| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 288 of 25-10-2018 Decided on : 24-1-2022 Jagtar Singh aged about 54 yeas son of Swaran Singh @ Sarwan Singh R/o VPO Khemuana, Tehsil Goniana Mandi, District Bathinda. ........Complainant Versus Oriental Insurance Co. Ltd, Oriental House A-25/27, Assaf Ali Road, New Delhi, 110002, through its The M.D/D.M/ In-charge. Oriental Insurance Co. Ltd, Divisional House 4501, Ist Floor, Bank Bazar, Bathinda, through the Divisional Manager. Raksha TPA Pvt, Ltd, Tower 359,360, First Floor, Sector 44-D,Chandigarh 160047, through its Managing Director. PNB- Oriental Royal Medi Claim, Policy Schedule, Bank Street, Bathinda 1510001, through its Branch Manager. .......Opposite parties.
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member. Smt. Paramjeet Kaur, Member Present : For the complainant : Sh. Naveen Goyal, Advocate For the opposite parties : Sh. J D Nayyar, counsel for OPs No. 1 to 3 Sh. Rajan Singla, counsel for OP No. 4. ORDER Kanwar Sandeep Singh, President The complainant Jagtar Singh (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against Oriental Insurance Company Ltd, and others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that he is working as foreman in BCL Industries, Hazi Rattan Link Road, Bathinda. He purchased Insurance policy from opposite parties bearing No. 233200/48/2017/4481, insured code 60531239 which was issued on 29-03-2017 and valid up to 28-03-2018. Thereafter said policy was renewed vide policy No. 233200/48/2018/4585 on 29-03-2018 and valid up to 28-03-2019. In that scheme, all the dependents of the complainant have also been insured for total sum of Rs, 1,00,000/- The opposite parties never issued complete terms and condition of the policy to complainant and only policy was issued. As per this insurance complainant and his dependents are fully covered under medical insurance under cashless scheme for Rs. 1 lacs each. It is alleged that on 24-01-2018 complainant met with a road side accident within revenue limit of PS Nehianwala and in this connection FIR No. 12 dated 02-02-2018 under section 279/337/338 IPC was registered. After accident, complainant was admitted in Ortho Care Hospital, Ganesha Basti, Bathinda, and remained admitted from 24-01-2018 to 03-02-2018 and he paid an amount of Rs, 39,463/- to the said hospital from his own pocket under compelling circumstances. It is further alleged that after treatment, complainant filed claim with opposite party No.3 and fulfilled all formalities as required by the opposite parties and also sent bill amounting to Rs, 39,463/-, but the opposite parties did not pay any payment under insurance policy intentionally and purposely, whereas they are duty bound to make the payment to the hospital before discharge of the complainant. The opposite parties intentionally and purposely harassed the complainant without any cause to swallow the amount of Rs. 39,463/-. It is alleged by complainant that before issuing the policy the agent of opposite parties kept on visiting the house of the complainant for issuing the policy and at that time, opposite parties also committed and promised to make the payment immediately in case of any mishap but now the complainant is running from pillar to post get his rightful claim. The complainant approached the officials of the opposite parties repeatedly and requested them to reimburse the amount incurred by him on his medical treatment, but they refused to do anything in the matter rather they rejected the claim without disclosing any reason. The complainant also got issued legal notice in this regard and Oriental Insurance Company given reply of notice on the basis of false facts. It is further alleged that the above said act of the opposite parties is illegal, arbitrary, unconstitutional and against principles of natural justice and due to this, the complainant has suffered financial loss for which he claims compensation to the tune of Rs. 1.00 Lac. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay claim amount of Rs. 39,463/- with interest @ 18% and Rs. 1,00,000/- as compensation in addition to Rs. 10,000/- as litigation expenses. Upon notice the opposite parties put in appearance through their repective counsel and contested the complaint by filing separate written reply. In their joint written reply, the opposite party No.1 to 3 raised legal objections that complaint is not maintainable in the present form and the complainant does not have any cause of action to file the present complaint; that this Commission does not have the jurisdiction to try and entertain the present complaint; that the complainant has filed false and frivolous complaint; that the complainant is not entitled to the relief prayed for; that the complainant is not consumer and that there is no deficiency in service on the part of the opposite parties. It is pleaded that the actual facts of the case are that the complainant obtained PNB- Oriental Royal Medi Claim Policy, vide policy No.233200/48/2017/4481 effective from 29-03-2017 to 28-03-2018 with sum insured Rs, 1,00,000/- and the complainant had been informed then and there that the claim if any shall be paid subject to the rules and regulations and terms and conditions of the policy, the copy of which had been supplied to him then and there along with the copy of the insurance policy. It is further pleaded that the complainant informed to have received injuries on 24-01-2018 regarding which FIR No.12 dated 02-02-2018 was recorded in PS Nehianwal, District Bathinda and he also informed that after the accident, he was admitted in hospital and remained admitted at Ortho Care Hospital G.T Road Bathinda for the period from 24-01-2018 to 03-02-2018. As per the procedure, the case of the complainant along with all the documents supplied by him were sent to the TPA i.e. opposite parties No.3 whose panel of experts and doctors, after going through the documents found that in the discharge summary/discharge card Dr. Shoubhic Kaushal of Ortho care Hospital has mentioned “ patient is Osteo Penic due to chronic Alcoholism History of Chronic Alcoholism consuming about 250 ml to 280 ML of whiskys daily from the past 15 years”. This report of the doctor, which was provided by the complainant himself clearly goes to provide that it was a clear cut case of violation of terms and conditions of aforesaid Medi claim policy. It is further pleaded that the complainant is a known case of Chronic Alcoholism so claim of the complainant has rightly been repudiated by Raksha TPA vide email dated 18-07-2018 and thereafter on the same ground by the opposite parties by vide registered letter dated 29-09-2018, as such claim of the complainant is not payable. On merits, the opposite party No.1 to 3 pleaded that the capital sum insured was Rs, 1,00,000/- and it was a family floater policy i.e. all the insured persons were entitled for medi claim together for Rs, 1,00,000/- and not each member. Moreover the claim if any, was subject to rules and regulations, terms and conditions of the policy the copy of which was supplied to the complainant along with the Insurance policy. Had the complainant not received the terms and conditions he was at liberty to ask the opposite party for the same. It is further pleaded that the complainant had been fully apprised regarding repudiation of claim and the reasons thereof. There has been nothing illegal, arbitrary, unconstitutional and against the principles of natural justice. The complainant has not suffered any mental agony, harassment or financial loss as alleged. The complainant is not entitled for any such compensation, litigation expenses or any such payment of medical bills. After controverting all other averments, the opposite parties No. 1 to 3 prayed for dismissal of complaint. In separate written reply opposite party No. 4, also raised legal objections that complainant has concealed material facts and documents from this Commission as well as from opposite party No. 4, therefore, complainant is not entitled to any relief. It has been pleaded that the complainant has concealed the fact that he purchased the policy in question of opposite parties No.1 & 2 voluntarily, of his own accord after paying premium against the policy in question directly to opposite parties No.1 and 2. However, complainant took benefit of opposite party No. 4 being the account holder of opposite party No. 4 as the premium is less to account holders of opposite party No. 4, otherwise opposite party No. 4 has no concern with the purchase of alleged policy by complainant from opposite parties No.1 and 2 from any corner as the complainant has not paid the premium of the policy in question through opposite party No. 4. Further legal objections are that there is no cause of action or locus standi against opposite party No. 4. The complainant purchased the insurance policy in question from the opposite parties No.1 and 2 directly his own free will; that the complainant is estoped from filing the present complaint; that the complainant is not consumer of opposite party No. 4 qua the alleged cause of action; that the present compliant is not maintainable and that the complaint is bad for mis-joinder of parties as the complainant has unnecessarily impleaded the replying opposite party. On merits, the opposite party No. 4 pleaded that the complainant has not purchased the policy in question through opposite party No. 4 nor the complainant has paid the premium against the policy in question to opposite parties No.1 and 2 through his account maintained with opposite party No. 4. Rather the complainant has purchased the policy of opposite parties No.1 and 2 directly. The allegations are totally false and baseless. No legal notice has been received by opposite party No. 4. After denying other averments of the complaint, the opposite party No. 4 prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence photo copy of policy (Ex.C-1 & Ex.C-2), photocopy of FIR (Ex.C-3), photocopy of medical bills containing 15 pages (Ex.C-4), photocopy of letters (Ex.C-5 to Ex.C-8), photocopy of legal notice (Ex.C-9), photocopy of receipts ( Ex.C-10 to Ex.C-12), photo copy of rely to legal notice ( Ex.C-13), photocopy of prescription (Ex.C-14) affidavit of Jagtar Singh dated 20-10-2018 (Ex.C-15) and closed the evidence. In order to rebut the evidence of complainant, the opposite party No.1 to 3 tendered into evidence affidavit of Ashwani Kumar dated 02-01-2019 (Ex.OP1/1), photocopy of letter (Ex.OP1/2 & Ex.OP-1/3), photocopy of reply to legal notice (Ex.OP1/4), photo copy of policy (Ex.OP-1/5), photocopy of claim form ( Ex.OP-1/6), photocopy of policy (Ex.OP-1/7), photocopy of bill ( Ex.OP-1/8), photocopy of discharge card ( Ex.OP-1/9) and closed evidence. The opposite party No.4 also tendered into evidence affidavit of Manmath Nath Sethi dated 29-01-2019 ( Ex.OP-4/1), photocopy of account statement ( Ex.OP-4/2) and closed the evidence. We have heard learned counsel for the parties and gone through the record. There is no dispute between the parties that complainant and his dependents were insured vide PNB-Oriental Royal Med-claim Policy Schedule 233200/48/2017/4481 for the period from 29-3-2017 to 28-3-2018 for Rs. 1.00 Lac (Ex. C-1). The complainant met with an accident on 24-1-2018 and he remained admitted in Ortho Care Hospital, Bathinda, for the period from 24-1-2018 to 3-2-2018. F.I.R. No. 0012 dated 2-2-2018 (Ex. C-3) at P S Nehianwala, was registered in this regard. After discharge from hospital, complainant submitted his claim amounting to Rs. 39,463/- and opposite parties repudiated claim of the complainant vide letter dated 29-8-2018 (Ex. C-7). A perusal of repudiation letter dated 29-8-2018 (Ex. C-7) reveals that the opposite parties No. 1 & 2 have repudiated the claim of the complainant under Clause 4.7 of the Insurance policy. Clause 4.7 of the Insurance policy reads as under :- “ Convalescence, general debility, “run down” condition or rest cure, congenital external and internal disease or defects or anomalies, sterility, any fertility, sub fertility or assisted conception procedure, venereal diseases, intentional self injury/suicide, all psychiatric and psychosomatic disorders and diseases/accident due to and/ or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc”. The claim submitted by complainant was perused by opposite party No. 3 and after perusal of claim, opposite party No. 3 submitted their observation and opinion to opposite parties No. 1 & 2 as under “- TBW for medical malleolus + Rush Nail for Fibula # - Patient is chronic alcoholic and regularly take alcohol. Alcohol may be a cause for accident and alcohol related expenses are permanent exclusion as per policy terms and conditions. So the claim is recommended to be non-payable as per clause 4.7. Ex. OP-1/9 is the Discharge Card issued by Dr. Shoubhic Kaushal of Ortho Care Hospital. A special note has been given by said doctor on this Discharge Card that : Patient is Osteopenic due to Chronic Alcoholism K/C/O Chronic Alcoholism consuming about 250 ml- 280 ml of whisky daily from past 15 years.” H/O Binge alcohol intake - Positive Even on this Discharge Card while prescribing medicine for post operative period, the said doctor has given advise to complainant to quit Alcohol consumption. Hence, it is proved fact that the complainant consumes 250-280 ml whisky daily from past 15 years. Thus, due to Chronic Alcoholism he is Osteopenic. Moreover, after accident, at the time of admission in Hospital, complainant was found with Binge Alcohol intake as positive which itself proves that at the time of incident, complainant was under the influence of liquor. Since the alcohol related expenses are permanent exclusion as per policy terms and conditions, the claim of the complainant is not payable under clause 4.7 of the policy, the opposite parties No. 1 & 2 rightly repudiated the claim of the complainant. The complainant has placed on file a certificate dated 30-10-2018 (Ex. C-14) issued by Dr. Shoubhick Kaushal of Ortho Care Hospital to the effect that on 24-01-2018 at the time of admission in the said hospital, complainant was not under influence of alcohol and was fully conscious. This certificate is an after thought. This certificate was issued by doctor on 30-10-2018 whereby the doctor has given opinion regarding patient who was admitted on 24-01-2018 i.e. nine months old case. Moreover, this evidence was collected/obtained by complainant after filing of complaint before this Commission. Therefore, the complainant failed to prove any deficiency in service on the part of the opposite parties in repudiating his claim. In the result, this complaint fails and is hereby dismissed with no order as to costs. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 24-01-2022 (Kanwar Sandeep Singh) President (Shivdev Singh) Member (Paramjeet Kaur) Member
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