. It is submitted that as per clause 2.3 PNB Oriental Royal Mediclaim Policy covers only “Hospitalization period: Expenses on hospitalization are admissible only if hospitalization is for a minimum period of 24(twenty four) hours” and thus the expenses incurred by the complainant on his treatment are not payable under the policy in question and the claim of the complainant was rightly repudiated vide letter dated 21.7.2015 having after scrutinized the claim documents and having observed that the claim is not maintainable in view of the following:
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- It is also submitted that the complainant was also advised that if he is not satisfied with the denial of the claim he can write for his grievance before the Grievance Cell in their Regional Office or Head office for redressal. After denouncing the all other averments made in the complaint, it is prayed to dismiss the complaint.
- In support of the compliant, the learned counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith the documents Exs.C1 to C21 and closed the evidence.
- On the other hand, the ld. counsel for the Ops tendered in evidence Ex.OPA, the sworn affidavit of Sh.A.S.Dhingra,Sr.Divisional Manager of the Op alongwith the documents Exs.OP1 to OP5 and close the evidence of the Ops.
- The parties failed to file the written arguments. We have heard the learned counsel for the parties and gone through the evidence on record.
- The ld. counsel for the complainant has submitted that the main controversy involved in the present complaint is that despite having a valid medical policy the claim of the complainant was repudiated by the OPs by giving a frivolous reason. The ld. counsel also stated that the OPs have admitted in their reply with regard to the treatment taken by the complainant and have not disputed the evidence placed on record. The ld. counsel pleaded that when it has been established from the documents tendered in evidence from Ex-C1 to Ex-C21 that the complainant was admitted in the Hospital for treatment and after hospitalization, he was discharged then the OPs were bound to reimburse the claim of the complainant. The ld. counsel argued that the complainant is entitled to a sum of Rs.62,603/- on account of medical reimbursement. The ld. counsel further argued that it is evident from the act and conduct of the OPs that they have committed deficiency of service by repudiating the claim of the complainant and he deserves to be compensated for the same.
- On the other hand, the ld. counsel for the OPs has stated that the OPs have not committed deficiency of services by repudiating the claim of the complainant. He submitted that rather the claim had been repudiated keeping in view the terms and conditions of the policy and the same are binding on both the parties. The ld. counsel further submitted that it is evident from the discharge summary i.e. Ex-OP2/10 and Ex-OP2/12 that the complainant was not hospitalized for a minimum period of 24 hours. The ld. counsel pleaded that the complainant was admitted as a case of Diabetic CME both eyes and Injection Accentrix was given. He also pleaded that the treatment for the same is generally given on OPD and no hospitalization is required for the same. The ld. counsel argued that the claim of the complainant was repudiated as per Clause 2.3 of the terms and conditions i.e Ex-OP4/3 and the treatment undergone by the complainant is excluded as per the Clarification on Medical issues i.e. Ex-OP5/4.
- After hearing the Ld. Counsel for the parties and going through the pleadings and evidence produced by them as well as oral submissions, we find force in the submissions made by the ld. counsel for the OPs. It is evident from the discharge summary i.e. Ex.OP2/10 and Ex.OP2/12 that the complainant was not hospitalized for a minimum period of 24 hours. In order to get his claim reimbursed the complainant was required to be hospitalized for a minimum period of 24 hours as per the Clause 2.3 of the terms and condition i.e. Ex-OP4/2:“2.3 HOSPITALISATION PERIOD: Expenses on hospitalization are admissible only if hospitalization is for a minimum period of 24 (twenty four) hours”. The claim of the treatment of the complainant was excluded as per the Clarification on Medical issues i.e Ex-OP5/4: “Clarification on Medical Issues:-The medical issues taken-up in the workshop are clarified as under-
1. Clarification in respect of b Inj. Lucentisb b The Inection is administered in cases of Age-related macular degeneration b ARMDb. It is clarified that the expenses on injections Lucentis/Avastin/Macugen will continue to be disallowed in cases of ARMD, as the procedure involved is within OPD protocol only”. - Accordingly in view of our aforementioned discussion, we are of the opinion that the OPs have not committed any deficiency of service. The claim had been rightly repudiated keeping in view the Clause 2.3 of the terms and conditions and the exclusion clause. We do not find any merits in the submissions of the ld. counsel for the complainant. Hence present complaint is hereby dismissed being denuded of any merits. Parties to bear their own costs.
- The arguments on the complaint were heard on 3.3.2016 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.
Pronounced Dated:17.3 .2016 Sonia Bansal Neelam Gupta A.P.S.Rajput Member Member President | |
