DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA

Received by way of transfer Consumer Complaint No.161 of 2018

                                            Date of institution:07.03.2018

                                            Date of Decision:10.10.2022

1. Rajesh Kumar son of Lachman Dass, C/o Rankeshwar Collection, House No.B-III-1232, Kalyan Nagar, Ludhiana
2. Parfulit Singla daughter Rajesh Kumar, C/o Rankeshwar Collection, House No.B-III-1232, Kalyan Nagar, Ludhiana. …….Complainants

Versus

United India Insurance Company Limited, Gulmohar Hotel, Ferozepur Road, Ludhiana

                                                          ……..Opposite Parties

 QUORUM:   

   HON’BLE MR. RANJIT SINGH, PRESIDENT.

                  HON’BLE MRS. RANVIR KAUR, MEMBER

PRESENT:

Sh. AB Sharma, Adv. for complainant

Sh. MR Saluja, Adv. for OPs

ORDER

RANJIT SINGH, PRESIDENT

1. The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Party on the ground that the complainant had obtained one insurance policy from the opposite party in the year 2006. Since then the complainants are continuously renewing the insurance policy. Lastly the insurance policy was renewed on 12.9.2017 which was valid upto 11.09.2018.  The name of the policy was Raksha Policy and the same was taken by the complainant No.1 for his entire family. The complainant had paid a premium of Rs.32,736/- for the current policy year. Unfortunately, complainant No.2, who is the daughter of the complainant No.1 developed a disease namely Pemphigus vulgaris in October 2017. The complainant No.2 firstly took medicine from various doctors at Ludhiana as well as from Mendata Hospital, but there was no improvement in the said skin disease. Lastly the complainant No.2 approached PGI Hospital, Chandigarh, where after consultation, the complainant No.2 had taken the treatment from the PGIMER, Chandigarh. During the treatment, she spent Rs.74,103/-. Complainant No.2 was again admitted in the PGIMER Hospital on 5.12.2017 to 6.12.2017 and spent Rs.60,419/- were spent by the complainant No.1 for the entire treatment. Thereafter, the complainant approached to the OP to refund the claim amount but OP rejected the claim of the complainant. Thus, alleging deficiency in service on the part of the OP. Therefore, the complainant prayed for the following reliefs against the OP:- 

1. To pay the claim amount of Rs.1,34,522/-

2. To pay Rs.1,00,000/- as compensation on account of mental suffering harassment and torture.

4. Any other additional or alternative relief to which the complainant is found entitled to in the facts and circumstances of the case to the complainant.

2. Upon notice, the OP have filed written reply taking preliminary objections; that there is no deficiency in service on the part of the OP as the claim of the complainant has been rightly repudiated vide letter of M/s Raksha Health Insurance TPA Private Limited, Chandigarh containing the reason of repudiation of the claim of the complainant. The repudiation letter of the Raksha TPA speaks as under:-

“Injection Rituximab given which is an OPD based procedure and does not require hospitalization. Therefore, the claim does not fall under the scope of the policy, hence, claim recommended to be non payable as per clause 3.14.”. on merits, it is stated that complainant’s daughter Ms. Perfulit Singla developed a skin disease namely Pemphigus Vulgaris and she taken treatment of the said disease. The admission of complainant No.2 is not required for treatment of said disease. Thus, alleging no deficiency in service on the part of answering OPs and prayed for dismissal the complaint.

3. In support of the complaint, the complainant has tendered various documents. On the other hand, the OPs has also tendered documents in support of their evidence.
4. We have heard the learned counsel for the complainant and have gone through the record of the file, carefully.
5. The learned counsel for the OP has placed on record the terms and condition of the policy and in terms and condition, as per clause 3.14. Hospitalization means admission in a hospital/nursing home for a minimum period of 24 in patient care consecutive hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours. As per letter of M/s Raksha Health Insurance TPA Private Limited, Chandigarh, the OPs has repudiated the claim of the complainant.  
6. In view of our above discussion, we feel that the complainant is not entitled for any claim amount as per policy terms and condition clause 3.14. Therefore, the present complaint stands dismissed. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.
7.  

October 10, 2022

(Ranjit Singh)

(Ranvir Kaur)