| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PATIALA. Complaint No. CC/15/48 of 26.2.2015 Decided on: 10.9.2015 Manwinder Pal Singh resident of House No.395, Sector-46A, Chandigarh working in Faderal Mogul Goetze, Bahadurgarh, Mobile No.98145-19864. …………...Complainant Versus - United India Insurance Co.Ltd.,Leela Bhawan Market, Adalat Bazaar, Patiala, Punjab.
- Paramount Health Services TAP Ltd.,D-39,Okhla Industrial Area Phase-1,New Delhi-110020.
…………….Ops Complaint under Section 12 of the Consumer Protection Act. QUORUM Sh.D.R.Arora, President Smt.Neelam Gupta, Member Smt.Sonia Bansal,Member Present: For the complainant: Sh.H.S.Chawla , Advocate For Op No.1: Sh.B.L.Bhardwah,Advocate ORDER D.R.ARORA, PRESIDENT - It is the case of the complainant that he is working in Federal Mogul Goetze, Bahadurgarh,Patiala and is covered for health insurance under the Group Insurance Scheme vide ID No.PHSID UI 21424029-FMGL valid upto 30.11.2014.Ishwinder Singh, son of the complainant being dependant upon him is also covered under the health insurance policy.
- The son of the complainant namely Ishwinder Singh was diagnosed as a patient of Congenital Posterior subscapsusar contract, chronic myeloid leukemic choronic phase, RQPLR for BCR-ABL transcripts=75.118% sokal score=0.97m and acute febrile illness(Enteric fever). It is a kind of blood cancer and for the treatment of the same, the son of the complainant required chemo therapy. The treatment record of the son of the complainant is Annexure 3.In the treatment record the doctors of the PGI have specifically observed that the treatment given by the PGI is chemo therapy and no admission for the same is required and the treatment is required for the whole of life..
- Op no.2 to whom the complainant used to submit the discharge summary, refused to entertain the claim on the ground that for claim reimbursement indoor admission is required for 24 hours. The son of the complainant remained admitted in the PGI from 1.5.2013 to 14.5.2013 and the treatment now being taken by him is a part of the treatment given during admission and therefore, the reason given by Op no.2 is not sustainable and rather as per the verbal advice given by the doctor of the PGI, the admission in the hospital will be an additional burden on the patient/insuree. The medicines itself is a chemo therapy and the same line of treatment is adopted worldwide.
- It is further averred that when the Ops did not respond to the e-mail sent by the complainant regarding the payment of the claim, he got the Ops served with a legal notice dated 6.10.2014 whereby he called upon the Ops to disburse the expenses incurred in the treatment of his son but the Ops failed to respond the notice. The act of the Ops in not having disbursed the claim of the complainant is said to be an unfair trade practice as also a deficiency in service. Accordingly the complainant brought this complaint against the Ops under Section 12 of the Consumer Protection Act,1986 ( for short the Act) for a direction to theOps to pay the claim regarding the treatment of chemo therapy for Rs.90,000/-, the bills in this regard already being in the possession of Op no.1; to pay Rs.50,000/- by way of compensation on account of the harassment, unfair trade practice as also the deficiency in service on the part of the Ops and to award Rs.11000/- towards the expenses of the litigation.
- The cognizance of the complaint was taken against Op no.1 only, who on appearance filed the written version having raised certain preliminary objections, interalia, that the complaint is not maintainable for want of M/s Federal Mogul Goetze,(India) being a necessary party in the complaint and that the complainant had no cause of action to file the complaint as no reference of any repudiation to have been made by Op no.2 is made. As regards the facts of the complaint, it is denied by the Op that the complainant is insured under the Group Insurance Scheme got by Federal Mogul Goetze, Bahadurgarh, Patiala. The claim for Rs.6799/- was received by the Op from the complainant but the same was repudiated by Op no.2 vide letter dated 8.7.2014 on the ground that as per the insurance policy, the treatment done on OPD basis is not covered and the intimation in that regard was also sent to M/s Federal Mogul Goetze, (India)Ltd vide letter dated 8.7.2014 who did not raise any objection. It is further averred that from the bills and the prescriptions attached with the claim dated 29.5.2014, it is clear that the same does not pertain to the chemotherapy and therefore, is not payable by the Op. No specific details of any other claims, which may have been repudiated by Op no.2 have been provided in the complaint except the claim dated 29.5.2014, which was repudiated by Op no.2 vide letter dated 8.7.2014. Further details as regards the repudiation of the claim of the complainant could be provided by the op only on receipt of the claim details, if any, submitted by the complainant to the Op. As regards the legal notice dated 6.10.2014, got sent by the complainant against the Op, it is averred by the Op that the same is not found in the record of the Op. After denouncing the other averments of the complaint, going against the Op, it was prayed to dismiss the complaint.
- In support of his complaint, the complainant produced in evidence Ex.CA his sworn affidavit alongwith documents Exs.C1 to to C18 and the counsel for the complainant closed the evidence.
- On the other hand, on behalf of the Op, it’s counsel tendered in evidence Ex.OPA, the sworn affidavit of Smt.Kanta Devi, Deputy Manager, in the Divisional Office of the Op at Patiala alongwith documents Exs.OP1 to OP4 and closed the evidence.
- The complainant filed the written arguments. We have examined the same, heard the learned counsel for the parties and gone through the record on file.
- Ex.OP3 is the Group Mediclaim policy No.040600/48/13/41/00000345 issued by United India Insurance Co.Ltd., in favor of M/s Federal Mogul Goetze, (India) Limited valid for the period 1.12.2013 to 30.11.2014. Ex.OP4 is the Employee Benefits Manual, in respect of the client Federal Mogul Goetze (India)Ltd., and under the heading given on page no.3 Program Details, it is stated Group Mediclaim Cover provides insurance coverage to employees for expenses related to hospitalization due to illness, disease or injury.
- It was submitted by Sh.B.L.Bhardwaj, the learned counsel for the Op that it is no where stated by the complainant that his son Ishwinder Singh was ever got admitted in the hospital for imparting the treatment of chemotherapy. Already the Op has repudiated the claim of the complainant in respect of the claim of Rs.6799/- lodged vide mediclaim insurance policy claim form, Ex.OP2 dated 29th May,2014, vide repudiation letter Ex.OP1 dated 8.7.2014 on the ground that the treatment done on OPD basis is not payable. It is submitted by Sh.Bhardwaj that when Employee Benefits Manual,Ex.OP4 categorically provides the insurance coverage to employees for expenses related to hospitalization due to illness, disease or injury, any treatment in respect of the illness, disease or injury done on OPD basis is not reimbursable.
- It was fairly submitted by Sh.Bhardwaj, the learned counsel for the Op that under the policy, Ex.OP3, there is a waiver of 30 days waiting period and waiver of exclusion of condition 4.1,4.2,4.3and 4.4, 30 days pre and 90 days post hosp. covered, Corporate floater Rs.50 lacs without any sub-limit per family and without any restriction of critical disease. The complainant has placed on file the retail invoices Ex.C6 daed 29.7.2013 for the purchase of tablets Veenat-400MG(IMATINIB) for Rs.2700/-,Ex.C7 dated 28.8.2013 for the said medicine for Rs.7799/-,Ex.C8 the cash receipt dated 29.10.2013 obtained from Dr.Lal Path LabsChandigarh for Rs.5675/-,Ex.C9 cash receipt dated 8.8.2013 for Rs.225/- obtained from Dr.Lal Path Labs Chandigarh, Ex.C10, the receipt dated 9.1.2014 for Rs.1080/- for the purchase of serum + CBC blood from Medicos Centre, Chandigarh, Ex.C11, invoice–cum-cash receipt dated 1.5.2014 for Rs.5680/- obtained from Dr.Lal Path Labs, Chandigarh, Ex.C12, the retail invoice dated 1.6.2014 regarding the purchase of Tablet Veenat-400MG for Rs.8100/-,Ex.C13 the retail invoice dated 6.3.2014 for the purchase of the said medicine from Kumar Brothers (Chemists) Pvt. Ltd., Chandigarh and Ex.C14, the receipt dated 7.8.2014 for Rs.928/- for the purchase of Tissue Transglutaminase Antibody serum and CBC blood purchase from Medicos Centre, Chandigarh, Ex.C15, the retail invoice dated 19.8.2014 regarding the purchase of the tab.Veenat-400MG from Kumar Brothers (Chemists)Pvt.Ltd.Chandigarh,Ex.C16, the invoice –cum- cash receipt dated 29.10.2014 obtained from Dr.Lal Path Labs, Chandigarh, Ex.C17, the retail invoice dated 27.11.2014 for the purchase of the medicine Veenat-400MG and Ex.C18 retail invoice dated 20.2.2014 for the purchase of the aforesaid medicine for Rs.6597/- made from Kumar Brothers Limited. Except the retail invoice Ex.C6 dated 29.7.2013 for Rs.2700/- for the purchase of the Tablets Veenat-400MG, the other bills/invoices are not covered within the exclusions clause of 90 days from the date of the discharge from the hospital in as much as the son of the complainant was admitted in the PGI on 1.5.2013 and discharged on 14.5.2013 as would appear from the discharge summary Ex.C3 and as the cash receipts obtained from Dr. Lal Path Labs, are not the payments made for any treatment and rather the payments were made for clinical investigations mainly pertaining to blood.
- It was submitted by Sh. Bhardwaj that the retail invoice Ex.C6 is dated 29.7.2013 but the claim in respect of the same was never lodged by the complainant with the Op as can be said with a certainty with the help of Mediclaim Insurance Policy claim form Ex.OP2 dated 29th May,2014 lodged by the complainant with the Op for Rs.6799/- and the same does not cover the said retail invoice dated 29.7.2013. Even in the legal notice got sent by the complainant against the Ops, no detail of any claim to have been lodged by the complainant regarding the said cash invoice dated 29.7.2013 is made. Unless and until the claim was lodged by the complainant, there was no question of the same being repudiated. Here, it is important to note that on the one hand it is alleged by the complainant in para no.4 of the complaint that Op no.2 refused to entertain the claim on the ground that for claiming any compensation indoor admission for 24 hours is required but then it is alleged by the complainant in para no.5 that when the Ops did not respond about the e-mails sent by the complainant regarding the payment of the claim, he got the Ops served with a legal notice dated 6.10.2014. Then in the prayer clause, it is submitted by the complainant that the original bills worth Rs.90,000/-are already in the custody of Op no.1.
- As an upshot of our aforesaid discussion, we are of the considered view that in respect of the claim of Rs.51,723/- as detailed out in the sworn affidavit Ex.CA of the complainant only claim regarding the retail invoice dated 29.7.2013 Ex.C6 for Rs.2700/- could be admitted by the Op being within the period of 90 days from the date of the discharge of the patient from the hospital while the other bills/cash memos are beyond that period and the cash invoices obtained from the Dr.Lal Path Lab do not pertain to any treatment. Consequently, we do not find any substance in the complaint and the same is hereby dismissed with the observation that the complainant may if so advised lodge the claim in respect of cash invoice dated 29.7.2013 for Rs.2700/- and the Op shall not raise plea of limitation as the complainant shall be entitled to the exclusion of the period spent by him in pursuing his remedy before this Forum.
Pronounced Dated: 10.9.2015 Sonia Bansal Neelam Gupta D.R.Arora Member Member President | |
