| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 177 of 5-07-2018 Decided on : 12-1-2022 Labh Singh Bhullar S/o Sh. Pilla Singh, R/o H. No. 20798, Street No. 24-A, Ajit Road, Bathinda. ........Complainant Versus Oriental Insurance Co. Ltd., Divisional Office 4501, Bank Bazar, Bathinda through its Manager Oriental Insurance Co. Ltd., A-25/27, Asaf Ali Road, New Delhi 110 002, through its Managing Director Medi Asstt. TPA Pvt. Ltd., Tower D, 4th Floor, IBC Knowledge Park 41, Bannergahatta Road, Bangalore through its Managing Director
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Kanwar Sandeep Singh, President Smt. Paramjeet Kaur, Member Present For the complainant : Sh. Kulwinder Singh, Advocate For opposite parties : Sh. J D Nayyar , Advocate. ORDER Kanwar Sandeep Singh, President The complainant Labh 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 Co. Ltd., and anothers (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that he is holder of Policy No. 233200/48/2016/4039 valid from 14-3-2016 to 13-3-2017 and thereafter renewed vide policy No. 233200/48/2017/4224 valid upto 13-3-2018. It is alleged that complainant received only cover note from opposite party No. 2. The opposite parties issued only card to the complainant but no terms and conditions has been issued. It is also alleged that complainant went to Mumbai in the first week of November, 2017 to meet his son. After some days, he suffered pain in his back and leg. He consulted Dr. Sonawane's Hospital and the doctor advised him for MRI L.S. Spine from Gurmeet Imaging Comprehensive Diagnostic Solutions. After going through MRI report, Dr. Aninash Sonawane advised the complainant to take immediate treatment otherwise the problem will increase resulting major operation. On the advise of said doctor, complainant started taking treatment and he remained admitted in the hospital from 6-12-2017 to 7-12-2017. The complainant was provided treament by Dr. Avinash B Sonawane, Navi Mumbai and during admission, he was undergone various tests. The complainant alleged that since his immediate treatment was required and he was in Mumbai at that time, he could not give intimation to the opposite parties prior to treatment. So on 1-1-2018, after taking treatment, at Mumbai, when complainant came back to Bathinda, he submitted claim bills to the opposite parties and completed all the requisite formalities. The officials of the opposite parties assured the complainant that they will reimburse the bills as early as possible but vide letter dated 28-1-2018, the opposite parties repudiated the claim of the complainant on false pretext that minimum period of stay should be 24 hours except for specified procedures/treatment where such admission could be for a period of less than 24 consecutive hours. It is further alleged that complainant remained admitted for two days in the hospital at Mumbai. The claim of the complainant has been illegally rejected by the opposite parties. The complainant spent total amount of Rs. 23,171/- on his treatment and thus, he is entitled to the said amount being treatment expenses. The complainant alleged that he made repeated requests to the opposite parties to pay his claim, but to no effect. Due to said illegal and arbitrary act of the opposite parties, complainant is suffering great mental tension, agony, botheration and harassment for which he claims compensation to the tune of Rs. 25,000/-. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to reimburse the medical expenses to the tune of Rs. 23,171/- and also pay him Rs. 25,000/- as compensation in addition to Rs. 11,000/- as litigation expenses. Upon notice, opposite parties appeared through counsel and contested the complaint by filing written reply. In written reply, the opposite parties raised preliminary objections that complaint is not maintainable; complainant does not have any cause of action; this Commission has got no juridiction to try and entertain the complaint; complainant has filed false and factitious complaint and unncessary dragged the opposite parties into uncalled litigation; that the complainant is not consumer; complainant is estopped from filing the complaint and that there is no deficiency in service on the part of the opposite parties. It has been pleaded that claim of the complainant has rightly been repudiated vide letter dated 19-1-2018 in the light of clause 3.5 of the policy. The said letter has been written on the basis of recommendation of Raksha Health Insurance TPA vide their letter edated 19-1-2018. On merits, the opposite parties have pleaded that claim if any, was payable subject to rules, regulations and terms and conditions of Insurance policy and copy of policy has been supplied to complainant. It is denied that any assurance regarding reimbursement of medical claims bill was given by the official of the opposite parties. It has been pleaded that claim has been rightly repudiated vide letter dated 29-1-2018. After controverting all other averments, the opposite parties prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence photocopy of Insurance card (Ex. C-1), photocopy of payment receipt (Ex. C-2), photocopy of policy schedule (Ex. C-3), photocopy of letter dated 29-1-2018 (Ex. C-4), photocopy of prescription (Ex. C-5), photocopy of certificate of registration (Ex. C-6), photocopy of lab reports (Ex. C-7 to Ex. C-10), photocopy of letter (Ex. C-11), photocopy of MIR report (Ex. C-12), photocopy of letter (Ex. C-13), photocopy of discharge card (Ex. C-14), photocopy of discharge bill (Ex. C-15), photocopy of payment receipts (Ex. C-16 & Ex. C-17), photocopy of bill (Ex. C-18), photocopy of medical recored (Ex. C-19 to Ex. C-22), photocopy of payment receipts (Ex. C-23 to Ex. C-30), photocopy of letter (Ex. C-31) and affidavit dated 13-7-2018 of complainant (Ex. C-32). In order to rebut the evidence of complainant, opposite parties tendered into evidence affidavit dated 12-9-2018 of Sh. R L Baleem (Ex. OP-1/1), photocopy of policy (Ex. OP-1/2), photocopy of terms and conditions (Ex. OP-1/3) and photocopy of letters (Ex. OP-1/4 & Ex. OP-1/5). We have heard learned counsel for the parties and gone through the record. There is no dispute between the parties regarding Medi-claim Insurance Policy No. 233200/48/2017/4224 for the period from 14-3-2017 to 13-3-2018 (Ex. OP-1/2) of the complainant. There is also no dispute that complainant got treatment from Dr. Avinash B Sonawane, Navi Mumbai and he filed claim for reimbursement of medical bills with the opposite parties. The opposite parties repudiated the claim of the complainant vide letter dated 29-1-2018 (Ex. C-4) under clause 3.5 of the policy in question. A perusal of repudiation letter Ex. C-4 reveals that opposite parties repudiated the claim of the complainant taking shelter of clause 3.5 of policy which reads as under :- “ Clause 3.5 Hospitalisation period : The period for which an insured person is admitted in the hospital as inpatient and stays there for the sole purpose of receiving the necessary and reasonable treatment for the disease/ailment contracted/injuries sustained during the peirod policy. The minimum period of stay shall be 24 hours except for specified procedures/treatment where such admission could be for a period of less than 24 consecutive hours.” Ex. C-14 is the Discharge Card issued by Dr. Sonawane's Hospital, Navi Mumbai. This document shows that date of admission of complainant in the hospital is 6-12-2017 at 8.00 a.m. and date of discharge is 11.00 a.m. on 7-12-2017. on 6-12-2017 operation was performed by Dr. Avinash Sonawane and name of Anaesthetist is mentioned as Dr. Vandana Jawalkar. Moreover, Ex. C-18 & Ex. C-19 also corroborates the case of complainant. Therefore, these documents are sufficient evidence to prove that complainant remained admitted in Dr. Sonawane's Hospital, Navi Mumbai, for more than 24 hours. Hence, repudiation of claim by the opposite parties on flimsly grounds without any solid reason, amounts to deficiency in service on the part of the opposite parties.Thus, the complainant is entitled to reimbursement of medical bills under the policy in question. The complainant has claimed total sum of Rs. 23,171/- being medical expenses and submitted bills with the opposite parties. The opposite parties did not dispute the bills rather they have repudiated the claim of the complainant on the ground that period of stay in hospital is less than 24 hrs. Resultantly, this complaint is partly allowed with Rs. 10,000/- as cost and compenstion against the opposite parties. The opposite parties are directed to pay to complainant the aforesaid medical claim of Rs. 23,171/- alongwith interest @ 9% P.A. from the date of repudiation of claim i.e. 29-1-2018 till payment. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. 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 : 12-01-2022 (Kanwar Sandeep Singh) President
(Paramjeet Kaur) Member | |
