DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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[1]  Suman Sharma aged 46 years w/o Sh. Ashwani Sharma, R/o Vill. Abota, Near Govt. Primary School, Sector 5, Parwanoo, P.O. Parwanoo – 173220, Tehsil Kasauli & District Solan (H.P.).

[2]  Ashwani Sharma, aged 46 years, husband of Smt.Suman Sharma, insured person, R/o Vill. Abota, Near Govt. Primary School, Sector 5, Parwanoo, P.O. Parwanoo – 173220, Tehsil Kasauli & District Solan (H.P.).

              ---Complainants

Vs

United India Insurance Company Limited, Division Office-III, situated at SCO No. 149-150, Sector 8-C, Chandigarh, through its Divisional Manager.

---- Opposite Party

BEFORE:    MRS.MADHU MUTNEJA               PRESIDING MEMBER

           SH.JASWINDER SINGH SIDHU        MEMBER

Argued By:    Sh. B.J. Singh, Counsel for Complainants.

Sh. Rajneesh Malhotra, Counsel for Opposite Party.

PER MADHU MUTNEJA, PRESIDING MEMBER

1.        The Complainants had obtained a “Health Insurance Policy” from the Opposite Party, valid from 27.12.2008 to 26.12.2009, by paying a premium of Rs.4756/- (copy of cover note & policy is at Annexure C-1, C-2 and C-3). The Health Insurance cover including Accident Risk cover of Rs.1,00,000/- each and domiciliary hospitalization limit of Rs.20,000/- per person. Accidental death/ injury and various other health insurance benefits were also part of the Policy. The Complainants has stated that they were the holders of this Policy since 27.12.2006.  

          Unfortunately, on 25.12.2009, the Complainant No.1 had an accidental fall in the bathroom of her house, due to which she suffered multiple injuries. She was rushed to the nearest ESI Hospital, Parwanoo where she was given emergency treatment by the doctors. Since there was a compound fracture in right leg, the doctors referred the Complainant to the Govt. Medical College & Hospital, Sector 32, Chandigarh for further management (medical treatment/ prescription slip is at Annexure C-4).

          The Complainant has stated that on 26.12.2009, she was shifted to Bone & Joint Surgical Centre of Dr. Pardeep Aggarwal, NAC, Manimajra, U.T. Chandigarh for better treatment & medical care. An operation was conducted for comminuted fracture on right leg on 27.12.2009 O.R & plating, screwing and fixation titanium was done and the Complainant was discharged on 29.12.2009. The Complainant was advised medication and further visit on 1.1.2010. The Complainant has stated that she incurred a total expenditure of Rs.28,000/- at the Bone & Joint Surgical Centre (copy of bill along with discharge summary & follow up care is at Annexure C-5). The Complainant has also stated that another amount of Rs.21,808.80 was incurred on her medical expenses and medicines (Annexure C-6).

          The Complainant has submitted that when she informed the Opposite Party about her claim she was asked to supply all claim papers. The Complainant accordingly informed the Opposite Party that the papers would be submitted after the treatment concluded. As per the Complainant the Opposite Party threatened to treat the case as ‘No Claim’, if the papers were not submitted. The case was eventually treated as ‘No Claim’ vide letter dated 26.5.2010 by the Opposite Party (Entire correspondence is at Annexure C-7 to C-11). The Complainant has further submitted that she also incurred an additional sum of Rs.5,200/- for her subsequent visits and treatment with the Bone & Joint Surgical Center. Hence, the total medical expenses as per the Complainant on the treatment were Rs.91,403.70P which is being claimed by her. 

          The Complainant has contended that despite the claim papers being duly completed and original bills and cash memos submitted, her claim has not been paid by the Opposite Party. The Complainant has therefore filed the present complaint, praying that the Opposite Party be directed to pay the medical expenses, besides costs for transportation, pain & suffering, attendants, exp. on special diet, compensation for deficiency & unfair trade practice, mental harassment, besides litigation expenses. 

2.        After admission of the complaint, notice was sent to the Opposite Party.

3.        The Opposite Party in reply has taken preliminary objections to the effect that this Forum has no territorial jurisdiction to entertain and try the present complaint. The Opposite Party has pleaded that there is no deficiency in service on their part because the Complainants did not supply the requisite medical bills and record during the currency of the insurance policy despite repeated requests and the claim was eventually closed as no claim. No claim can be paid after the policy had expired.

          On merits, Opposite Party has admitted the issuance of the Health Insurance Policy to the Complainants, valid for the period from 27.12.2008 to 26.12.2009. Opposite Party has also admitted the receipt of intimation with regard to hospitalization of Complainant No.1, but no medical bills were submitted during the currency of the insurance policy due to which the claim was repudiated as ‘No Claim’. All correspondence exchanged between the parties have also been placed on record, wherein the Complainant was specifically informed to provide necessary documents for the claim. As the Complainant failed to provide relevant bills, the claim was closed as ‘No claim’. Opposite Party has therefore, prayed for dismissal of complaint, as according to them it is without merit and beyond the terms and conditions of the policy.

4.        In the rejoinder to the written statement, the Complainant has stated that the Complainant was very much covered under the Policy on the date of accident i.e. 25.12.2009. However, as bills were to be submitted after completion of treatment, they could not be submitted with the Opposite Party, immediately. Hence, treating the claim as no claim by the Opposite Party is illegal and arbitrary. The Complainant has asserted the averments of her complaint again through her rejoinder.  

5.        Parties led evidence in support of their contentions.

6.        We have heard the learned counsel for the parties and have perused the record.

7.        Addressing the preliminary objection by the Opposite Party on the ground of territorial jurisdiction, the documents on record show that the Policy has been issued from Parwanoo, but the miscellaneous cover note is from Chandigarh. The claim has been processed and repudiated also from Chandigarh. Hence, there is definite cause of action in favour of the Complainant at Chandigarh. As such, the contention of the Opposite Party for dismissal of the complaint on the ground of territorial jurisdiction is rejected.

8.        The basic point involved in the dispute is whether a claim for an accident occurred on 25.12.2009 is payable by the Opposite Party when the policy was till 26.12.2009. The patient was admitted in hospital on 26.12.2009, while entire treatment taken by the Complainant for the said accident as well as all expenses incurred by the Complainant for the said accident was after the date of expiry of insurance. It is not disputed that immediately after the accident on 25.12.2009, the Complainant was taken to the ESI Hospital, Parwanoo, who referred her to the Govt. Medical College & Hospital, Sector 32, Chandigarh, but the Complainant choose to go to the Bone and Joint Surgical Centre of Dr. Pardeep Aggarwal for treatment where she was admitted on 26.12.2009. The Complainant has averred that a total sum of Rs.91,403.70P  was incurred on the treatment as well as medicines. Opposite Party has denied this claim by submitting that the amount has been spent after the expiry of the period of policy and the papers have also been lodged after the policy term was over. In this regard, the terms and conditions of the policy placed on record by the Opposite Party at Annexure R-1 (Pg.15) need to be examined. Clause 3.2 which deals with “Post Hospitalization” reads as under:- 

“3.2 POST HOSPITALIZATION: Relevant medical expenses incurred during period up to 60 days after hospitalization on disease/ illness/ injury sustained will be considered as part of claim as mentioned under item 1.2 above.”

          The Complainant was hospitalized on the date when the policy was in force. The amounts spent on her treatment as well as medical expenses incurred within 60 days after the hospitalization would hence be payable as per the terms and conditions of the policy, reproduced above. Denial of the insurance claim by the Opposite Party on a technical ground that the treatment is beyond the period of policy, in our opinion, is not justified and is not in consonance with Clause 3.2 of their own policy document which has been appended by them at annexure R-1. On a perusal of bills places on record to substantiate the claim, we find that the bills are upto June, 2010. But as per the Policy Clause 3.2, the Opposite Party is liable only to make payment of the bills upto 60 days after the date of admission of the Complainant in the hospital which 26.12.2009. 

9.        The complaint is allowed accordingly. The Opposite Party is directed to make payment as per terms of policy to the Complainant against all bills dated upto 60 days from the date of hospitalization only. A claim treatment expenses summary has been placed on record by the Complainant at Annexure C-13. In our opinion, as per this summary and terms of policy only Items from Sr. No.1 to 8 need to be considered for the payment of the claim. The later bills are rejected as not payable. Opposite Party is directed to make payment against the claim to the Complainant accordingly in terms of the policy. In addition, the Opposite Party is also directed to pay Rs.10,000/- to the Complainant towards compensation and cost of litigation.

10.       The awarded claim amount be paid by the Opposite Party within 45 days of the receipt of this order, failing which Opposite Party shall be liable to pay the complete claimed amount as per bills at Sr. No.1 to 8 at Annexure C-13, along with interest @12% per annum, from the date of this order, till the date of payment. However, the compensation and cost of litigation shall be payable without interest.  

11.       Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

18^th September, 2012.                                            

Sd/-

(MADHU MUTNEJA)

 PRESIDING MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER

“Dutt”