Punjab

StateCommission

FA/13/67

Deepak Sharma - Complainant(s)

Versus

UIIC Ltd. - Opp.Party(s)

Deepak Gupta

04 Dec 2015

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION,   PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.

                                     

                   First Appeal No.67 of 2013

 

                                                Date of Institution: 21.01.2013

                                                Date of Decision:  04.12.2015

 

1.      Deepak Sharma son of Raj Kumar Sharma

2.      Navneet Rani Sharma wife of Deepak Sharma

          Both residents of Grewal Chowk, Defence Colony, Malerkotla          District Sangrur.

 

                                                                   …Appellants/Complainants       

             Versus

 

1.      United India Insurance Company Limited, Khati Bazar,   Rampura Phul, through its Manager.

 

2.      United India Insurance Company Limited, Divisional Office,     The Mall, Bathinda, through its Divisional Manager.    

 

                                                          ..Respondents/Opposite Parties

                                                           

 

First Appeal against order dated 26.11.2012 passed by the District Consumer Disputes Redressal Forum, Bathinda

Quorum:-

 

          Shri J. S. Klar, Presiding Judicial Member.

             Shri. H.S.Guram, Member

 

Present:-

 

          For the appellants                 : Sh. Deepak Gupta, Advocate

          For the respondents              : Sh.Parminder Singh,                                                                                Advocate

                    . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

          The appellants of this appeal (the complainants in the complaint) have filed this appeal against the respondents of this appeal (the opposite parties in the complaint), challenging order dated 26.11.2012 of District Consumer Disputes Redressal Forum Bathinda, accepting the complaint of the complainant by directing the OPs to pay Rs.49,057/- to complainant no.1 in whose name the policy was issued, as reimbursement of expenses incurred on the treatment of complainant no.2, besides Rs.5,000/- as compensation and costs of litigation. The instant appeal has been preferred against the same by the complainants now appellants for enhancement of compensation amount as awarded by District Forum in order dated 26.11.12.

2.      The complainants have filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averments that on the inducement of the agent of OPs, the complainant no.1 purchased policy bearing no. 200404/48/11/06/00000054 from OPs for his entire family by paying the premium of Rs.7,038/-, vide receipts dated 30.06.2011 to 29.06.2012 . This policy was taken, as a "Family Care Policy" under the Medi-claim for any diseases suffered by the complainant or his family members. Suddenly, Navneet Rani/complainant no.2 (wife of the complainant) suffered from Hepatitis C and was admitted with Dr. Rupinder Singh Sidhu Hospital Bathinda on 08.12.2011 and was discharged therefrom on 09.12.2011 after necessary treatment. Follow up treatment was also taken by her since 08.12.2011 to 09.12.2012, as indoor patient and thereafter, as OPD patient up to 23.05.2012 by spending Rs.1,67,682/- thereupon. The complainant no.1 applied for reimbursement of medical bills of treatment of his wife to OPs by complying with all terms and conditions thereto. The OPs repudiated the insurance claim of the complainant arbitrarily, on the ground that the patient was given injection IFN SUB CUTANOUSLY and OPD based treatment, which did not require any hospitalization  and hence claim is not payable, as per repudiation letter dated 23.02.2012. The complainant alleged deficiency in service on the part of OPs in connivance with each other. The complainants have, thus, filed the complaint against the OPs directing them to pay the medi-claim expenses of Rs.1,67,682/- incurred by complainant on the treatment of the complainant no.2 with interest @ 18%  per annum, besides compensation of Rs.1 lac for mental harassment and Rs.30,000/- as costs of litigation.

3.      Upon notice, OPs appeared and filed written reply and contested the claim of the complainant. It was stated in the legal objections of the written reply by the OPs that complainant obtained medi-claim policy, vide insurance policy no. 20040448110600000054  with insured amount of Rs.3,,00,000/- and policy was for one year. After receipt of intimation regarding treatment of complainant from "Delhi Heart Institute and Research Center Bathinda" on 08.12.2011 to 09.12.2011, OP No.1 sent documents to Raksha TPA, being third party administrator of OP No.1 and 2, to assess the lawful claim of the complainant. On examining documents, it was found that claim of the complainant was not payable and the same was repudiated by the OPs, as per policy clause 2.3 of the Standard Medi-claim policy, vide letter dated 23.02.2012. The claim was repudiated on the ground that patient suffered from Hepatitis C and was given injection IFN SUB CUTANOUSLY, which is an OPD based treatment only not requiring any hospitalization. The complainants have no locus standi or cause of action to file the complaint. The complaint is alleged to be not maintainable. On merits, OPs averred that the injection IFN SUB CUTANOUSLY is an OPD based treatment, which did not require any hospitalization. The complainant has shown the admission in the above-said hospital, just for the purpose of present claim and as per terms and conditions, a minimum admission of 24 hours was required for claiming any hospital charges. The complainant has not remained admitted in the above hospital. It was further pleaded that claim of the complainant was to be examined by Third Party Administer RAKSHA TPA and TPA found that patient suffered from HEPATITIS C and was given injection IFN SUB CUTANOUSLY, which was an OPD based treatment without requirement of hospitalization.  

4.      The complainant tendered in evidence, his affidavit Ex.C-1 along with copies of documents Ex.C-2 to Ex.C-46 and affidavit of Navneet Rani Ex.C-47.  As against it; OPs tendered in evidence affidavit of Sh. Gobind Aggarwal Sr. Divisional Manager United India Insurance Company Limited Ex.R-1 along with copies of documents Ex.R-2 to Ex.R-3 and affidavit of Dr. Rakesh Kalra C/o Raksha TPA Pvt. Ltd. Ex.R-4. On conclusion of evidence and arguments, the District Forum Bathinda, accepted the complaint of the complainant by virtue of order of District Forum Bathinda dated 26.11.2012. Dissatisfied with the order of the District Forum Bathinda dated 26.11.2012, the complainants now appellants have preferred this appeal against the same for enhancement of compensation.

5.      We have heard learned counsel for the parties at considerable length in this appeal and have also gone through the record of the case.

6.      We have to refer to the evidence on the record, Ex.C-1 is affidavit of Navneet Rani, wife of the complainant on the record. Ex.C-2 is original receipt of premium for Rs.7,038/- paid by the complainant to OPs. Ex.C-3 is copy of certificate of Delhi Heart Institute & Research Centre Bathinda to the effect that Navneet Rani was admitted in the hospital on 08.12.2011 at 10.00 am for treatment of IFN. The treatment was given and she was discharged in the stable condition on 09.12.2011 at 11.00 am.  Ex.C-4 is the repudiation letter addressed by Branch Manager United India Insurance Company Limited of OPs to complainant dated 23.02.2012.  Ex.C-5 is "Health & Family Welfare Department Instructions" dated 14.06.2010. The diseases have been enumerated, vide letter no.12/77/2000-5/13137 dated 1 July 2004, covering 27 chronic diseases, as detailed in it. Ex.C-6 is cover note of the policy. Ex.C-7 to Ex.C-46 are the various copies of the bills including receipts for the treatment of the complainant no.2. Ex.C-47 is the affidavit of Navneet Rani/complainant no.2 on the record that she incurred the expenses of Rs.1,67,682/- on her treatment by getting admitted with Dr. Rupinder Singh Sidhu Hospital Bathinda on 08.12.2011 and she was discharged on 09.12.2011 after necessary treatment. She further stated that she got the follow up treatment from 08.12.2011 to 09.12.2012, as indoor patient and thereafter, as OPD patient up to 23.05.2012 and spent, the above amounts thereon.

7.      To counter this evidence, OPs relied upon affidavit of Gobind Aggarwal Sr. Divisional Manager United India Insurance Company Limited Bathinda, Ex.R-1, wherein he stated that claim of the complainant was repudiated, as per clause 2.3 of the Standard Medi-claim policy, vide letter dated 23.02.2012, on the ground that the patient suffered from Hepatitis C  and was given injection IFN SUB CUTANOUSLY, which is OPD based treatment without requiring any hospitalization. The claim of the complainant was investigated by Raksha TPA of OP No.1 and 2 and as such found that patient suffered from Hepatitis C and was given above injection, which is an OPD treatment without hospitalization. Ex.R-2 is repudiation letter. The claimed amount is Rs.49057/- and passed amount is Nil in this case. Ex.R-3 is the list of expenses, showing that complainant spent Rs.49057/- on the treatment. Affidavit of Dr. Rakesh Kalra C/o Raksha TPA Pvt. Ltd Ex.R-4 is also on the record to the effect that treatment received by the complainant no.2 is OPD based treatment only, without requiring any hospitalization.

8.      From evaluation of the above-referred evidence on the record and hearing the respective submissions of counsel for the parties, we are to determine, whether there is violation of Clause 2.3 of the Standard Medi-claim Policy requiring 24 hours admission in the hospital. Clause 2.3 of the Insurance Policy is reproduced as under _

          "2.3 Expenses on Hospitalization for minimum period of 24     hours are admissible. However, this time limit is not applied to        specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy,          Eye Surgery, Dental Surgery, Lithotripsy (Kidney Stone    Removal), D & C, Tonsilectomy taken in the Hospital/Nursing Home and the insured is discharged on the same day, the        treatment will be considered to be taken under hospitalization      benefit. This condition will also not apply in case of stay in        hospital of less than 24 hours provided:-

          a) The treatment is such that it necessitates hospitalization and        the procedure involves specialized infrastructural facilities   available in hospital."

9.      From perusal of the above-referred clause, 24 hours hospitalization is required for the diseases recorded therein. Treatment must involve the extraordinary multi super specialty facilities available in the hospital. The doctor, who issued certificate Ex.C-3, is a qualified doctor and his certificate remained un-refuted on the record by the Ops. The complainant claimed the total reimbursement of the amount of Rs.1,67,682/- on the basis of bills Ex.C-7 to Ex.C-46. From perusal of Ex.R-2 the letter of Raksha TPA, it was found that complainant only claimed Rs.49057/- (1600 for diagnostic services and 47457 for Medication charges). It is, thus, proved on the basis of Ex.R-2 that complainant claimed Rs.49057/-, which was also repudiated by the OPs. The District Forum has, thus, rightly found that in view of certificate of treating doctor Ex.C-3, which remained un-rebutted on the part of OPs, the claim of the complainant cannot be repudiated on account of violation of clause no. 2.3 of the insurance policy. The District Forum rightly directed the OPs to pay the amount of Rs.49,057/- to the complainant, as reimbursement of the expenses for treatment of the complainant no.2 and Rs.5000/-, as composite compensation. We are in agreement with the findings of the District Forum in the order under challenge in this appeal. The order of the District Forum Bathinda under challenge in this appeal is accordingly affirmed  in this appeal.

10.    In light of our above discussion, finding no merit in the appeal, the same is hereby dismissed.

 11.       Arguments in this appeal were heard on 01.12.2015 and the order was reserved. Copies of the order be communicated to the parties as per rules.

12.    The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                          (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

                       

                                                         

                                                                           (H.S.GURAM)

                                                                              MEMBER

 

December 4,  2015                                                             

(rb)