DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 213 of 18.6.2018

                                      Decided on:         1.4.2021

Smt.Anil Kanta, aged 61 years wife of Hari Chand Bansal, H.No.04, Gian Colony near Sant Clinic Patiala- 147001.

                                                                   …………...Complainant

                                      Versus

1. Oriental Insurance Company Limited, Sai Market, Lower Mall, Patiala 147001, through its Divisional Officer.
2. Raksha TPA Private Limited, SCO 359-360, Sector 44-D, Chandigarh-160047, through its authorized representative/signatory.

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Sh. Jasjit Singh Bhinder, President

                                      Sh.Vinod Kumar Gulati, Member    

                                      Sh.Y.S.Matta, Member

ARGUED BY

                                      Sh.Anand Puri,counsel for complainant.

                                      Sh.B.L.Bhardwaj, counsel for OPs.

 ORDER

                                      JASJIT SINGH BHINDER,PRESIDENT

Facts of the complaint

1. This is the complaint filed by Anil Kanta (hereinafter referred to as the complainant) against Oriental Insurance Company and another (hereinafter referred to as the OP/s) under the Consumer Protection Act ( for short the Act).
2. Briefly the case of the complainant is that he is the consumer as defined under Section 2(g) of the Act. It is averred that Hari Chand Bansal, husband of the complainant purchased Oriental Bank Medi Claim Policy bearing No.233500/48/2016/3104 through Oriental Bank of Commerce valid from 6.1.2016 to midnight 5.1.2017 covering the complainant under the policy. The policy got renewed from 6.1.2017 to 5.1.2018 and again from 6.1.2018 to 5.1.2019.
3. It is averred that on 5.10.2017, suddenly the complainant suffered from stomach problem and was taken to Balaji Heart Institute Eye & General Surgery Centre, Patiala where she admitted in the hospital  and was discharged on 7.10.2017.She was diagnosed as “Acute Gastroenteritis with severe dehydration with HTN/DM II. The complainant and hospital authorities informed OP No.2 for payment as the policy was cashless but OP No.2  requested the hospital authority for collecting the expenses from the patient and also requested the patient for submission of hospitalization papers for reimbursement. Accordingly husband of the complainant paid Rs.18518/- as hospitalization charges to the hospital. Thereafter he lodged the claim of Rs.18518/- with OP No.2 and also submitted the claim documents alongwith bills on 5.1.2018 but the claim of the complainant was wrongly rejected vide letter dated 1.3.2018 on the ground that “the claim is not payable under clause 4.1 of the policy which excludes the treatment of DM type 2 and HTN which was main factor of causing LVF”. Thereafter complainant and her husband made several requests to the OPs for the payment of the bills and also sent legal notice dated 4.5.2018 for the payment of Rs.18,518/- but the OPs failed to do so. The act and conducts of the OPs caused mental agony and harassment to the complainant. There is thus deficiency in service on the part of the OPs.
4. On the back ground of the facts, the complainant has filed this complaint with the prayer to accept the same by giving direction to the OPs to pay a sum of Rs.18,518/- alongwith interest @ 18% per annum and also to pay Rs.10,000/-as damages for causing mental agony and harassment and Rs.22000/-as litigation expenses.

Reply/Written statement

5. Upon notice OPs appeared through counsel and contested the complaint by filing written reply. In the written statement it is admitted that complainant and her husband Hari Chand Bansal are insured for the period from 6.1.2018 to 5.1.2019 vide policy No.233500/48/2018/3873 for the sum of Rs.5lacs subject to terms and conditions of the policy. It is further submitted that no cashless facility was permitted by the OPs and the complainant made the payment to the hospital and also that for the medical treatment for which the complainant was admitted in the hospital was not covered under the subject insurance policy under clause 4.1 of the policy, which excludes the treatment of DM Type 2 and HTN, the main factor of causing LVF. As such the action taken by the OPs is legal and bonafide and have rightly repudiated the claim of the complainant. There is no deficiency in service on the part of the OPs. After denying all other averments made in the complaint, the OPs have prayed for the dismissal of the complaint.
6.  
6. In support of the complaint, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C17 and closed the evidence.
7. On the other hand, the ld. counsel for the OPs has tendered in evidence Ex.OPA affidavit of Sh.Mukesh Malhotra,DM, OIC alongwith documents Exs.OP1 to OP5 and closed the evidence.
8.  
8. The OPs have also filed the written arguments. We have gone through the same, heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
9. The ld. counsel for the complainant has argued that the complainant is consumer as defined under Section 2(g) of the Act. The ld. counsel further argued that Hari Chand Bansal, husband of the complainant has purchased  Oriental Bank Medi claim policy through Oriental Bank of Commerce, Bhupindra Road, Patiala valid from 6.1.2016 to 5.1.2017 and was again renewed from 6.1.2018 to 5.1.2019.The ld. counsel further argued that  the complainant suffered from Acute Gastroenteritis with severe dehydration with HTN/DM II and was admitted to Balaji Heat Institute Eye & General Surger Centre, Patiala and  was discharged on 7.10.2017  and total sum of Rs.18518/- was spent as hospitalization charges. Thereafter claim was submitted with the OPs but the same was wrongly rejected. The ld. counsel has relied upon the citations Manish Goyal Vs. Max Bupa Health Insurance Company Limited 2018(2)CLT 205, Balwinder Singh Jolly Vs. Paramount Health Services(TPA) Ltd. 2016(4) CLT 372  of the Chandigarh State Consumer Disputes Redressal Commission(Union Territory).
10. On the other hand, the ld. counsel for the OPs has argued that no cashless facility was provided by the replying insurance company and the Balaji Heart Institute Eye & General Surgery Centre, Patiala is not covered subject to the insurance policy. The ld. counsel further argued that the disease DM II and HTN was the main factor of causing LVF and falls under exclusion clause. So the claim was rightly repudiated and the claim be dismissed.
11. To prove the case, the complainant has tendered her affidavit Ex.CA and she has deposed as per the complaint,Ex.C1 is the insurance policy valid from 6.1.2016 to 5.1.2017,Ex.C2 is also insurance policy for the period from 6.1.2017 to 5.1.2018,Ex.C3 is the another insurance policy for the period from 6.1.2018 to 5.1.2019,Ex.C4 is discharge summary of Balaji Heart Institute Eye and General Surgery Centre, whereby the complainant was diagnosed as Acute Gastroenteritis with Severe dehydration .The wrong statement has been filed. In paras No.3to5 it is mentioned that the payment was not made as the treatment of DM Type 2 and HTN which is the main factor of causing LVF .But in the present case complainant was not suffering from hypertension or DM II and HTN.She is only suffering from gastroenteritis and dehydration. These are the simple ailments and do not fall under exclusion clause.Ex.C5 is bill of Balaji Heart Institute for Rs.17400/-,Exs.C6 to C11 are also the bills,Ex.C12 is letter written by complainant to Raksha TPA Pvt. Ltd.,Ex.C13 is proposal form,Ex.C15 is legal notice.
12. On the other hand Mukesh Malhotra,Divisional Manager, of the OPs tendered his affidavit,Ex.OPA and he has deposed as per the written statement,Ex.OP1 is the letter written to Hari Chand Bansal,Ex.OP2 is the insurance  cover, Ex.OP3 is also insurance policy,Ex.OP4 is insurance policy.
13. As per the discharge summary Ex.C4 of Balaji Heart Institute Eye & General Surgery Centre, Anil Kanta of age 60 years was admitted and she was diagnosed with the acute gastroenteritis  with severe  dehydration.So main cause of admission in the said hospital was acute gastroenteritis  and dehydration and the main cause was not sugar or hypertension or any other disease. She was admitted in the said hospital on 5.10.2017 and she was discharged on 7.10.2017 and total amount of Rs.17400/- was received.As per the policy she was duly insured with Oriental Bank Meclaim policy and the insurance company on the wrong presumption had declined the bill.It has been held by the Chandigarh State Consumer Disputes Redressal Commission (Union Territory) in the case of SBI General Insurance Company Ltd. versus Balwinder Singh Jolly that it was duty of the insurer to put insured to thorough medical examination.Claim raised after issuance of insurance policy could not be declined on account of non-disclosure of the fact of pre-existing disease when policy was taken.
14. So it is clear that the complainant was not suffering from any sugar or hypertension and she was admitted in the hospital for the problem of gastroenteritis  and dehydration. After that the bill was submitted but it was wrongly repudiated.
15. So by taking into consideration the law laid down by the complainant and the documents on record, the complaint stands allowed and the OPs are directed to pay the amount of Rs.17400/- to the complainant alongwith interest @6% per annum from the date of repudiation i.e. 1.3.2018 till realization. The OPs are further directed to pay Rs.2500/- as costs and Rs.2500/- as compensation. Compliance of the order be made by the  OPs within a period of 45 days from the date of the receipt of the certified copy of this order.

ANNOUNCED

DATED:1.4.2021         

                   Y.S.Matta         Vinod Kumar Gulati       Jasjit Singh Bhinder

                    Member                 Member                                  President