Haryana

Gurgaon

CC/719/2010

Inderjeet Yadav - Complainant(s)

Versus

1. United India Insurance Co. Ltd - Opp.Party(s)

09 Feb 2015

ORDER

 

DISTRICT   CONSUMER   DISPUTES   REDRESSAL FORUM, GURGAON-122001.

                                                                                                                       Consumer Complaint No: 719 of 2010                                                                                                                                           Date of Institution: 09.09.2010                                                                                                                                            Date of Decision: 09.02.2015

Inderjeet Yadav age 27 years, R/o 52-B, Mianwali Colony, Sector 12, Gurgaon-122001.

                                                                                        ……Complainant.

 

                                                Versus

 

1. United India Insurance Co. Ltd, Plot No.25, MCH No.8-2-334, Azam Colony, Road No.03, Banjara Hills, Hyderabad.

 

2. Family Health Plan (TPA) Plot No.8, 2^nd Floor, Retail  Business Center, Nangal Raya, Opposite Jankapuri “D” Block, New Delhi-46.

 

3. The Manager, Andhra Bank, Sector 14, Main Market, Gurgaon.

 

                                                                                       ….Opposite parties.

                                               

Complaint under Sections 12 & 14 of Consumer Protection Act,1986                                                                  

 

BEFORE:     SH.RAGHVINDER SINGH BAHMANI, PRESIDENT.

                     SMT JYOTI SIWACH, MEMBER.

 

Present:        Sh.Inderjeet Singh Yadav, complainant in person.

                    Sh.V.K.Bhardwaj, Adv for OP-1

                    Representative of OP-2 (Defense Struck Off)

                    Representative of OP-3.

 

ORDER       R.S.BAHMANI, PRESIDENT.    

 

              The complainant alleged that he has Medi-claim Policy AB AROGYADAAN of the OP-Company bearing Policy No.050400/48/09/41/00000074 by which complainant Inderjeet Yadav, mother Murti Devi, wife Banita and son Hitesh have been insured for a sum of Rs.1 Lac  for the period 07.11.2009 to 06.11.2010 as per terms and conditions attached with it (C-1). The complainant further alleged that his wife Mrs. Banita Yadav insured suffered enteric fever in May, 2010 and she got treatment from Yadav Hospital, Sector 10-A,Gurgaon initially on 19.05.2010  and then on 23.05.2010 vide Prescription Slip (C-2) but as she could not recover she was admitted to said hospital on 30.05.2010 and remained indoor patient till 03.06.2010. The complainant also informed the official of OP-1 and 2 on 31.05.2010 in this regard and the complainant also got intimation No.123282. He has incurred expenses of Rs.11700/- as per detailed Bill No.179 of Yadav Hospital, Gurgaon (C-3) showing date of admission 30.05.2010, date of discharge 03.06.2010 showing Registration charges Rs.200/-, Professional Charges, Duty Doctor + Consultation Charges Rs.3500/- (Rs.700/- x 5 days), Nursing Care Rs.1500/- (Rs.300/- x 5 days), and Room rent Rs.6500/- (Rs.1300/- x 5 days) =total Rs.11700/- and also produced the payment receipt No.187 dated 30.05.2010 of Yadav Hospital,  for Rs.5000/- (C-3A) and Receipt No.220 dated 03.06.2010 for Rs.6700/- (C-3B). The complainant has also produced the following Bill of Investigation as well as Bills for purchase of the medicines (C-3C to C-3I):

 

Bill No.        Date            Name of the Medical Store/Firm                   Amount

7265            26.05.2010   Yadav Diagnostic,                               Rs.850.00

                                      Sector 10-A, Gurgaon

 

6922            26.05.2010   Shri Sai Vardaan Pharmacy,               Rs.183.00

                                      Sector 10-A, Gurgaon

1030            30.05.10      Dang Medical Store, New                    Rs.759.00

                                      Railway Road, Gurgaon

 

6943            30.05.10      Shri Sai Vardaan Pharmacy,               Rs.580.00

                                      Sector 10-A, Gurgaon

 

6944            31.05.10      Shri Sai Vardaan Pharmacy,               Rs.480.00

                                       Sector 10-A, Gurgaon

 

6945            31.05.10      Shri Sai Vardaan Pharmacy,               Rs.234.00

                                      Sector 10-A, Gurgaon

 

7320                               Yadav Diagnostic,                               Rs.700.00

                                      Sector 10-A, Gurgaon

                     

                                         Total                                         Rs.3786.00

 

Thus, the complainant has alleged that he has incurred a total sum of Rs.11700/- + Rs.3786 = Rs.15486.00. The complainant, however, filed the claim with the OP as per Claim Form dated 11.06.2010 for Rs.15486/-(C-4). However, they have repudiated his claim wrongly vide Letter dated 16.07.2010 (C-5). Consequently, Legal Notice dated 02.08.2010 was given to the OP but of no use (C-6). Thus, it is alleged that the OPs are deficient in providing services to the complainant and thus, is entitled to reimbursement of Rs.15,486/-. They have also harassed the complainant and caused mental agony and thus, claimed compensation of Rs.50,000/-. He also claimed litigation expenses of Rs.7500/- or any other relief deem fit by this Forum. The complaint is supported with an affidavit of complainant Inderjeet Yadav.

2.                OP-1 in its written reply however denied the claim of the complainant and has taken objections that the complaint is premature as they have been provided a remedy while repudiating his claim to approach Grievance Department of the Insurance Company which he failed to avail and thus, the complaint is not maintainable. Moreover, he has not come to the Forum with clean hands and suppressed the material facts and filed this false and frivolous claim which is liable to be dismissed. Infact, initially he did not provide receipt for the amount claimed and other documents and whenever they were produced they were found not genuine and valid document. On investigation from Yadav Hospital it was found that it is not a registered hospital as no full time doctors are available and nurses employed were not found to be registered with Nursing Council. The Carbon copy of the receipts issued for treatment were not produced, no room occupation record to justify the patient-insured admission for 5 days was available. There was no proper admission register and there was over writing and manipulations even in the registration number of the patient. The record furnished with the insured claim and found in the hospital did not tally as Rs.3500/- were shown charged towards duty doctor + consultation charges @ Rs.700/- for 5 days i.e. Rs.3500/- whereas the hospital record shows only one visit of the doctor per day. Similarly, as per Discharge Certificate insured was discharged on 03.06.2010 at 5.00 pm but the hospital record shows giving injection at 8.00 pm and 10.00 pm. Again charges for 31 injections were claimed but hospital record shows only use of 9 injections. Their investigator has furnished his report dated 06.07.2010 in this regard which is (OP-1) and consequently, the claim of the complainant was not found based on reliable documents and they have rightly repudiated his claim vide Letter dated 16.07.2010. There is no deficiency of service on the part of answering OPs and thus, the complainant is not entitled to any claim of Rs.15,486/- for reimbursement though receipts produced were only of Rs.11,700/-. The complainant is not entitled to any compensation of Rs.50,000/- or litigation expenses as claimed. Infact, the complaint is false, frivolous and liable to be dismissed with costs. The written reply is duly supported with affidavit of Shri T.D.Kajala, Deputy General Manager of OP-1 besides the report of Surveyor dated 06.07.2010 referred above.

3                 Notice of the complaint was given to OP-2. However, OP-2 failed to file the written reply within the stipulated period and thus, its defence was struck off on 07.12.2010.

4                 OP-3 in its written reply has alleged that complainant Inderjeet Yadav has Saving Bank A/c No.115010100002263 with their Branch Office. They were offering additional facility of Health Insurance through AROGYADAAN Scheme to their Bank Customers and their family members through OP-1. The complainant has joined the above Scheme on 07.11.2009 for a sum of Rs. 1 Lac and they have forwarded his Application to OP-1 who had accordingly issued Arogyadaan Identity cards to Complainant and his family members with following UHID Nos-FHAU-0000995847, 0000995848 0000995849 and  0000995850.

5                 We have heard the parties and appraised the material on record carefully. Keeping in view the facts and circumstances discussed above and after going through the documents produced by the parties we are of the considered opinion that there is no dispute that the complainant along with other family members including his wife, the patient were duly insured vide Medi-Claim Policy called Family Health Plan (TPA) Limited bearing Policy No.050400/48/09/41/00000074 for the period 07.11.2009 to 06.11.2010 with sum assured Rs. 1 Lac (C-10. The complainant, however, alleged that his wife Banita Yadav was suffering from enteric fever and was treated in Yadav Hospital, Sector 10-A, Gurgaon as per Prescription Slip (C-2). However, she could not be cured and accordingly, she was admitted to Yadav Hospital, Sector 10-A, Gurgaon for her treatment where after necessary tests and investigations she was treated as Indoor patient for the period 30.05.2010 to 03.06. 2010 as per Discharge Card (C-3AA) and has incurred Rs.6700/- vide Receipts dated 30.05.2010 (C-3A) and dated 03.06.2010 (C-3B). The complainant has also incurred Rs.3786/- before her treatment vide Bill/Receipts (C-3C to C-3I). The complainant admittedly filed his claim with the OP. However, they got the matter investigated from their Surveyor Dr. Biswendu Bardhan who has filed his Report dated 06.07.2010 (OP-1). In his 7 page report the Conclusion reads as under :-

4        Conclusion:

4.1      The hospital does not have the license with the appropriate local or other authorities competent to register hospitals in the relevant area and is not under the constant supervision of a Medical Practitioner

4.2      Though the hospital has 10 beds but the hospital is not under the constant supervision of a Medical Practitioner, and does not have fully qualified nursing staff (that hold a certificate issued by a recognized nursing council) under its employment in constant attendance, does not maintain daily records of each of its patients, and does not have fully equipped and functioning operation theatre.

4.3      Manipulation of the date is evident in all  the documents of the hospital

4.4      The discharge medication purchase record is traceable to 3 days prior to the discharge shown in the discharge card.

4.5      The nursing record, medication administration record, indoor case paper is found to be manipulated. Infact there is no documents without any manipulation which proves that the submitted claim is supported by an act of dishonesty and fraudulent means.

4.6      Hospital had some accounting mal practices like in appropriate records of the payments, not issuing bills, and receipts to all patients and lack of transparency in billing and no accounting clarity. Dual billing system for the cash and insurance patients suggestive of billing malpractice.

4.7      The hospital is not under the constant supervision of a qualified Medical Practitioner who is authorized to practice Allopath (RMO’s on duty are not authorize to practice Allopath and is considered to be an offence under section 15(3) of medical council of India Act 1956). The Supreme Court has held that a person who does not have knowledge of a particular system of medicine but practices in that system is a QUACK and a mere pretender to medical knowledge or skill, or to put it differently, a CHARLATAN.

4.8      The hospital charged for the medication more than the MRP which is a punishable offence “As per Sec. 7 of Essential Commodities Act, the penalty for contravention of DPCO is minimum imprisonment of 3 months, which may extend to seven years and the violator is also liable to a fine (The Drugs Prices Control Order, 1955).”

4.9      The hospital does not have any appropriate records in place

            Not maintaining a proper record amounts to deficiency in service as  “The Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002 (4) states that every physician shall maintain the medical records pertaining to his/her indoor patients for a period of three years from the date of commencement of the treatment. If any request is made for medical records either by the patients/authorized attendant or legal authorities involved, the documents shall be issued within a period of 72 hs and refusal to do so would be misconduct”. (Published on 6, April, 2002 in Part III, Section 4 of Gazette of India).

 

On the basis of this report the OP has repudiated the claim of the complainant being not in accordance with the terms and conditions of the Policy as there is concealment of true facts and have obtained the Bills by way of manipulation against the said hospital record by giving reason :

 

“Certain discrepancies and manipulations were observed during the investigation of the case and therefore claim has been repudiated as  per policy terms and conditions.

In the event of your not being satisfied with our decision, you may kindly approach the Grievance Department at the below address within 12 calendar months

                   Grievance Department

                   4^th Floor, United India Towers,

                   Basheerbagh, Hyderabad-29.

 

The Report of the Investigator as referred above clearly shows various material discrepancies and manipulations in the record of alleged hospital which even was not found registered, material discrepancies besides manipulation of certain bills regarding purchase of medicine and investigation etc as discussed above. However, the report of the Surveyor is to be given due weightage as held by the Hon’ble National Consumer Disputes Redressal Commission as well as Hon’ble apex Court  in case Zainul Abedin & Anr. Vs New India Assurance Co. Ltd & Ors. II (2008) CPJ 173 (NC), National Insurance Co. Ltd v Nipha Exports Pvt. Ltd 2007 (1) CPR 80 (SC), Oriental Insurance Co. Ltd v Mehta Wool Store 2008  NCJ 82 (NC).

Consequently, there is violation of the terms and conditions of the Insurance Policy which infact           is a contract of utmost good faith between the parties. Thus, the Insurance Company is justified in repudiating his claim. The complainant even failed to take efficacious remedy available to him as per notice to him in the repudiation letter before Grievance Department within a specified period. Hence, the complaint is false, frivolous and liable to  be dismissed.

Compliance be made within 30 days.

Copy of this order be sent to the parties free of costs.

 

Pronounced in open court.                           

Dated: 09.02.2015.

                                                                                       President,

                                                                             District Consumer Disputes

                                                                                                                                                          Redressal Forum, Gurgaon

                 (Jyoti Siwach)

                       Member