Punjab

Ludhiana

CC/14/466

Pardeep Kumar - Complainant(s)

Versus

United India Ins.Co.Ltd - Opp.Party(s)

26 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 466 of 04.07.2014

                                                                                                                    Date of Decision: 26.02.2015

                                                                                                                   

1. Pardeep Kumar Bhatia S/o Sh.Goverdhan Dass Bhatia

2. Renu Bhatia w/o Sh.Pardeep Kumar Bhatia

Both residents of H.No.281-A, Rishi Nagar, Backside Kali Mata Mandir, Ludhiana.

……Complainants

Versus 

1. United India Insurance Co. Ltd., Head Office at 24, Whites Road, Chennai-600014.

2. United India Insurance Co. Ltd. DIV. Office no.1, 455, The Mall Ludhaina-141001.

 

                                                                                      …..Opposite parties 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                     Sh.Sat Paul Garg, Member

                     Smt.Babita, Member

 

Present:       Sh.Mohit Verma, Advocate for complainant.

                   Sh.Rajeev Abhi, Advocate for OPs.  

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Pardeep Kumar Bhatia S/o Sh.Goverdhan Dass Bhatia and Smt.Renu Bhatia w/o Sh.Pardeep Kumar Bhatia, residents of H.No.281-A, Rishi Nagar, Backside Kali Mata Mandir, Ludhiana (herein-after in short to be referred as ‘complainant’) against United India Insurance Co. Ltd., Head Office at 24, Whites Road, Chennai and others (herein-after in short to be referred as ‘OPs’)- directing them to clear the pending amount of mediclaim of the complainant amounting to Rs.70,476/- alongwith interest @ 18% p.a. from the date of lodging the claim till its realization, to pay Rs.20,000/- as compensation on account of suffering mental harassment, agony and torture, to pay Rs.11,000/- as cost and Rs.10,000/- as litigations expenses to the complainant alongwith any other additional or alternative relief.

2.                Brief facts of the complaint are that complainant no.1 got the insurance policy under the Individual Health Insurance Policy bearing policy no.200700/48/13/97/00001464 for himself as well as two dependents namely complainant no.2 and his son Anmol Bhatia. The complainant no.2 was covered under Gold plan with sum insured of Rs.2,50,000/-. The date of the inception of the policy is 25.10.13 to 24.10.14. The complainant no.2 was admitted in Hope Hospital with complaints of Post Memo Pausal Vaginal bleeding for past three months and surgery was conducted on 18.12.13 by Dr.Achla Gupta and was discharged on 28.12.13. The complainant no.1 lodged the claim with the Ops and submitted the medical bills and requisite documents with the Ops. The complainant furnished the medical bills, hospital bills etc. amounting to Rs.1,41,290/- to the Ops. On 6.2.14 Ops deposited amount of Rs.70,814/- in the account of complainant no.1, through NEFT without taking the acceptance letter of claim. Whereas, the total bills amounts to Rs.1,41,290/-. Being not satisfied with the claim amount complainant no.1 went to the office of OP2 and asked the reason for submitting short payment of claim, but Ops never gave satisfactory reply. ON 17.2.14 Ops dispatched a letter Ref no.Misc/2014/334 to the complainant stating that ‘In this regard we may inform you that the claim has been settled as per condition no.1.2.1 of the policy. The said condition restricts the hospitalization benefits upto 25% of the sum insured for cataract, hernia hysterectomy’. Again on 21.2.14 complainant no.1 wrote a letter to Ops that complainant no.2 was suffering from ‘Cancer of Cervix’, but not from ‘Hysterectomy’ and again requested the Ops to re-examine the claim. But Ops remained adamant and remained in negligent mode. The complainant no.1 many time visited the office of Ops, but nothing happened. Further alleged that the complainant duly supplied all the requisite documents, which clearly shows that complainant no.2 was suffering from ‘Cancer of cervix’. Doctor Achla Gupta has also mentioned in detail that the complainant no.2 was suffering from ‘Cancer of cervix and not from Hysterectomy. But the Ops has malafidely and dishonestly rejected the rightful claim of the complainant. Claiming the above act as deficiency in service on the part of the Ops, the complainant has filed this complaint.

3.                On notice of the complaint, Ops appeared through their counsel and filed written statement taking preliminary objections that the complaint is barred under section 26 of the Consumer Protection Act; the present complaint is not maintainable since the complainant has obtained individual health insurance policy 2010 bearing policy no.200700/48/13/97/00001464 valid from 25.10.13 to 24.10.14 for a sum insured of Rs. 2 lacs qua Anmol Bhatia, Rs.2 lacs in respect of Pardeep Kumar Bhatia and Rs.2,50,000/- in respect of Mrs.Renu Bhatia. As per the condition no.1.2.1 of the policy ‘expenses in respect of the following specified illness will be restricted as detailed below:-

Hospitalization benefits	LIMITS per surgery RESTRICTED TO
a. Cataract, Hernia, Hysterectomy   b. Major surgeries	a. Actual expenses incurred or 25% of the sum insured whichever is less b. Actual expenses incurred or 70% of the sum insured whichever is less

 

*          Major Surgeries include cardiac surgeries, brain tumour surgeries, pace

maker implantation for sick sinus syndrome, cancer surgeries, hip, knee, join

replacement surgery, organ transplant.

*          The above limits specified are applicable per hospitalization/surgery.

 

As per condition no.1.2.2 Pre and Post hospitalization in respect of each hospitalization- Actual expenses incurred subject to maximum of 10% of sum insured whichever is less.

 

                        The claim was lodged for the reimbursement of the medical expenses incurred on the treatment of disease malignant growth, cervix with uterus fibroids with date of admission from 18.12.13 to 28.12.13 as per discharge summary of M/s Hope Hospital, Roshan Bhawan, 28-B, Tagore Nagar, Civil Lines, Ludhiana after the receipt of the documents from complainant no.1, the entire claim file was sent to Dr.Suresh Kumar Gupta, MBBS, DPH, MIPH, Ex-PCMS-1, for his professional opinion. Dr.Suresh Kumar Gupta after scrutinizing the entire claim file, examining the patient and having discussion with her regarding her illness, had prepared his report dated 18.1.14 in his hand and under his signature and submitted the same with the observations that the complainant no.2 is entitled to actual expenses incurred or 25% of the sum insured whichever is less as per clause 1.2.1 and in addition to the above said amount, the patient is entitled to pre and post hospitalization charges which shall be actual expenses incurred subject to the maximum of the 10% of the sum insured whichever is less. The claim of the complainant has been settled in full and final settlement. As per the terms and condition of the policy an amount of Rs.70,855/- has been paid to the complainant. No further amount is entitled to the complainant. On merits, admitting the contents mentioned in the preliminary objections and denying the contents of all other paras, Ops prayed for the dismissal of the complaint.

4.                Ld. Counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant no.1 Sh.Pardeep Bhatia Ex.CA1, whereby he deposed that the fact contained in accompanying complaint, the contents of which have not been repeated here in for the sake of brevity may be read as an integral part of this affidavit and is true and correct and also attached documents Ex.C1 to Ex.C30 and also adduced the evidence by way of duly sworn affidavit of Dr.Mohan Gupta, aged 66 years M.B.B.S, M.A.M.S, F.A.I.S, F.I.M.S.A, F.I.C.S) General and Laproscopic Surgeon in Hope Hospital, Formerly Professor and Head Department of Surgery in DMC and Hospital from 1975 to 2008, from 2008 till present Surgeon in Hope Hospital, Ludhiana Ex.CB, wherein, it is very clearly deposed that surgery of Modified Radical Hysterectomy is different from simple Hysterectomy alongwith documents Ex.CB/A, Ex.CB/1 and Ex.CB/2. On the other hand, Ld. Counsel for Ops has adduced the evidence by way of duly sworn affidavit of Sh.H.S.Bedi, Divisional Manager, United India Insurance Co. Ltd. DO-I, 455, The Mall, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and affidavit of Dr.Suresh Kumar Gupta, MBBS, DPM, MIPH, Ex.PCMS-I resident of B-34-9824, Near Suraj Book Shop, Haibowal Kalan, Ludhiana Ex.RB, wherein he deposed that he had been handed over the claim file of Mrs.Renu Bhatia by United India Insurance Co. Ltd. He had scrutinized the entire claim file, examined the patient and have discussions with her regarding her illness and thereafter prepared his report dated 18.1.14 in his hand and under his signatures and submitted the same with the observations that Renu Bhatia was entitled to actual expenses or 25% of the sum insured whichever was less as per clause 1.2.1 and in addition to the above said amount, Renu Bhatia is entitled to pre and post hospitalization charges, which shall be actual expenses incurred subject to the maximum of 10% of the sum insured whichever is less. His report dated 18.1.14 is true and correct as per examination of the documents, claim file, and policy conditions etc. and his observation and be read as a part of his affidavit and the same is Ex.R7 and also attached documents Ex.R1 to Ex.R16.

5.                Case was fixed for arguments. Ld. Counsel for complainant argued orally that complainant admitted in Hope Hospital with complaints of Post Memo Pausal Vaginal bleeding for the past three months and surgery was conducted on 18.12.13 by Dr.Achla Gupta and was discharged on 28.12.13. Claim of Rs.1,41,290/- was lodged with the OPs. But the claim of the complainant was settled for Rs.70,814/- as per the condition no.1.2.1 of the policy. But the case of the complainant is not covered under the condition no.1.2.1 and 1.2.2 of the policy since it was not a simple Hysterectomy, rather it was surgery of Modified Radical Hysterectomy, which is different from simple Hysterectomy. Ld. Counsel for complainant also relied upon the judgements passed in cases titled as Rajni Tiwari Vs Jabalpur Hospital and Research Centre and others-2007 (3) C.P.J (NC) 428, Vudumula Leelakumari and others Vs M.Ravindra-2004(3) C.P.J 475 (Andhra Pradesh State Commission, Hyderabad).

6.                Refuting the allegations leveled by the complainant, Ld. Counsel for Ops filed written arguments averring that complainant has filed the complaint against the Ops after the receipt of the claim amount in full and final settlement of the claim without any protest unconditionally and without reserving any right to recover any balance amount. The Ops appeared, filed the written statement taking various defenses which are detailed in the written statement and the grounds taken in the letter dated 17.2.14 and reply to the representation sent by the Ops, vide letter dated 13.5.14. The complainant has not led any reasonable and cogent evidence to prove the onus cast upon the complainant except for tendering his own affidavit and affidavit of Dr.Mohan Gupta alongwith the documents. The Ops had lead reasonable and cogent evidence to prove the defenses taken by them by tendering in evidence the affidavit of Sh.H.S.Bedi, Divisional Manage, United India Insurance Co. Ltd. and affidavit of Dr.Suresh Kumar Gupta alongwith documents Ex.R1 to Ex.R16. Further at the ground of defences and points of arguments submitted that Insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy. It is clearly mentioned in condition no.1.2.1 that the company shall be liable to pay actual expenses incurred at 25% of the sum insured whichever is less in case of hysterectomy and actual expenses incurred subject to the maximum of 10% of the sum insured whichever is less for the pre and post hospitalization in respect of each hospitalization. As per Ex.R5, R8, R9 and R15 of Hope Hospital hysterectomy was performed for removal of uterus fibroids. As per report of Ex.R14 of SRL Diagnostics of biopsy the patient was having fibroids (3.5 mm) of uterus non malignant (which was authenticated to be correct by Hope Hospital) as per the signature of the doctors and stamp thereon. As per report of Dr.Suresh Kumar Gupta Ex.R3 and Ex.R7 the hysterectomy was performed on the patient. As per affidavit of Dr.Mohan Gupta submitted by the complainant as Ex.CB he has clearly stated that Renu Bhatia underwent Modified Radical Hysterectomy. The claim has been settled in terms of the insurance policy Ex.R16 and accepted by the complainant in full and final settlement of the claim without any protest unconditionally and without reserving any right to recover any further amount. This fact is clear from Ex.R4, which is the representation sent by the complainant to the company after the receipt of the amount in full and final settlement of the claim. The representation Ex.R4 was duly considered by the OPs. The matter was referred to Dr.Suresh Kumar Gupta again who has submitted his report Ex.R3 and thereafter the complainant was informed vide letter dated 17.2.14 and 13.5.14 i.e. Ex.R1 and Ex.R2 about the fate of his representation. Ld. counsel for OPs also relied upon the judgements passed in cases titled as United India Insurance Co. Ltd. Vs Harchand Rai Chandan Lal-2004 (IV) CPJ 15 passed by Hon’ble Supreme Court of India, New India Assurance Co. Ltd. Vs Deepak Anand-2014 (III) CPJ 373 passed by Hon’ble National Commission, National Insurance Co. Ltd. Vs Vinod Puri and another-2014 (1) CPJ 341 passed by Hon’ble National Commission, Ind Swift Ltd. Vs New India Assurance Co. Ltd.-2012 (IV) CPJ 148 passed by Hon’ble National Commission, Vijay Stationers Vs United India Insurance Co. Ltd.-2013 (I) CPJ 637 passed by Hon’ble National Commission, Haryana State Co-operative Supply and Marketing Federation Ltd. Vs Iffco Tokio General Insurance Co. Ltd.-2013 (II) CPJ 364 passed by Hon’ble National Commission etc. etc.

7.                We have gone through the pleadings of the complainant as well as defence taken by the OPs and have gone through the written arguments submitted on behalf of the OPs as well as judgements placed on filed and have also perused the entire record placed on file.

8.                It is evident that the complainant no.2 was covered under Gold plan with sum insured of Rs.2,50,000/-. The date of the inception of the policy is 25.10.13 to 24.10.14. The complainant no.2 was admitted in Hope Hospital with complaints of Post Meno Pausal Vaginal bleeding for past three months and surgery was conducted on 18.12.13 by Dr.Achla Gupta and was discharged on 28.12.13. The complainant no.1 lodged the claim with the Ops and submitted the medical bills and requisite documents with the Ops. The complainant furnished the medical bills, hospital bills etc. amounting to Rs.1,41,290/- to the Ops. On 6.2.14 Ops deposited amount of Rs.70,814/- in the account of complainant no.1, through NEFT without taking the acceptance letter of claim. Whereas, the total bills amounts to Rs.1,41,290/-. Being not satisfied with the claim amount complainant no.1 went to the office of OP2 and asked the reason for submitting short payment of claim, but Ops never gave satisfactory reply. On 17.2.14 Ops dispatched a letter Ref no.Misc/2014/334 to the complainant stating that ‘In this regard we may inform you that the claim has been settled as per condition no.1.2.1 of the policy. The said condition restricts the hospitalization benefits upto 25% of the sum insured for cataract, hernia hysterectomy’. Again on 21.2.14 complainant no.1 wrote a letter to Ops that complainant no.2 was suffering from ‘Cancer of Cervix’ and again requested the Ops to re-examine the claim. But Ops remained adamant and remained in negligent mode. The complainant no.1 many time visited the office of Ops, but nothing happened. Further alleged that the complainant duly supplied all the requisite documents, which clearly show that complainant no.2 was suffering from ‘Cancer of cervix’. Doctor Achla Gupta has also mentioned in detail that the complainant no.2 was suffering from ‘Cancer of cervix’ which required Modified Radical Hysterectomy. On the other hand according to OPs deposition, the complainant has obtained individual health insurance policy 2010 bearing policy no.200700/48/13/97/00001464 valid from 25.10.13 to 24.10.14 for a sum insured of Rs. 2 lacs qua Anmol Bhatia, Rs.2 lacs in respect of Pardeep Kumar Bhatia and Rs.2,50,000/- in respect of Mrs.Renu Bhatia. As per the condition no.1.2.1 of the policy ‘expenses in respect of the following specified illness will be restricted as detailed below:-

Hospitalization benefits	LIMITS per surgery RESTRICTED TO
a. Cataract, Hernia, Hysterectomy   b. Major surgeries	a. Actual expenses incurred or 25% of the sum insured whichever is less b. Actual expenses incurred or 70% of the sum insured whichever is less

 

*          Major Surgeries include cardiac surgeries, brain tumour surgeries, pace

maker implantation for sick sinus syndrome, cancer surgeries, hip, knee, join

replacement surgery, organ transplant.

*          The above limits specified are applicable per hospitalization/surgery.

 

As per condition no.1.2.2 Pre and Post hospitalization in respect of each hospitalization- Actual expenses incurred subject to maximum of 10% of sum insured whichever is less.

                   But the present case is not covered under clause 1.2.1.

9.                In view of the above discussion, the present complaint is allowed being maintainable and Ops are directed to settle and pay the claim of the complainant qua the remaining amount as admissible under terms and conditions as prayed in the complaint. Further OPs are directed to pay Rs.2500/-(Two thousand five hundred only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days from the receipt of the copy of the order, which be made available to the parties, free of costs. File be consigned to record room.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.

Dated:27.02.2015 

Hardeep Singh