Chandigarh

StateCommission

A/13/2017

The Oriental Insurance Company Ltd. - Complainant(s)

Versus

Vikrant Goyal - Opp.Party(s)

R C Gupta, Adv.

24 Jan 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

Appeal No.	:	13 of 2017
Date of Institution	:	13.01.2017
Date of Decision	:	24.01.2017

 

The Oriental Insurance Company Ltd., Divisional Office-2, SCO No.48-49, Sector 17-A, Chandigarh through its Senior Divisional Manager, now through the Authorized Signatory of Chandigarh Regional Office, SCO 109-110-111, Surindera Building, Sector 17-B, Chandigarh. 

……Appellant/opposite party no.1

V e r s u s

1. Vikrant Goyal son of Sh.Suresh Goyal, age 40 years, resident of 1001-D, Sector 21, Panchkula, at present House No.2146, Sector 21, Panchkula.
2. Shikha Goyal wife of Vikrant Goyal, age 40 years, resident of 1001-D, Sector-21, Panchkula, at present House No.2146, Sector 21, Panchkula.

   ....Respondents/complainants

3. Medi Assist India TPA Pvt. Ltd., SCO 61, IInd Floor, Phase-VII, Mohali, SAS Nagar, Punjab.
4. Alchemist Hospital, Registered Office, Sector 21, Panchkula 134112, Haryana, through its Medical Superintendent.
5. Punjab National Bank, Saket, Chandimandir, District Panchkula, Haryana.

   ....Respondents/Opposite Parties No.2 to 4

Appeal under Section 15 of the Consumer Protection Act, 1986.

BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                MR. DEV RAJ, MEMBER.

                MRS. PADMA PANDEY, MEMBER

 

Argued by: Sh.R.C. Gupta, Advocate for the appellant.   

 

PER JUSTICE JASBIR SINGH (RETD.), PRESIDENT

                This appeal is directed against an order dated 29.11.2016, rendered by the District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (hereinafter to be called as the Forum only), vide which, it accepted a complaint, filed by the complainants (now respondents no.1 and 2).

2.         As per facts on record, respondents no.1 and 2/complainants purchased a Medical Insurance Policy namely Oriental Royal Medi-Claim Policy, covering both the complainants and also their minor son Varundeep Goyal. The said policy was purchased through opposite party no.4, for a sum of Rs.2.00 lacs. It was initially purchased by the complainants on 01.10.2012, which was renewed, from time to time and was valid till 12.10.2015.  Before the last renewal, in the year 2014, no claim whatsoever was raised by the complainants, qua any medical treatment.

                Complainant no.1 was got admitted in Alchemist Hospital on 21.11.2014, Sector 21, Panchkula.  He was operated upon, due to Obscure Overt GI bleed cause Gastro Intestinal Stromal Tumor and remained hospitalized from 21.11.2014 to 05.12.2014, for the said surgery/treatment, for which, a bill for an amount of Rs.2,99,056/- was raised by the hospital. Cashless facility was declined by the appellant and the complainants were made to pay Rs.2,99,056/-, for the above said medical treatment. Thereafter, claim was submitted to realize the above said amount, however, it was repudiated by the appellant, vide letter dated 16.03.2015 with the following observations:-

 

‘Policy: PNB Oriental Royal Mediclaim insurance Policy DOA:22/11/14 DOD: 05/12/14 Diagnosis: obscure overt GI bleed-small bowel Gastro intestinal stromal tumour, CAD, Schizophrenia on perusal of claim documents, it is noted that as per treating Doctor Certificate attached, the cause of GIST is unknown and most likely genetic in nature. As per terms and conditions, genetic disorders are not covered under the present Policy conditions.  Hence, the present claim is falling under exclusion clause 4.1 and is being denied.  Hence, we regret our inability to admit this liability under the present policy conditions and the claim is being repudiated under exclusion clause 4.1 of above mentioned policy.  We also reserve the right to repudiate the claim under any other ground/s available to us subsequently.’   

3.         Primarily, the claim was declined by taking note of discharge note, written by a Doctor of Alchemist Hospital. It was stated that, as per Doctor, cause of GIST was most likely genetic in nature. Stating that genetic disease was not covered under the policy, claim was rejected. The complainants alleged before the Forum that there was no evidence to say that disease was genetic or that any misrepresentation was made by the complainants, when policy was obtained. Their claim was opposed by the appellant, on the grounds, referred to above.
4.          The Forum vide order under challenge allowed the complaint and directed the appellant to pay an amount of Rs.2 lacs to the complainants alongwith litigation expenses of Rs.5,000/-, to be paid within a period of 30 days, from the date of receipt of a certified copy thereof. Hence this appeal.
5.         We have heard Counsel for the appellant, at the preliminary stage and have also gone through the entire record, and are satisfied that there is no evidence on record worth the name to say that disease suffered by one of the complainants was genetic in nature. If any benefit of exclusion clause in the Policy is claimed by the appellant, it is for it, to prove on record with cogent evidence that the disease was genetic in nature. Simply, one unconfirmed/vague report given by a Doctor, cannot be relied upon to deny relief to the claimants. The same fact was noticed in the judgment under challenge by the Forum. It was observed as under:-

“The complainants have valid medical health insurance policy with effect from 1.10.2012 to 12.10.2015 for sum assured of Rs.2.00 lacs.  The complainant NO.1 suddenly fell ill on 21.11.2014 and operated upon for Obscure Overt GI bleed cause Gastro Intestinal Stromal Tumor and remained admitted in the hospital of Opposite Party No.3 from 21.11.2014 to 05.12.2014 for the said surgery/treatment.  Before claiming for his ailment from Opposite Party NO.1 for the period from 21.11.2014 to 05.12.2014, the complainant NO.1 never claimed any other insurance claim benefit from Opposite Party NO.1.  Dr.Daksh Khurana of Alchemist Hospital Ltd., who treated the complainant No.1, has given his observation in Certificate (at Page 74), the relevant portion of which reads as under:-

 “…Vikrant Goyal is admitted in hospital on 21-11-2014 & discharged on 05-12-2014.  He is suffering from Obscure Overt GI bleed cause Gastro Intestinal Stromal Tumor & underwent surgery on 24-11-2014. Etiology for disease is unknown most likely genetic & he does not require any further management.”

 The observation of Dr.Daksh Khurana in the said certificate that origin for the disease is unknown mostly likely genetic, is totally superficial and casual in nature. If the cause or origin of the disease is unknown, as per observation of Doctor, then how can he said this to be genetic?  The observation of Dr.Daksh Khurana of Alchemist Hospital, is vague and self-contradictory too. He has casually pointed out this and observed without having any hereditary/genetic medical record of the claimant/complainant NO.1 with him.  More so, the Opposite Party NO.1 has also failed to produce any documentary proof to prove the said disease of complainant NO.1 being genetic/hereditary.  There must be something on record with reference to medical record of ascendants of the complainant NO.1.  There is no evidence on record that the Complainant No.1 had any history of suffering from Schizophrenia.  Nonetheless, the medical claim for disease/surgery on account of Gastro Intestinal Stromal Tumor cannot be denied. Therefore, the claim of complainants for medical claim of Rs.2.00 lacs under the policy in question is legally valid and maintainable.  The Opposite Party NO.1 cannot repudiate the claim merely on the observation of Dr.Daksh Khurana, which is totally untenable under the law. Therefore, the repudiation of medical claim of complainants by Opposite Party NO.1 is held to be unjustified and amounts to deficiency in service on its part.”

6.         It was rightly noticed that except one small vague note given by a Doctor, there is no other evidence on record to say that disease suffered by the one of the complainants was genetic in nature. Besides as above, not even a single piece of evidence was brought on record to prove the defence taken by the appellant. The rejection of claim by the appellant was totally uncalled for. It shows the appellants` mindset to harass its customers. For two years, of a valid policy, when no claim was raised by the complainants, the appellant was happy, however, when a genuine claim was raised, it was rejected by it, which amounts to deficiency in rendering service and adoption of unfair trade practice, on the part of the appellant. The appellant has failed to make out any case, for getting the order impugned set aside.
7.         For the reasons recorded above, the appeal being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the Forum is upheld.
8.         Certified copies of this order, be sent to the parties, free of charge.
9.         The file be consigned to Record Room, after completion.

Pronounced.

24.01.2017

Sd/-

[JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

 

 

 

Sd/-

(DEV RAJ)

MEMBER

 

 

Sd/-

 

(PADMA PANDEY)

        MEMBER

 

 

Rg