BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 345 of 2015

Date of Institution: 27.05.2015

Date of Decision: 20.01.2016.  

Jaswant Kaur (aged 64 years) D/O Piara Singh and wife of Mohinder Singh resident of H.No.231-B/13, Gali No.1, Tehsilpura, Amritsar.

Complainant

Versus

1. TPA-Medi Assist India TPA Private Limited, B-20, Sector-2, Noida Utter Pardesh-201301, Near Sector  15, Metro Station Opposite HCL Comnet.
2. The Oriental Insurance Company Limited, Regd.Office: Oriental House PB No.7037 A 25/27, Asaf Ali Road, New Delhi-110002.
3. The Oriental Insurance Company Limited, Dwarka Deesh Complex, Queens Road, Amritsar, Punjab-143001.  

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act, 1986 as amended upto date.

Present: For Complainant: Sh.Mohinder Singh husband of complainant.

              For the Opposite Parties: Sh. Subodh Salwan, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Smt.Jaswant Kaur under the provisions of the Consumer Protection Act alleging therein that she purchased medi claim policy bearing No. 233300/48/2014/849 dated 20.5.2013 valid upto 19.5.2014 from Opposite Parties No.2 and 3 by paying annual premium of Rs.6830/-. The complainant further renewed  the said policy upto 19.5.2015 after having regular premium of Rs.6830/- vide policy No. 233300/48/2015/991 and the Opposite Parties No.2 and 3 appointed TPA-Opposite Party No.1 for settlement of claims of insurer i.e. complainant.  Complainant alleges that all of sudden a cyst  developed in the complainant right breast region. The complainant approached Hargun Hospital, Batala Road, Amritsar and the doctor advised the complainant to get the cyst removed immediately. After getting the complainant admitted in the said hospital on 7.6.2014 Dr.Gurinder Singh, Surgical Specialist operated the same and sent the removed part for Histopathology examination. In all this treatment, an amount of Rs.9,816/- was incurred. The complainant submitted a medical reimbursement claim worth Rs.9,816/- alongwith bills duly verified by Hargun Hospital, Batala Road, Amritsar, to Opposite Party No.1 through registered post on 10.6.2014 for settlement of the claim, but the Opposite Parties  did not settle the claim of the complainant despite a lapse of 11 months.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to reimburse the medical bill amounting to Rs.9816/-. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Parties appeared and filed written version in which it was submitted that the complainant has lodged the claim with Opposite Parties  and the medical record of the complainant was duly scrutinized and processed by the Opposite Parties and thereafter the claim of the complainant was repudiated as per  condition No.3.5 of the policy. The period for which an insured person is admitted in the hospital as inpatient and says there for the sole purpose of receiving of necessary and reasonable treatment for the disease/ ailment contracted/ injuries sustained during the period of policy. The minimum period of stay shall be 24 hours. The treatment record of the complainant shows that she has got removed a cyst in the right breast reason from the concerned hospital and for that purpose she went to the hospital around 9:00 AM on 7.6.2014 and discharged on the same day i.e. 7.6.2014 around 7:30 PM meaning thereby the clause 3.5 of the terms and conditions of the policy is fully applicable to the facts of the present case, as the hospitalization for claiming any benefit under the policy shall be minimum 24 hours and therefore, the claim of the complainant has rightly been repudiated, keeping in view the terms and conditions of the policy.  While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence her affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C7 and closed the evidence on behalf of the complainant.
4. Opposite Parties tendered into evidence affidavit of Ms.Abha Mathur Ex.OP 1,2,3/1 alongwith documents Ex.OP1,2,3/2 to Ex.Op1,2,3/9 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the representative of the complainant and  ld.counsel for the Opposite Parties  and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for the Opposite Parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant purchased medi claim policy bearing No. 233300/48/2014/849 dated 20.5.2013 valid upto 19.5.2014 from Opposite Parties No.2 and 3 by paying annual premium of Rs.6830/- which was  further renewed  upto 19.5.2015 vide policy No. 233300/48/2015/991 (Ex.C7).  Complainant developed cyst over the right breast region and she was admitted in Hargun Hospital, Batala Road, Amritsar on 7.6.2014, where she was operated and the cyst was removed and sent  for Histopathology examination. The complainant was discharged from the hospital on the same day i.e. 7.6.2014 as per discharge card Ex.C3. The complainant spent  Rs.9,816/- on her treatment. The complainant submitted the claim with Opposite Parties vide claim form Ex.C2, but the Opposite Parties repudiated the claim of the complainant vide letter dated 16.7.2014 Ex.OP1 to 3/5 on the ground that as per the submitted documents, the period of hospitalization of the complainant is less than 24 hours nor she was required for more than 24 hours, therefore, the Opposite Parties  are not under liability to pay the amount spent by the complainant on her treatment as per condition No. 3.5 of the terms and conditions of the policy (Ex.C7/ Ex.OP1 to 3/7). Ld.counsel for the complainant submitted that the complainant submitted the certificate from Hargun Hospital, Batala Road, Amritsar dated 7.6.2014 to Opposite Parties  and as per  clause 2.3 (xxv) of the terms and conditions of the policy in question,  any surgery under General Anesthesia is covered under the policy, even if the minimum period of 24 hours is not there. So, the Opposite Parties  have wrongly repudiated the claim of the complainant which amounts to deficiency of service on the part of the Opposite Parties. 
7. Whereas the case of the Opposite Parties  is that the treatment record of the complainant shows that she has got removed a cyst in her right breast reason from Hargun Hospital, Batala Road, Amritsar  and for that purpose she went to the hospital around 9:00 AM on 7.6.2014 and discharged on the same day i.e. 7.6.2014 around 7:30 PM meaning thereby the clause 3.5 of the terms and conditions of the policy is fully applicable to the facts of the present case, as the hospitalization for claiming any benefit under the policy shall be minimum 24 hours and therefore, the claim of the complainant has rightly been repudiated, keeping in view the terms and conditions of the policy. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party.
8. From the entire above discussion, we have come to the conclusion that  the complainant purchased medi claim policy bearing No. 233300/48/2014/849 dated 20.5.2013 valid upto 19.5.2014 from Opposite Parties No.2 and 3 by paying annual premium of Rs.6830/- which was  got renewed  from 20.5.2014 to 19.5.2015 vide policy No. 233300/48/2015/991 (Ex.C7).  Complainant developed cyst over the right breast region and she was admitted in Hargun Hospital, Batala Road, Amritsar on 7.6.2014, where she was operated and the cyst was removed and sent  for Histopathology examination. For all this treatment, an amount of Rs.9,816/- was incurred. The complainant was discharged from the hospital on the same day i.e. 7.6.2014 as per discharge card of the concerned hospital Ex.C3. The complainant lodged  the claim with Opposite Parties vide claim form Ex.C2 dated 10.6.2014, but the Opposite Parties repudiated the claim of the complainant vide letter dated 16.7.2014 Ex.OP1 to 3/5 on the ground that as per the documents submitted by the complainant, she was admitted in Hargun Hospital, Batala Road, Amritsar  for the treatment of cyst over the right breast region and was discharged on the same day i.e. 7.6.2014. As such she remained hospitalized for less than 24 hours, therefore as per clause 3.5 of the terms and conditions of the policy (Ex.OP1 to 3/7), the Opposite Parties  are not liable to reimburse the amount spent by the complainant on her treatment.
9. We have gone through the terms and conditions of the policy Ex.OP1 to 3/7. No doubt, as per clause 3.5 minimum period  of stay in hospital shall be 24 hours, but as per clause 2.3 (A) (xxv) the expenses on hospitalization are admissible only if hospitalization is for a minimum period of 24 hours. However, this time limit shall not apply  to specific treatment taken in the Network Hospital/ Nursing Home where the insured is discharged on the day. Such treatment shall be considered to be taken under Hospitalization Benefit and any surgery under general anesthesia is included in this exception. Here in this case, the complainant was operated upon under general anesthesia to remove the cyst over the right breast region of the complainant and the removed part was sent for Histopathology examination and this fact is clearly confirmed vide certificate issued by Hargun Hospital, Batala Road, Amritsar  dated 7.6.2014 Ex.OP1,2,3/4 which is placed on record by the Opposite Parties itself in which it has been categorically mentioned that the complainant was admitted in the hospital on 7.6.2014 with cyst  over right breast region. She was operated for the same and discharged on the same day. In the surgery the cyst was excised and sent for H.P.E. Therefore, this part of the treatment undergone by the complainant at Hargun Hospital, Batala Road, Amritsar which is a network hospital, is fully covered under the terms and conditions of the policy. The Opposite Parties  were not justified in repudiating the claim of the complainant vide letter dated 16.7.2014 Ex.OP1 to 3/5.
10. Consequently, we allow the complaint with costs and the Opposite Parties No.2 and 3 are directed to reimburse this amount of Rs.9,816/- to the complainant, within one month. Opposite Parties No.2 and 3 are also directed to pay compensation to the complainant to the  tune of Rs.2,000/- and also to pay Rs.1,000/-  as cost of litigation to the complainant.   Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 20.01.2016.                                                             (Bhupinder Singh)                                                                                                                                                                                                    President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member