Haryana

Karnal

CC/140/2015

Sanjeet Kumar - Complainant(s)

Versus

Oriental Bank Mediclaim - Opp.Party(s)

Gaurav Kant Sharma

22 Nov 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                         Complaint No.140 of 2015

                                                        Date of instt. 08.07.2015

                                                        Date of decision: 22.11.2017

 

Sanjeet Kumar son of Shri Moti Lal residence of House no.166-R Model Town, Yamuana Nagar, Tehsil Jagadhari, District Yamuna Nagar. Since deceased through his legal heirs_

1. Mrs. Kusum Lata (wife)

2. Sh. Raj Kumar Gupta (son)

3. Sh. Vijay Kumar Gupta (son)

4. Sh. Dr. Ajay Gupta (son)

                                                                                                                                                                  …….Complainants.   

                                        Versus

 

1. The Manager, Oriental Bank Medi Claim, CBO-1-Karnal, near York Hotel, G.T. Road, Karnal 132001 (Haryana)

2. The Oriental Insurance Company Limited, Registered Office Oriental House P.B. no.7037, A-25/27, Asaf Ali Road, New Delhi (110002), through its General Manager.

3. Medi Assist India, TPA Private Limited, 49, Shilpa Vidya Building, 1^st main Sara KK. Industrial Layout, 3 phase J.P. Nagar, Bangalore 560078, through its General Manager.

                                     

                                                                     …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.    

       

 

Before   Sh. Jagmal Singh……President.

      Sh. Anil Sharma……….Member

             

 

 Present  Shri Gaurav Bansal Advocate for complainant.

                Shri Narender Chaudhary Adv. for OPs no.1 and 2.

                OP no.3 exparte.

               

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that Sanjeet Kumar (since deceased hereinafter referred as DLA) alongwith his wife Smt. Kusum Lata had got insured by the OP no.2, through OP no.1, vide policy no.261301/48/2013/2461 issued on 28.3.2013. OP no.3 is the third party administrator of OPs no.1 and 2. The said policy was health insurance. In the said policy DLA, was nominee and he has also covered under the said policy. In May, 2013, DLA felt severe pain in his hip and legs and got conducted x-ray he came to know that he had fracture in his left hip and knee initially he had suffered an injury by slipping and falling down. Due to that he remained admitted in Apex Hospital at Varanasi from 17.5.2013 to 28.5.2013 and spent Rs.1,97,801/- upon his treatment. The OPs were duly informed about the said incident. While filing the claim he had completed all the necessary formalities. OPs refused to pay the claim amount on the falser and frivolous reasons. DLA visited the office of OPS several times and requested for reimbursement of the claim amount, but OPs did not pay any heed to his request. Then, DLA sent a legal notice dated 8.5.2015, but to no effect. In this way there was deficiency in service on the part of the OPs and hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs. OPs no.1 and 2 appeared and filed written statement raising preliminary objections regarding concealments of material facts, jurisdiction, deficiency in service and claim of the DLA has rightly been repudiated. On merits, it has been submitted that the DLA covered under the abovementioned policy was admitted at Apex Hospital for the treatment of intertrochantric Fracture Lt. Femur with CPN Palsy with Osteoprosis on 17.5.2013 and discharged on 28.5.2013. As per the policy terms and conditions, during the period of insurance cover, the expenses on the treatment of ailment/disease/surgeries for age related Osteoarthritis and Osteoprosis disease for specified period of three years are not payable if contracted and/or manifested during the currency of the policy. As per the discharge summary, it is evident that the complainant was suffering from the ailment Osteoprosis leading to the Fracture from a fall from bed and warranting Hip Replacement. Under the policy terms and conditions the claim has been repudiated under exclusion 4.2 of the policy. Hence there is no deficiency in service on the part of the OP in repudiating the claim. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.    

3.             OP no.3 did not appear despite service. Hence exparte proceedings were initiated against him vide order dated 8.4.2016.

4.             Complainant tendered into evidence affidavit Ex.CW1/A and documents Ex.C2 to Ex.C53 and closed the evidence on 29.7.2016.

5.             On the other hand, OPs tendered into evidence affidavit Behlan Sr. Divisional Manager Ex.OP1 and documents Ex.OP2 to Ex.OP6 and closed the evidence on 20.1.2017

6.             We have heard the learned counsel for both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             From the pleadings and evidence of the cased, it is clear that there is no dispute between the parties regarding the purchase of policy no. 261301/48/2013/2461 issued on 28.3.2013 by the DLA from the OPs and the DLA got treatment from Apex Hospital Varanasi from 17.5.2013 to 28.5.2013. There is also no dispute that the DLA has made the claim regarding his treatment to the OPs but the same has been repudiated by the OPs on the ground that “As per the policy terms and conditions, during the period of insurance cover, the expenses on treatment of ailment/disease/surgeries for age related osteoarthritis and osteoporosis disease for specified periods of 3 years are not applicable if contracted and/or manifested during the currency of the policy. As per the Discharge Summary it is evident that the claimant was suffering from the ailment Osteoprosis leading to the Fracture from a fall from bed and warranting Hip replacement. As such under the policy terms and conditions, the claim has been repudiated under exclusion clause 4.2 of above mentioned policy.

8.             According to the complainant that the DLA,  in the month of May, 2013 felt severe pain in his hip and legs and got conducted x-ray upon which it was found that he had a fracture in his left hip and knee initially he had suffered an injury by slipping and falling down. According to the DLA he suffered injuries on 5.4.2013 as is clear from the claim form Ex.C-47 wherein it is so mentioned by the DLA. The complainant has placed on the file the medical record of the DLA from 17.5.2013 to 28.5.2013 of the Apex Hospital Varanasi.  As already stated above the DLA has got fracture in the hip and knee due to the injury caused to him on 5.4.2013, then there might be some record that he had got treatment regarding the said fracture but the complainant has not placed any record from 5.4.2013 to 16.5.2013 of the DLA. It is pertinent to mention here that if a person received fractured he might have so much pain which cannot be tolerated and for that medical treatment becomes necessary, but the DLA has not placed any such record on the file which falsify his contention that he received the fracture of hip bone and left knee on 5^th April, 2013. Therefore, from the above facts it is clear that the DLA has failed to prove that he received the fracture of hip bone and left knee on 5.4.2013. The OPs have repudiated the claim of DLA under exclusion clause 4.2 which is as under-

4.2   The expenses on treatment of following ailment/disease/ surgeries for the specified periods are not payable if contracted and/ or manifested during the currency of the policy.

If these diseases are pre-existing at the time of proposal the exclusion no.4.1 for pre-existing condition shall be applicable in such cases.

i to xxii………….

Xxiii  Age related osteoarthritis and Osteoporosis - 3 years.

 

9.             As already stated above the DLA has failed to prove on the file that his fracture were caused on 5.4.2013, therefore, it impliedly said that the disease of DLA was age related and the clause 4.2 is applicable in the case of DLA. In these circumstances, we are of the considered view that OPs have committed no mistake in repudiating the claim of the DLA.

10.           Thus, as a sequel of above discussion, we do not find any merit in the present complaint and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:22.11.2017

                                                                       

                                                                  President,

                                                          District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

                       (Anil Sharma)

                            Member