DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 1622
Instituted on: 12.12.2015
Decided on: 11.08.2016
Nitish Maghan son of Chand Maghan, resident of Kothi No.5, Mann Colony, Sangrur.
…Complainant
Versus
United India Insurance Co. Ltd. City Road, NRG Complex, 1st Floor, Sunam, District Sangrur through its Branch Manager.
..Opposite party
For the complainant : Shri S.S.Ratol, Adv.
For OP : Shri Ashish Garg, Adv.
Quorum: Sukhpal Singh Gill, President
K.C.Sharma, Member
Sarita Garg, Member
Order by : Sukhpal Singh Gill, President.
1. Shri Nitish Maghan, complainant (referred to as complainant in short) has preferred the present complaint against the opposite party (referred to as OP in short) on the ground that the complainant was having a medicare policy for the last so many years by paying the requisite premium. As such, in continuation of the previous policies, the complainant purchased an insurance policy number 1117022914P104628630 for the period from 23.9.2014 to 22.9.2015 from the OP. It is further averred that during the subsistence of the insurance policy the complainant fell ill and remained admitted in Mayo Healthcare Super Speciality Hospital Mohali for the period from 29.6.2015 to 12.7.2015, where he spent an amount of Rs.1,04,379/- on the treatment. Further the complainant remained admitted in DMC Hospital, Ludhiana for the period from 17.7.2015 to 25.7.2015 and spent an amount of Rs.51,160/- and by this way, he spent the total amount of Rs.1,55,539/-. It is further averred that the complainant immediately informed the OP regarding his illness and submitted the bills of medicines etc, but the OP repudiated the claim of the complainant on the ground that the psychiatric disorders are not payable under the policy, which is said to be wrong and illegal. Thus, alleging deficiency in service on the part of the OP, the complainant has prayed that the OP be directed to pay to the complainant an amount of Rs.1,55,539/- along with interest @ 18% per annum from the due date till realisation and further claimed compensation and litigation expenses.
2. In reply filed by the OP, it is admitted that the complainant obtained the medicare policy in question for the period from 23.9.2014 to 22.09.2015 for Rs.3,00,000/- and the terms and conditions of the policy were supplied to the complainant. It is stated further that the policy includes nursing care, RMO charges, IV fluids/blood transfusion/injection administration charges and other expenses. It is further stated that as per clause 4.16 any kind of service charges, surcharge, admission fee, registration charges levied by the hospital are not payable. The complainant took the policy first time and pre existing diseases are not covered until 48 months of continuous coverage of such insured person. It is further stated that as per the record provided by the complainant, he admitted in Mayo Health Care Super Speciality Hospital on 29.6.2015 and discharge on 12.7.2015, where the complainant got treatment of sadness of mood, restlessness, decreased interaction and diagnosed as bipolar affective disorder, but the said hospital did not disclose the diagnosis. The complainant again remained admitted in DMC Hospital Ludhiana from 17 July 2015 in psychiatric ward and discharged on 25.7.2015, therefore, it is said that the depressive systems are pre-existing and on this ground the insured is not entitled to get any claim amount. It is stated that the claim has rightly been repudiated and any deficiency in service on the part of the OP has been denied.
3. The learned counsel for the complainant has produced Ex.C-1 copy of repudiation letter, Ex.C-2 to Ex.C-4 copies of patient details, Ex.C-5 copy of discharge summary, Ex.C-6 copy of final bill, Ex.C-7 and Ex.C-8 copies of receipts, Ex.C-9 and Ex.C-10 copies of discharge summary, Ex.C-11 to Ex.C-14 copies of insurance policies and Ex.C-15 affidavit and closed evidence. On the other hand the leaned counsel for the OP has produced OP-1 affidavit, Ex.OP-2 copy of insurance policy, Ex.OP-3 copy of guidelines and closed evidence.
4 We have carefully perused the complaint, written version of the opposite parties, evidence of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.
5. The version of the complainant is that he had obtained the family medicare policy of the OP since last many years. During the subsistence of the insurance policy, he fell ill and got treatment from Mayo Health Care Super Speciality Hospital, Mohali for the period from 29.06.2015 to 12.07.2015 and spent a sum of Rs.1,04,379/- on his treatment. The complainant had also remained admitted in DMC Hospital, Ludhiana for the period from 17.7.2015 to 25.07.2015 and had spent a sum of Rs.51,160/-. But the OP had repudiated the claim on the ground that the psychiatric disease is not covered as per the terms and conditions of the policy, but the complainant had submitted that no guidelines with regard to the policy were ever supplied to the complainant.
6. In the written reply, the OP has submitted that the policy in question was for the sum assured of Rs.3,00,000/- and the terms and conditions were explained to the complainant. The OP also submitted that the pre existing diseases are not covered under the policy before 48 months of the coverage, as such the complaint has been rightly repudiated by the OP.
7. After hearing the arguments of the learned counsel for the parties and on the perusal of the documents placed on record, we find that the complainant had placed on record document Ex.C-11, which is a copy of the policy dated 23.09.2012, whereas the counsel for the complainant had argued that the complainant had been obtaining the policies since 2010 and as such the Op cannot take the plea that the pre existing diseases are not covered until 48 months of continuance coverage of the insured person.
8. In repudiating the claim, the OP has relied upon the discharge summary of Dayanand Medical College and Hospital Ludhiana which is document Ex.C-9. In this document, it has been mentioned that “HTBT 3 months when patient started of having C/O sadness of mood, decreased interactions with the family members, Patient also started having sleep disturbances, feeling of worthlessness, low confidence patient also had c/o deceased appetite. Past H/o – patient had H/o episodes of depressive symptoms in 2000 and 2002 and episodes of manic in 2004 & 2014.” But, from the documents placed on record, we do not find any evidence of the OP in support of its version. The counsel for the complainant has cited the judgment of the Hon’ble National Commission delivered in the Revision Petition No.2738 of 2008 in which it has been held that history recorded in hospital bed ticket is not to be treated as evidence as the doctor, recording the history has not been examined. The Hon’ble National Commission has mentioned that “To be noted that in support of which is stated in the case sheet neither the doctor who recorded their case sheet was examined nor his affidavit filed as also mentioned in its order by the State Commission.”
9. Further it is the specific version of the complainant that the terms and conditions were never supplied by the Op. In such like situation, reliance can be made on the citation of the Hon’ble Supreme Court of India delivered in Civil Appeal No.6895 of 1997 in the case of Modern Insulators Limited versus Oriental insurance Company Limited. The Hon’ble Supreme Court has held that “as the above terms and conditions of the standard policy wherein exclusion clause was included were neither a part of the contract of insurance nor disclosed to the appellant, respondent cannot claim the benefit of the said exclusion clause.” In the light of the above citation, we find that the OP has failed to tender any reliable and cogent evidence in support of his version that the terms and conditions were supplied as no document has been placed on record to show that the terms and conditions were ever made known to the complainant.
10. Now the question arises as to what amount the complainant is entitled as per the policy document. In the document Ex.OP-2 it has been mentioned that room rent is 1% of the sum insured. So as the policy was for a sum of Rs.3,00,000/- the complainant was entitled for the room rent @ Rs.3000/- per day. As per document Ex.OP-2 the eligible room rent for 8 days come out to be Rs.3000x8 = Rs.24,000/- and the room rent for 13 days comes out to be Rs.3000x13 = Rs.39000/- and not Rs.39,200/- and Rs.66,300/- as claimed by the complainant. Further as per the document Ex.OP-2, the complainant is also not eligible for the reimbursement of admissible fee/registration fee. So, the amount of Rs.85/- claimed as per the document Ex.C-2 and Rs.1500/- as per the document Ex.C-6 are also not reimbursable. The different of room rent amounting to Rs.42,500/- and admission charges amounting to Rs.1585/- are not eligible for reimbursement and as such, the eligible amount for reimbursement to the complainant comes out to be Rs.155539/- minus Rs.44085/- (Rs.42500/-+Rs.1585/-) = Rs.1,11,454/-.
11. So, from the above discussion, we find that the OP is not only deficient in service, but also had indulged in unfair trade practice and as such, we allow the complaint and direct the OP to reimburse the complainant a sum of Rs.1,11,454/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 12.12.2015 till realisation. We further order the OP to pay to the complainant a sum of Rs.20,000/- being the amount of compensation for mental tension and agony and a sum of Rs.11,000/- being the litigation expenses.
12. This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
August 11, 2016.
(Sukhpal Singh Gill)
President
(K.C.Sharma)
Member
(Sarita Garg)
Member
