Haryana

Karnal

CC/257/2016

Harbhajan Lal Malhotra - Complainant(s)

Versus

Medi Assist India TPA Private Limited - Opp.Party(s)

S.K. Malhotra

13 Jun 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                              Complaint No.257 of 2016

                                                             Date of instt.: 01.09.2016

                                                               Date of decision:13.06.2017

 

Harbhajan Lal Malhotra son of Shri Des Raj, resident of House no.11, sector 8, Urban Estate, Karnal age 74 years.

 

                                                                   ……..Complainant.

                                      Vs.

1. Medi Assist India TPA Private Ltd. through its office Incharge, 8-B Second Floor, Tej Building, Bahadur Shah Jaffar Marg, New Delhi.

2. Oriental Insurance Company Limited through its Branch Manager, above Oriental Banka of Commerce Building Meera Ghati Chowk, Karnal.

 

                                                                   ………… Opposite Parties.

 

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Ms. Veena Rani……..Member

                   Sh.Anil Sharma…….Member.

 

Present:-     Shri S.K.Malhotra  Advocate for complainant.

                   Opposite party no.1 already exparte.

                   Shri Ravinder Chaudhary Advocate for opposite party no.2.

                    

 ORDER:

 

                   This complaint has been filed by the complainant u/s 12 of the Consumer protection Act 1986, on the averments that he obtained Medi Claim Policy, PNB-Oriental Royal Mediclaim Policy for Punjab National Bank Account Holders in the year 2010 and the same was renewed every year regularly. The last relevant policy no.261301/48/2016/1271 was valid from 8.8.2015 to 7.8.2016. The said policy being a Floater Policy also covered the risk of his wife late Smt. Veena Malhotra, who had been suffering from “Cryptogenic Cirrhosis of Liver with Lesion Right Lobe Liver and in Portahepatic “ since 2013 and regularly treated for the same at various Medical centers like Medanta Medicity Gurgaon, Artemis Hospital Gurgaon, Apollo Hospital New Delhi and specialists at Karnal. She was treated twice as indoor patient at Medanta Hospital. The claims with respect to earlier two admissions/treatments were lodged under the existing policy and opposite party no.1 allowed one claim for Rs.57840/- on 22.03.2013 and another claim for Rs.99,303/- on 9.5.2014. On 29.12.2015 his wife again developed the same problem and she was taken to Apollo hospital, as she complained of free liquid in Periteniel. Dr. Vishal Garg at Apollo Hospital after various clinical tests and CT Scan, found a large poorly marginated heterogeneous hypervascular SOL. Again on 8.1.2016 she was taken to Artemis Hospital for second opinion from Dr. Rakesh Chopra Head of Department Oncology. After number of clinical tests and PET Scan, it was found that she was not in a fit state of health to undergo any surgery and she was advised to be treated conservatively with Nexavar Tablets regularly as per the advice of the doctors. On 27.1.2016, in the early hours of the day, she complained of acute pain in abdomen and started vomiting due to the Liver ailment. Therefore, she was admitted in Karnal Nursing Home of Dr. V.K.Singla, where she remained as indoor patient for 2 days and was discharged when became a bit stable and was advised to take Nexavar Tablet. However, she had grown weak and was not in a position to resist the disease any more and ultimately expired on 27.2.2016. The mediclaim of Rs.2,76,140/-  with respect to her treatment for the period of 29.12.2015 to 15.2.2016 was submitted with opposite party no.2 on 15.2.2016, which was duly forwarded to opposite party no.1 for settlement under the terms of the policy, as opposite party no.1 was appointed by opposite party no.2 to settle the mediclaims. All necessary documents in support of the claim were duly attached with the claim from. On 18.3.2016 the representative of opposite party no.1 namely Chanderkant visited him to collect/verify more documents, which were furnished accordingly. The said representative even verified the record of Karnal Nursing Home. However, opposite party no.1 did not settle the claim on one pretext or the other. Therefore, on 18.4.2016 he visited the office of opposite party no.1 at Noida.  He was again given a letter to furnish information and accordingly required information was given by him alongwith the letter. There was no further response from the opposite party no.1, therefore, he again visited the opposite party no.1 at Noida on 17.5.2016. He was handed over a letter raising certain objections which also replied by him. Lateron, he came to know about repudiation of the claim from opposite party no.2. Even the request of opposite party no.2 to opposite party no.1 on 25.7.2016 to reconsider the claim on the ground that earlier two claims with respect to the same disease were allowed, was declined on 27.7.2016. The repudiation of the claim by opposite party no.1 is illegal, arbitrary and against the terms and conditions of the policy, due to which he suffered mental pain and agony apart from financial loss.

2.                Notice of the complaint was given to the opposite parties. None put into appearance on behalf of opposite party no.1, therefore, exparte proceedings were initiated against it, vide order dated 7.12.2016.

3.                Opposite party no.2 put into appearance and filed written statement disputing the claim of the complainant. It has been submitted that the complainant had submitted the claim form for settlement of the claim and the same was duly forwarded by opposite party no.2 to opposite party no.1 for settlement of the claim. The complainant had not submitted some documents alongwith the claim form and the letters dated 18.4.2016 and 17.5.2016 were written to him by opposite party no.1 to furnish (i) all original receipts, (ii) all investigation film with report and all other original documents for further processing the claim. Infact, on scrutiny of the claim documents, it was observed that the claim was not admissible as “no active line of treatment given.” The claim was not within the purview of the policy terms and conditions, therefore, the same was repudiated on 8.6.2016 and a letter in that regard was sent to the complainant on the same day. Therefore, the complaint is not maintainable. The other averments made in the complaint have been specifically denied.

3.                In evidence of the complainant, his affidavit Ex.C1 and documents Ex.C2 to C26 have been tendered.

4.                On the other hand, in evidence of the opposite party no.2, affidavit of R.S.Bahlan Senior Divisional Manager Ex.R1 and documents Ex.R2 to Ex.R6 have been tendered.

6.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.                The complainant had obtained PNB-Oriental Royal Mediclaim Policy, being Account Holders of Punjab National Bank, in the year 2010 and got renewed the same every year. Lastly, the policy was renewed for the period of 8.8.2015 to 7.8.2016. As per the case of the complainant, his wife late Smt. Veena Malhotra had been suffering from “Cryptogenic Cirrhosis of Liver with Lesion Right Lobe Liver and in Portahepatic“ since 2013 and she got treatment from various hospitals. In respect of previous treatment two claims were allowed by opposite party no.1 one for  Rs.57840/- on 22.3.2013 and second for Rs.99303/- on 9.5.2014. It has further been alleged that on 29.12.2015 she was taken to Apollo Hospital where various clinical tests and CT Scan were done and the doctor found a large poorly marginated heterogeneous hypervascular SOL. Again on  8.1.2016 she was taken to Artemis Hospital and after conducting clinical tests and PET Scan, it was found that she was not in a fit state of health undergo any surgery. Therefore, she was advised to be treated conservatively with Nexavar Tablets. It has also been alleged that on 27.1.2016 she was admitted in Karnal Nursing Home of Dr. V.K. Singla with the complaint of acute pain in abdomen and vomiting due to the Liver ailment, where she remained as indoor patient for two days and was discharged when she became a bit stable. However, she expired on 27.2.2016. The complainant lodged claim with opposite party no.2 for Rs.2,76,140/- for treatment of his wife for the period of 29.12.2015 to 15.2.2016, but the claim was repudiated by opposite party no.1, vide letter dated 8.2.2016.

8.                Learned counsel for the complainant laid emphasis on the contention that the wife of the complainant remained admitted in Karnal Nursing Home for two days due to acute pain in abdomen and vomiting on account of liver problem and prior to that she was got checked from Apollo Hospital and Artemis Hospital and for her treatment an amount of Rs.2,76,140/- was spent by the complainant. The claim was admissible as per conditions no.2.2, 2.8 and 2.9 of the terms and conditions of the policy Ex.C22/R6. It has further been argued that the certificate issued by Dr. V.K.Singla of Karnal Nursing Home Ex.C22 clearly shows that the patient was admitted with acute abdominal pain associated with vomiting. She was put on conservative treatment and responded to the treatment. He also clarified that the patient was known case of Cryptogenic Cirrhosis of Liver with Lesion Right Lobe Liver and in Portahepatic. Thus, active regular treatment was given by the Doctor of Karnal Nursing Home to the wife of the complainant and she remained admitted in the said hospital for two days, therefore, repudiation of the claim by opposite party no.1 was arbitrary, illegal and against the terms and conditions of the policy.

9.                To wriggle out the aforesaid contentions learned counsel for the opposite party no.2 vehemently argued that as per condition no.4.20 of the policy, the copy of which is Ex.R6/C22, any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist, is excluded. The wife of the complainant was admitted in Karnal Nursing Home only for pain of abdomen and vomiting, she was treated conservatively and no active regular treatment was given to her by a specialist, therefore, the claim of the complainant was rightly repudiated.

10.              Thus, the matter in controversy boils down into a narrow compass and main question which falls for consideration is whether the claim of the complainant falls within the purview of exclusion clause no.4.20 of the terms and conditions of the insurance policy.

11.              The wife of the complainant was patient of Cryptogenic Cirrhosis of Liver with Lesion Right Lobe Liver and in Portahepatic. The opposite parties had allowed two claims regarding her treatment one for Rs.57,840/- and the other for Rs.99,303/-, as is evident from the documents Ex.C3 to Ex.C5. Her CT Scan Abdomen with contrast was done on 2.1.2016 in Apollo Hospital Delhi and the copy of the report is Ex.C6. Her whole body Positron Emission Tomography with contrast enhanced CT Scan was done in Artemis Hospital on 9.1.2016 and copy of the report is Ex.C8. Copy of the discharge summary of Karnal Nursing Home prepared by Dr. V.K. Singla is Ex.C3, according to which she was admitted in the said hospital on 27.1.2016 with complaint of acute abdomen pain associated with vomiting. She was put on conservative treatment, to which she responded. She had recovered from the pain and vomiting, therefore, discharged and advised further to continue with the previous management i.e. Tablet Nexavar 400 BD. It was also clarified that she was a known case of Cryptogenic Cirrhosis of Liver with Lesion Right Lobe Liver and in Portahepatic. The problem of acute abdominal pain and vomiting related to the liver problem with which she was suffering and she was given regular treatment for two days in Karnal Nursing Home. She was not treated as OPD patient, rather she remained admitted in the hospital from 27.1.2016 to 28.1.2016. Therefore, it cannot be said that no active treatment line was given to her during her stay in Karnal Nursing Home. Had active treatment not been given, she could not recover. She responded to the treatment given to her and was discharged from the hospital after recovery from abdominal pain and vomiting. Under such facts and circumstances, the case of the complainant does not fall within the purview of the exclusion clause 4.20 of the terms and conditions of the policy. It is also worth pointing out that even opposite party no.2 wrote letter the copy of which is Ex.C20, to opposite party no.1 for reconsideration of the claim of the complainant in light of the previous claims paid to the complainant regarding treatment of his wife. However, the opposite party no.1 denied the claim on the ground that the patient was treated conservatively on OPD basis and no active regular treatment was given as per discharge summary. Infact, the patient was not treated on OPD basis, rather it is amply clear from the discharge summary that she got treatment as indoor patient, she was admitted on 27.1.2016 and discharged on 28.1.2016.

12.              In view of the aforediscussed facts and circumstances, we have no hesitation in observing that repudiation of the claim of the complainant by opposite party no.1 on the ground that no active line of treatment was given to his wife in Karnal Nursing Home is not legally justified, therefore, the same amounted to deficiency in service on the part of the opposite parties. The complainant is entitled to claim the expenses incurred by him on treatment of his wife as per terms and conditions of the policy and his case does not fall within the ambit of exclusion clause no.4.20 of the policy. The complainant has given summary of the expenses incurred by him on the treatment of his wife Ex.C10. Letter of the complainant dated 17.5.2016, the copy of which is Ex.C17 shows that he had already submitted the twenty three bills duly signed by the doctors alongwith prescribed performa on 18.4.2016 and the same was got checked at the counter of opposite party no.1 and thereafter submitted the copy of the performa i.e. the detail of the vouchers alongwith the said letter.

13.              As a sequel to the foregoing discussion, we accept the present complaint and direct the opposite parties to reimburse the amount of Rs.2,76,140/- to the complainant alongwith interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the opposite parties to pay Rs.20,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 13.06.2017

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

 

                             (Veena Rani)   (Anil Sharma)

                               Member             Member