DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

BATHINDA

C.C. No. 76 of 13-03-2018.

Decided on :19-01-2022.

Jyoti Arora aged about 41 years wife of Sh. Raman Kant Arora R/o H. No. 6, Street No.2, Vishal Nagar, Phase-1, Bathinda. ........Complainant

Versus

1. The Oriental Insurance Co. Ltd, D.O. 4501, Bank Bazar Bathinda through its Divisional Manager.

2. Raksha TA Private Ltd, C/o Escorts Corporate Center, 15/5, Mathura Road, Faridabad, Haryana-121003 through its Manager/ Incharge.

3. Punjab National Bank, Bank Street Branch, Bathinda through its Branch Manager. (Deleted vide order dated 14-3-2018).

.......Opposite parties.

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Kanwar Sandeep Singh, President

Sh. Shivdev Singh, Member.

Smt. Paramjeet Kaur, Member

Present

For the complainant : Sh. Sahil Bansal, Advocate

For the opposite parties : Sh. JD Nayyar, Advocate, for OPs No. 1 &2.

Opposite party No. 3 deleted.

ORDER

Kanwar Sandeep Singh, President

1. The complainant Jyoti Arora (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 Co. Ltd and others,, (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainant is that she has saving bank account with opposite party No. 3. The opposite party No. 1 and 3 at Bathinda issued one PNB- Oriental Royal Mediclaim Insurance Policy No. 233200/48/2018/1815 w.e.f. 14-08-2017 to 13-08-2018 under cashless scheme with TPA opposite party No. 2. Vide said policy Jyoti Arora, her husband and her children are duly insured for Rs,5 lacs each. The opposite parties never issued any complete policy to the complainant till date, rather they have issued insurance certificate only.

3. It is alleged that the said insurance is cashless insurance with the opposite parties and the opposite parties also assured the complainant that in case of any emergency the claim can be lodged any where in India and insured can be admitted in any hospital in India and also assured that this is the cashless insurance and the opposite parties shall pay the entire claim up to the sum assured i.e. Rs.5,00,000/- directly to the hospital.

4. It is further alleged that all of sudden, complainant suffered Dysfunctional Uterine Bleeding (DUB) problem in Oct, 2017. She got herself checked at Holy Children and Maternity Hospital, Bathinda and doctor prescribed some medicine but complainant was not cured. Thereafter in emergency case Dr. Renu of Holy Children and maternity Hospital, Bathinda done DNC (Dilation and Curettage) (Minor Surgery) of complainant on 05-11-2017 and discharged her on the same day. The claim was duly lodged with the opposite parties along with all bills amounting to Rs. 7431/-. The opposite parties demanded doctor certificate which was issued by Dr. Renu on 06-01-2018 and the same was duly submitted with the opposite parties. The disease of complainant was not cured and she was again admitted with Loona Nursing Home under the advise of doctors that the uterus removal surgery needed as such Dr. Upasana Loona ( Loona Nursing Home), done the surgery and removed the uterus. Complainant remained admitted in the said hospital from 24-12-2017 to 29-12-2017 where she spent Rs, 32,672/-. The complainant lodged the said claim with opposite parties with all the original bills and medical file.

5. It is further alleged that the opposite parties firstly registered the claim No. 55671718310495 for Rs, 7431/-( wrongly mentioned Rs. 7631/- and 2^nd time registered the claim No.55671718365043 for Rs. 32,672/-. The complainant duly submitted the claim forms along with bills. The opposite parties at the time of registration of first claim, never raised any objection that the said treatment is not covered in the said insurance, however, they demanded certificate from first treated doctor for processing first claim.

6. It is further alleged that an amount of Rs, 40,103/- (Rs.7431/- +Rs.32,672/-), is till pending with the opposite parties. The complainant and her husband visited the opposite parties and also handed over the total original medical treatment file and original bills, but they did nothing.

7. The complainant further alleged that opposite parties vide letters dated 29-01-2018 (two letters) along with letters dated 16-01-2018 and 18-01-2018 finally rejected both claims of Rs, 40,103/- by mentioning clause of pre-existing disease. The said rejection of claims of Rs, 40,103/- is illegal and the claim is still pending with the opposite parties.

8. On this backdrop of facts, the complainant has prayed for directions to the opposite party to pay total claim amount of Rs.40,103/- along with interest @ 18% p.a., and Rs. 25,000/- as compensation on account of mental agony and pains besides Rs. 15,000/- as litigation expenses.

9. Upon notice the opposite parties No. 1 and 2 put in appearance through counsel and contested the complaint by filing joint written reply. In written reply, the opposite parties raised legal objections that the complaint is not maintainable in its present form; that the complainant does not have any cause of action to file the present complaint; that this Commission does not have the jurisdiction to try and entertain the present complaint; that the complainant has filed this false and factitious complaint against the opposite parties and has unnecessarily harassed them by dragging into uncalled for litigation; that the complainant is not entitled to the relief prayed for; that the complainant is not a consumer as defined under the Act; that the complainant is estoped by his own act and conduct from filing the present complaint and that there is no deficiency of service on the part of the opposite parties.

10. It is pleaded that the complainant had purchased PNB Oriental Royal mediclaim Policy No.23300/48/2018/1815 for floater sum insured of Rs. 5.00 lacs, having policy period from 14-08-2017 to 13-08-2018 covering the risk for himself and his family as mentioned in the policy. At the time of issuing the policy, the insured had been supplied with the copy of the policy and the terms and conditions of the same for which he and his family were bound. The claim if any was payable subject to rules and regulations and terms and conditions of the said policy. During subsistence of said policy period, insured lodged a reimbursement of the total claim of Rs. 40,103/- ( which included the alleged treatment from Holy Children and Maternity Hospital Bathinda to the tune of Rs.7431/- and from Loona Nursing Home Abohar to the tune of Rs, 32672/- respectively), As per procedure, opposite party No.1, after receiving the intimation, referred the matter to TPA (opposite party No. 2) along with all the relevant documents so supplied by the insured. It is only after taking opinion of the experts of the TPA, the payment of claim if any recommended by them is made.

11. It is further pleaded that based on the recommendation of opposite party No. 2, the opposite party No.1 issued a final letter of repudiation dated 29-01-2018 to the complainant/her husband informing that : case of Menorrhagia/Smenorrhoea, dsc has been done, this treatment is covered after 2 years of policy completion but the policy is in the first year of inception. Hence, the claim is not payable.

12. On merits, the opposite parties have pleaded that the complainant had not only been provided with the cover note but also with the complete policy with terms and conditions and had also been explained regarding the same. The claim, if any, was payable subject to rules and regulations and terms and conditions of the policy which had been supplied to the contaminant at the time of insurance. It is admitted that intimation had been received from the complainant regarding the treatment and the surgery and the complainant lodged a claim of Rs, 7431/- with the opposite party No.1. However, the claim if any was payable subject to rules and regulations and terms and conditions of the policy. The complainant has furnished another bill for an amount of Rs. 32,672/- alleging further treatment. After receiving the intimation from the insured, the complainant in the present case, the same was sent to the TPA who after scrutinizing the same explained regarding the facts of the case as to whether the claim is payable or not. It has also been admitted by the complainant herself that the claim has been repudiated vide letter dated 29-01-2018. The claim has been rightly repudiated for the reasons fully explained above. The allegations levelled against the opposite parties are baseless and without any merits and are specifically denied. After controverting all other averments, the opposite parties No. 1 & 2 prayed for dismissal of complaint.

13. On the statement of learned counsel for the complainant, recorded separately, name of opposite party No. 3 was deleted from the array of the parties vide order dated 14-3-2018.

14. In support of her complaint, the complainant has tendered into evidence her affidavit dated 22-05-2018 (Ex.C-1), photocopy of insurance policy scheduled containing pages 1 to 2 (Ex.C-2), photocopy of claim form with medical bills and bills containing pages 1 to 15 (Ex.C-3), photocopy of claim form with medial file and bills containing pages 1 to 30 (Ex.C-4), photocopy of repudiation letters (Ex.C-5 & C-6) and closed the evidence.

15. In order to rebut the evidence of complainant, the opposite parties No. 1 & 2 tendered into evidence affidavit of RL Baleem dated 04-10-2018 (Ex.OP1/1), photocopy of policy (Ex.OP1/2,) photo copy of claim form (Ex.OP1/3), photo copy of letter ( ExOP1-4), photo copy of proposal form (ExOP1-5), photo copy of letters ( ExOP1-6 to OP-1/8,) photocopy of terms and conditions ( Ex.OP1/9) and closed evidence.

16. We have heard learned counsel for the parties and gone through the record.

17. These are undisputed facts between the parties that Raman Kant Arora, husband of complainant purchased Insurance policy for himself and his family namely PNB Oriental Royal Medi-claim policy of the opposite parties for the period from 14-8-2017 to 13-8-2018 for floater sum insured of Rs. 5.00 Lacs (Ex. C-2). Complainant suffered some health problem for which she took treatment and undergone surgery. She submitted medical bills for reimbursement with the opposite parties, but the opposite parties repudiated the claim of the complainant vide letter dated 29-1-2018 (Ex. C-5 & Ex. C-6).

18. The allegation of the complainant is that she suffered Dysfunctional Uterine Bleeding (DUB) problem in October, 2017. She took medicine but when her problem was not cured, Dr. Renu of Holy Children and Maternity Hospital, Bathinda, done DNC (Dilation and Curettage) (Minor surgery) on 5-11-2017. Complainant submitted her claim amounting to Rs. 7431/- with the opposite parties for reimbursement. The disease of the complainant was not cured and Dr. Upasna Loona (Loona Nursing Home) done surgery and removed her uterus. Complainant remained admitted in the above said hospital from 24-12-017 to 29-12-2017. She again submitted her claim amounting to Rs. 32,672/- with the opposite parties for reimbursement, but the opposite parties repudiated her claim.

19. Ex. C-5 & Ex. C-6 are the repudiation letter dated 29-1-2018 vide which opposite parties rejected the claim of the complainant on the ground that as per clause 4.2 of policy expenses on treatment of “Hysterectomy of menorrhagia or fibromyoma or myomectomy or prolapse of uterus” for the period of 2 years is not payable if contracted and/or manifested during the currency of policy.

20. Ex. C-3 (Page 15) shows that complainant suffered with the problem and she first time visited doctor on 23-10-2017 whereby she was treated with medicine. It is also mentioned on this prescription slip of doctor that “Adv – surgery as no relief with medicine”. Accordingly, DNC (Dilation and Currettage) (Minor surgery) was done on 5-11-2017 but again when there was no relief, complainant was undergone for another surgery and got removed her uterus. Therefore, the facts, circumstances and the evidence placed on file by complainant reveals that complainant suffered the problem all of sudden. It was not pre-planned to get the insurance and thereafter undergo for surgery. It was not at all a case of pre-existing disease.

21. The opposite parties have not placed on file even a single document to prove that complainant was supplied terms and conditions alongwith policy. When no terms and conditions were supplied to the complainant, she is not bound by such conditions. Moreover, policy in question in this complaint (Ex. C-2/Ex. OP-1/2) is having number IRDA/NL-HLT/OIC/P-H/V. 1/454/13-14, but the terms and conditions (Ex. OP-1/9) on the basis of which claims of complainant are repudiated is having No. IRDA/NL-HLT/OIC/P-H/V.1/455/13-14. So, it is proved that these terms and conditions do not relate to policy in question. Therefore, denial of claim by the opposite parties on the ground that expenses of disease/surgery for which complainant took treatment for the period of two years are not payable, is without any basis. Thus, there is deficiency in service on the part of the opposite parties in rejecting the genuine claim of the complainant.

22. In the result, this complaint is partly allowed with Rs. 10,000/- as cost and compensation. The opposite parties No. 1 & 2 are directed to pay both the claims totaling to Rs. 40,103/- (Rs. 7431/- + Rs. 32,672/-) to complainant with interest @9% p.a. from the date of repudiation i.e. 29-1-2018 till payment.

23. The compliance of this order be made by the opposite parties No. 1 & 2 jointly and severally within 45 days from the date of receipt of copy of this order.

24. The complaint could not be decided within the statutory period due to heavy pendency of cases.

25. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced :

    19-01-2022

    (Kanwar Sandeep Singh)

    President

     

     

    (Shivdev Singh)

    Member

     

    (Paramjeet Kaur)

    Member