| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 121 of 09-05-2019 Decided on : 25-08-2022 Vikram Garg, aged about 40 years, son of Sh. Madan Lal Garg, resident of H.No.5146, Krishna Niwas, Street No.6, Nai Basti, Bathinda. ..........Complainant Versus The Oriental Insurance Co. Ltd., Divisional Office, 4501, Ist Floor, Bank Bazar, Bathinda through its Branch Manager. Raksha Health Insurance TPA Pvt. Limited, SCO No.39, Ist Floor, Sector 26, Madhya Marg, Above Barbedque Nation, Chandigarh.
.........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.Vikas Singla, Advocate. For opposite parties : Sh. M.L. Bansal, for OP No.1 Opposite party No.2 ex-parte ORDER Kanwar Sandeep Singh, President The complainant Vikram Garg (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 The Oriental Insurance Company and another (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that he purchased medical insurance Policy of opposite party No.1 vide Policy No.233200/48/2018/2850, ID No. YA0000000338 for the period from 14.11.2017 to 13.11.2018. It is alleged that complainant fell ill due to Acute Fibril Illness and he remained admitted in Mann Hospital, opposite St. Xaiver Convent School, Power House Road, Bathinda under Dr. Beant Singh Mann w.e.f. 11.9.2018 to 14.9.2018. The complainant spent a total sum of Rs.49,055/- on his treatment which includes hospital charges and medicines etc., purchased from M/s R.S.Medical Agencies, Bathinda. After discharge from hospital, complainant filed insurance claim for reimbursement of medical expenses and submitted documents regarding his medical treatment record and bills of purchase of medicines, duly counter-signed by Dr.Beant Singh Mann of Mann Hospital, Bathinda. The complainant requested the opposite parties to reimburse the said amount of Rs.49,055/- to him but the opposite parties have failed to do so rather they kept on putting the matter off under, one or the other false pretext. The complainant alleged that he submitted documents required by the opposite parties from time to time and repeatedly requested them to honour his lawful claim, but the opposite parties instead of paying the claim, vide letter 23.1.2019, repudiated his insurance claim on the ground that as per clause 5.7, "Disclosure of Information norm", the policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of mis-representation, mis-description or non disclosure of any material fact and further on the ground that as per clause 2.1, Hospital/Nursing Home: a hospital/nursing home means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under the clinical establishments or under the enactments specified under the Schedule of Section 56(1) of the said Act or complies with all minimum criteria as mentioned in the alleged repudiation letter. It is alleged that the repudiation letter is totally wrong, illegal, null and void and same is having no binding effect upon the rights of the complainant as the complainant took treatment from Dr.Beant Singh Mann who is MD (Medicine), Ex.PCMS-1, as indoor patient in his hospital under the name of "Mann Hospital" which is reknown Hospital in the locality, having facilities of ICU, Ventilator, Central Oxygen, Cardiac Monitor, Defibrillator, Spirometry, X-ray, E.C.G., Lab, Indoor, Operation Theatre and Bio-Thesio Vibratometer. The said hospital fulfills all the criteria i.e. qualified nursing staff, inpatient beds, qualified medical practitioner, fully equipped operation theater of its own and also maintains daily records of patients. As such, the claim of the complainant has been wrongly and illegally repudiated by the opposite parties in order to avoid their liablity. It is alleged that due to non payment of claim, the complainant suffered from great mental tension, agony, botheration, harassment and humiliation and huge financial losses 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 pay him claim amount to the tune of Rs. 49,055/- alongwith compensation of Rs.25,000/- in addition to litigation expenses to the tune of Rs.5500/-. Registered A.D. Notice of complaint was sent to the opposite parties. None appeared on behalf of opposite party No. 2. As such, exparte proceedings were taken against opposite party No. 2. Upon notice, the opposite party No. 1 put an appearance through counsel and contested the complaint by filing written reply. In written reply, the opposite party No. 1 raised legal objections that the complaint has been filed only to injure the goodwill and repudiation of the opposite parties. Even otherwise, the complaint is false, frivilous and vexatious to the knowledge of the complainant. That the intricate questions of law & facts are involved in the present complaint, which requires voluminous documents and evidence for determination which is not possible in the summary procedure and appropriate remedy, if any, lies only in the Civil Court. That the complainant has concealed material facts and documents from this Commission. It has been pleaded that true facts are that on receipt of claim papers from the complainant, the claim of the complainant was referred to opposite party No.2, which has been constituted as TPA (Third Party Administrator) to settle the medi-claim cases. The opposite party No.2 has processed the claim of the complainant and after scrutinizingthe case, found that case of the complainant fall out of the scope of the policy as per clause 5.7, which reads as `DISCLOSURE TO INFORMATION NORM: The policy shall be void and all premium paid here-on shall be forfeited to the company, in the event of misrepresentation, mis-description or non-disclosure of any material fact'. Further as per investigation got conducted by opposite party No. 2, it was found that the alleged hospital from where complainant took the treatment does not fall within the ambit of Hospital/Nursing Home. As per clause 2.1 'The term `Hospital/Nursing Home' shall not include an establishment which is a place of rest and/or recuperation, a place for the aged persons, a rehabilitation centre for drug addicts or alcoholics, a hotel or a similar place'. It has been pleaded that the opposite party No.2 observed as under:- - Patient admitted with c/o AFI with HEPATITIS, but no fever during the hospitalization found on Vital chart. - No medicine purchased from Hospital. - No investigation done in hospital only investigations done prior to hospitalization. - No receipt book shown by hospital. - All the IPD papers made single handed. - No round the clock Doctor available on investigation. It has been further pleaded that keeping in view the aforesaid facts & circumstances, opposite party No. 2 recommended the claim of the complainant for repudiation as per clause 5.7 and 2.1 vide letter dated 09.01.2019. Accordingly, the claim of the complainant has been repudiated by the opposite parties vide registered letter dated 23.01.2019. Further legal objections are that the complainant has no locus standi or cause of action to file the complaint. That the complaint is not maintainable in its present form. That the complainant is not a consumer as defined under the 'Act' and that there is no deficiency in service or unfair trade practice on the part of the opposite party. On merits, the opposite party No. 1 reiterated its stand as taken in legal objections and detailed above. After controverting all other averments of the complainant, the opposite party No. 1 prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his Affidavit dated 09-05-2019 (Ex.C-1) and the documents (Ex. C-2 to Ex. C-5). In order to rebut the evidence of complainant, the opposite party No. 1 tendered into evidence affidavit of Ashwani Kumar dated 25-06-2019 (Ex.OP-1/1) and the documents (Ex. OP-1/2 to Ex. OP-1/19). The learned counsel for the parties reiterated their version as pleaded in their respective pleadings. We have heard learned counsel for the parties and gone through the evidence produced by complainant. In the case in hand, the opposite parties repudiated the claim of the complainant vide letter dated 23-1-2019 (Ex. OP-1/6) wherein it has been mentioned claim has been repudiated under clause 2.1 and 5.7 of the policy. Ex. OP-1/7 is the letter of opposite party No. 2 vide which opposite party No. 2 recommended claim for repudiation as per clause 5.7 and 2.1. A perusal of letter (Ex. OP-1/7) reveals that following observations and opinion have been given by opposite party No. 2 :- - Patient admitted with c/o AFI with HEPATITIS, but no fever during the hospitalization found on Vital chart. - No medicine purchased from Hospital. - No investigation done in hospital only investigations done prior to hospitalization. - No receipt book shown by hospital. - All the IPD papers made single handed. - No round the clock Doctor available on investigation. This commission has also observed that opposite party No.2 on whose recommendations, opposite party No.1 repudiated claim of complainant, has neither appeared in commission nor opposite party No.1 examined opposite party No.2 as witness to prove its version. A perusal of file reveals that complainant has placed on file complete medical record regarding his admission in Mann Hospital, Bathinda, which is being run by Dr. Beant Singh Maan, M.B.B.S, MD (Medicine), Ex. PCMS-1, Formerly Med. Sp. Civil Hospital, Bathinda; Formerly Incharge Dialysis Unit, Civil Hospital, Bathinda. Ex. C-4 is the complete medical record which contains Licence of hospital issued to Maan Hospital by Municipal Corporation, medical prescriptions, lab reports, hospital admission and discharge record, treatment record and receipts of payment. The complainant was suffering from fever and Hepatitis for which he approached nereby doctor to get treatment. All relevant record regarding his treatment has been produced on file, but the opposite parties without any solid reason rejected his genuine claim. Insurance Regulatory and Development Authority (IRDA) vide circular “ Ref No. IRDA/HLTH/MISC/CIR/216/09/2011 Dated 20-09-2011 directed All life insurers and non-life insurers : “The Insurers' decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.” Thus, this Commission is of the considered opinion that there is deficiency in service on the part of the opposite parties in repudiating the genuine claim of the complainant on flimsy grounds. In the result, the complaint is partly allowed with Rs.10,000/- as cost and compensation. The opposite parties are directed to pay to complainant claim amount as per bills submitted by him with interest @ 8% p.a. w.e.f. 23-1-2019 (date of repudiation) 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 the copy of the order. The complaint could not be decided within statutory period due to Covid pandemic and heavy pendency of cases. Copy of order be supplied to parties free of cost as per law. File be consigned to record room.
Announced : 25-08-2022 President (Paramjeet Kaur) Member (Kanwar Sandeep Singh)
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