Punjab

Ludhiana

CC/19/21

Mohit Khullar - Complainant(s)

Versus

Oriental Insurance Co.Ltd. - Opp.Party(s)

Jagtar Singh Adv.

06 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:21 dated 04.01.2019.                                

                Date of decision: 06.06.2023.

 

Mohit Khullar aged 35 years son of Sh. P.S. Khullar, Resident of 665/4C, New Upkar Nagar, Civil Lines, Ludhiana.                                                                                                                                                    ..…Complainant

                                                Versus

1. The Oriental Insurance Company Ltd., Branch Office- II, Near Clock Tower, G.T. Road, Ludhiana, through its Branch Manager/Director/Managing Director/Authorized Signatory.
2. The Oriental Insurance Company Limited, Regd. & Head Office; A-25/27, Asaf Ali Road, New Delhi-110002, Manager/Director/Managing Director/Authorized Signatory.

…..Opposite parties 

Complaint Under section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. Jagtar Singh, Advocate.

For OPs                         :         Sh. G.S. Kalyan, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Succinctly put, the facts of the case are that the complainant obtained a Happy Family Floater Policy/Mediclaim Insurance Policy from the opposite parties for himself, his wife, children and his parents vide insurance policy No.234001/48/2011/818 w.e.f. 24.06.20210 to 23.06.2011, which was got renewed by the complainant from time to time as under:-

i)       Policy bearing No.234001/48/2012/963 w.e.f. 24.06.2011 to 23.06.2012.

ii)      Policy bearing No.234001/48/2013/631 w.e.f. 24.06.2012 to 23.06.2013.

iii)     Policy bearing No.234001/48/2014/595 w.e.f. 24.06.2013 to 23.06.2014.

The said policy covered the complainant, his wife and his parents and in the following policies, the complainant also covered himself, his wife, daughter and his parents.

iv)     Policy bearing No.234001/48/2015/699 w.e.f. 24.06.2014 to 23.06.2015.

v)      Policy bearing No.234001/48/2016/799 w.e.f. 24.06.2015 to 23.06.2016

vi)     Policy bearing No.234001/48/2017/783 w.e.f. 24.06.2016 to 23.06.2017.

vii)    Policy bearing No.234001/48/2018/790 w.e.f. 24.06.2017 to 23.06.2018

viii)   Policy bearing No.234001/48/2018/710 w.e.f. 24.06.2018 to 23.06.2019.

According to the complainant, he got renewed the policies from the opposite parties through their official Ajay (Manager/Authorized Person) who assured that the opposite party company will give much better facilities to him and his family members. The complainant further stated that in the year of 2016, the daughter of the complainant Tanisha Khullar was suffering from problem of redness in the backside of her head and she was also suffering itching on the same on which the complainant got his daughter checked from the doctors of “Looks The Aesthetic Clinic” on 02.05.2016 where her treatment was started and problem was mostly solved. However, again in the month of December 2016, the minor scalp was increased and on 19.02.2017, the complainant visited to the doctors of Vikram Sood’s Skin Clinic at Jalandhar where the doctors gage medicines for the said problem. Thereafter, the complainant took his daughter to Fortis Hospital on 27.12.2017 who advised to operate the scalp through laser and doctors got conducted tests of his daughter. Thereafter, the complainant took his daughter to DMC Hospital for the said problem where the doctors advised for surgery upon which the complainant got admitted his daughter at DMC Hospital on 05.07.2018 where the doctors got operated the scalp on the head of daughter of the complainant and was discharged on 07.07.2018 on which the complainant incurred Rs.43,166/- up to 13.07.2018. The complainant also spent other amount on medicine, foods, transportation etc. The complainant further stated that he lodged a claim on 05.07.2018 along with relevant documents with the opposite parties but on 06.07.2018, the opposite parties denied his claim. In the month of September, 2018, the complainant again lodged the claim with the opposite parties but they again rejected the claim with the different reasons. According to the complainant, he has been approaching the opposite parties with request to release the medi-claim but they always postponed the matter on one or the other false pretext. In the end, the complainant prayed for issuing direction to the opposite parties to release the claim amount of Rs.43,166/- as medical expenses and Rs.2,00,000/- as compensation to the complainant along with litigation expenses of Rs.30,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint, misrepresentation and concealment of facts and lack of cause of action etc. The opposite parties stated that the complainant approached them for medi-claim insurance policy for his family. They explained the entire terms and conditions to the complainant, who after understanding the terms and conditions, filled the proposal form and obtained Mediclaim Policy from the opposite parties vide policy No.234001/48/2019/710 w.e.f. 24.06.2018 to 23.06.2019 subject to policy terms and conditions. The opposite parties further stated that on receipt of preauthorized request from DMC Hospital, Ludhiana, they immediately entertained, registered and processed the claim through M/s. Park Mediclaim Insurance TPA Pvt. Ltd. The officials of the opposite parties scrutinized the claim documents in view of the policy terms and conditions and applied their mind and denied for the cashless request vide letter dated 06.07.2018 sent by M/s. Park Mediclaim Insurance TPA Pvt. Ltd., the operative part of which is reproduced as under:-

          “Expenses Treatment For Congenital External Disease Are Not         Covered.”

Thereafter, the complainant filed claim for reimbursement of medical expenses incurred during his hospitalization at DMC Hospital, Ludhiana from 05.07.2018 to 07.07.2018 on 05.07.2018 for complaint of swelling over head x 3 years, itching x 3 years and patient was apparently asymptomatic 3 years ago when parents noticed that had a birth mark which started having redness and itching over time and started increasing in size gradually. After scrutinized the claim of the complainant and as per terms and conditions of the policy, the opposite parties in view of exclusion cause No.4.8 rightly repudiated the claim of the complainant, which is reproduced as under:-

“Convalescence, general debility, “run down” condition or rest cure, congenital external disease or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal disease, 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 addition etc., any disease or injury as a result of committing or attempting to commit a breach of Law with criminal intent.”

The opposite parties further stated that they have rightly repudiated the claim of the complainant vide letter dated 13.09.2018, the operative part of which reads as under:-

“You were hospitalized at D.M.C. & Hospital, Ludhiana with complaints having a Birth Mark which started having redness, itching and started increasing in size gradually. You were diagnosed as Naevus Over Scalp and underwent Excision and Biopsy.

Happy Family Floater Policy does not cover the expenses incurred for treatment of congenital external disease or defects/anomaly vide exclusion clause 4.8. Hence, the claim is not admissible and your claim is repudiated as ‘No Claim’.”

The opposite parties further stated that after going through the claim documents, it shows that the complainant has the knowledge of the disease but he did not disclose at any point of time. The opposite parties stated that there is no deficiency in service on their part. All other allegations have been denied being wrong and in the end, a prayer for dismissal of the complaint has been made.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents i.e. Ex. C1 is copy of the repudiation letter dated 13.09.2018, Ex. C2 is the copy of cashless denial by TPA dated 06.07.2018, Ex.C3 and Ex. C4 is the treatment record of Looks The Aesthetic Clinic, Ex. C5 is the copy of prescription slip of Dr. Vikram Sood’s Skin Clinic, Ex. C6 is the copy of treatment record of Fortis Hospital, Ex. C7 to Ex. C9, Ex. C11 to Ex. C15, Ex. C18 to Ex. C31  are the receipts/bills and OPD card of the DMC Hospital, Ludhiana, Ex. C10 is the test report, Ex. C16 is the histopathology report dated 10.07.2018, Ex. C17 is the copy of discharge summary of DMC Hospital, Ludhiana, Ex. C32 is the copy of insurance policy w.e.f. 24.06.2010 to 24.06.2011, Ex. C33 is the copy of insurance policy w.e.f. 24.06.2011 to 23.06.2012, Ex. C34 is the copy of insurance policy w.e.f. 24.06.2012 to 23.06.2013, Ex. C35 is the copy of insurance policy w.e.f. 24.06.2013 to 23.06.2014, Ex. C36 is the copy of insurance policy w.e.f. 24.06.2014 to 23.06.2015, Ex. C37 is the copy of insurance policy w.e.f. 24.06.2015 to 23.06.2016, Ex. C38 is the copy of insurance policy w.e.f. 24.06.2016 to 23.06.2017, Ex. C39 is the copy of insurance policy w.e.f. 24.06.2017 to 23.06.2018, Ex. C40 is the copy of insurance policy w.e.f. 24.06.2018 to 23.06.2019, Ex. C41 is the copy of Aadhar card of the complainant, Ex. C42 is the copy of Aadhar card of Tanisha Khullar and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Rakesh Soni, Senior Divisional Manager of the opposite parties along with documents Ex. R1 is the copy of repudiation letter dated 13.09.2018, Ex. R2 is the copy of denial for the cashless request by TPA dated 06.07.2018, Ex. R3 and Ex. R4 is the copy of treatment record of Looks The Aesthetic Clinic, Ex. R5 is the copy of prescription slip of Dr. Vikram Sood’s Skin Clinic, Ex. R6 to Ex. R8, Ex. R11 to Ex. R14 are the copies of receipts/bills, Ex. R9 is the copy of prescription slip of Fortis Hospital, Ex. R10 is the cytology report, Ex. R15 is the copy of histopathology report, Ex. R16 is the copy of discharge summary of DMC Hospital, Ludhiana, Ex. R17 is the copy of insurance policy w.e.f. 24.06.2018 to 23.06.2019, Ex. R18 is the copy of policy terms and conditions and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

6.                Admittedly, the complainant had been availing medi-claim policies from the opposite parties since 24.06.2010 for his family members vide policy documents Ex. C32 to Ex. C40 = Ex. R17. In the year 2014, daughter named Tanisha Khullar was born and benefit of the insurance cover was also extended to her for the year 2014-2015 Ex. C36. In the year 2016, when the minor daughter of the complainant was of about 2 years old, the complainant saw a mark having redness and itching on the scalp of his daughter. On 02.05.2016, first check up was conducted by the doctors of “Looks The Aesthetic Clinic” and prescribed certain medicines Ex. C4 to Ex. C8 but in December 2016, resurgence of redness and itchiness coupled with the increase in size of the scalp was observed.  On 19.02.2017, doctors of ‘Vikram Sood’s Skin Clinic, Jalandhar’ also examined his daughter and medication was started. On 27.12.2017, she was taken to Fortis Hospital where she was diagnosed lesion Scalp area (occipital area) and advised laser surgery vide Ex. C6 and Ex. C9. The complainant hospitalized his daughter on 05.07.2018 at DMC Hospital, Ludhiana where she was operated and was discharged on 07.07.2018. The complainant incurred medical expenses to the tune of Rs.43,166/- vide Ex. C11 to Ex. C15 and Ex. C18 to Ex. C31.

                   The discharge summary of DMC Hospital, Ludhiana was produced as Ex. C17= Ex. R16, the operative part of which reads as under:-

          “Reasons for admission: Swelling over head X 3Yrs

                                                Itching X 3YRS    

History of present illness: PT was apparently a symptomatic 3YRS ago when parents noticed that had a birth mark which started having redness and itching over time and started increasing in size gradually. Patient sought local treatment but size gradually increased with itching and redness.  

Local Examination: Irregular shaped popular lesion measuring 4x2 over occipital area

HPE :Report awaited

Diagnosis- Naevus over scalp

Procedure- Excision and biopsy done on 06.07.2018.

Treatment given: Patient came to DMCH with above mentioned complaints. She was clinically assessed, investigated and was diagnosed as a case of Naevus Over Scalp. PAC was done and she underwent excision and biopsy on 6/7/18. Post OP Period uneventful. Patient is being discharged under satisfactory conditions.”

7.                During hospitalization, the pre-authorization request of the complainant was declined vide letter Ex. C2 = Ex. R2 on 06.07.2018 on the ground that “Expenses treatment for congenital external disease are not covered” but also gave option to complainant to submit all documents along with reimbursement claim after the discharge from the hospital. Accordingly, the complainant submitted reimbursement claim but the same was also declined on 13.09.2018 vide repudiation letter Ex. C1 = Ex. R1 by invoking exclusion clause 4.8 of the policy schedule. The contents of repudiation letter Ex. C1 = R1 are reproduced as under:-

“You were hospitalized at D.M.C. & Hospital, Ludhiana with complaints having a Birth Mark which started having Redness, Itching and started increasing in size gradually. You were diagnosed as Naevus Over Scalp and underwent Excision and Biopsy.

Happy Family Floater Policy does not cover the expenses incurred for treatment of Congenital External Disease or Defects/Anomaly vide exclusion clause 4.8. Hence, the claim is not admissible and your claim is repudiated as ‘No Claim’.”

The relevant clause 4.8 of the policy schedule reads as under:-

“Convalescence, general debility, “run down” condition or rest cure, congenital external disease or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal disease, 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 addition etc., any disease or injury as a result of committing or attempting to commit a breach of Law with criminal intent.”

Further clause 3.6 of the policy schedule reads as under:-

“3.6 Congenital anomaly: refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.

1. Internal Congenital Anomaly: which is not in the visible and accessible parts of the body.
2. External Congenital Anomaly: which is not in the visible and accessible parts of the body.”                

8.                Now the point of consideration arises whether the diagnosis of the ailment reflected in the discharge summary “Naevus Over Scalp” is a congenital or not.

9.                It appears that the opposite parties formed opinion for repudiation of claim by reading the diagnosis along with history recorded in the discharge summary. No independent opinion from any medical specialist was sought in this regard. More so, every birth mark cannot be considered as a congenital anomaly. During hospitalization, the Excised lesion-scalp was sent for biopsy and its histopathology report was received as Ex. C16 = R15 and the same is reproduced as under:-

                   “Gross examination:

Received a skin covered with grey white soft tissue piece with hair attached measuring 3x2x0.5 cm.

                   Cut section: A grey white area identified measuring 3x0.2 cm lying             at distance of 0.2 cm from the base.

“Microscopic examination:

Skin biopsy shows hyperkeratosis, acanthosis and papillomatosis or epidermis which is exhibiting an orderly cell maturation. Further Dermis shows a perivascular and periappendeal chronic inflammatory infiltrate.

Impression: Histology consistent with Squamous cell papilloma- Scalp lesion.”

In medical sciences, Squamous cell papilloma is a benign exophytic overgrowth and projection of the soft tissue. Such lesions are caused by a viral infection which usually occurs after birth through direct contact with virus. It is not typically associated with congenital factors or present at birth.  It is an acquired disease and not a congenital anomaly. It is evident that the opposite parties lost sight of report of histopathology and hastily formed an opinion and repudiated the claim. The opposite parties were also required to take into consideration the fact that the minor daughter of the complainant remained asymptomatic for two years from her birth and when the portion of scalp started gradually increasing, the same was noticed by the complainant. In the given set of fact and circumstances, the opposite parties were not justified in repudiating the claim of the complainant by invoking exclusion clause of the policy. It would be just and appropriate, if the opposite parties are directed to settle and reimburse the claim of the complainant with regard to the hospitalization period w.e.f.05.07.2018 to 07.07.2018 and also with regard to pre and post hospitalization expenses incurred by the complainant in terms of policy terms and conditions within 30 days from the date of receipt of copy of order, failing which, they are liable to pay interest @8% per annum from the date of filing of complaint till its realization. The opposite parties shall also pay composite cost of Rs.10,000/- to the complainant.

10.              As a result of above discussion, the complaint is allowed with direction to the OPs to settle and reimburse the claim of the complainant with regard to the hospitalization period w.e.f.05.07.2018 to 07.07.2018 and also with regard to pre and post hospitalization expenses incurred by the complainant in terms of policy terms and conditions within 30 days from the date of receipt of copy of order, failing which, they are liable to pay interest @8% per annum from the date of filing of complaint till its realization. The opposite parties shall also pay composite cost of Rs.10,000/- to the complainant.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                                (Sanjeev Batra)

Member                                                President         

 

Announced in Open Commission.

Dated:06.06.2023.

Gurpreet Sharma