DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No. 177/2017

Date of Institution: 09.05.2017

Judgment Reserved on: 05.07.2024

Judgment Passed on: 05.07.2024

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Judgment By: Shri S.S. Malhotra (President)

JUDGMENT

1. By this judgment the Commission would dispose off the complaint of the complainant alleging deficiency in service in not reimbursing the medical bill despite lodging a valid claim with the insurance company against the mediclaim policy.
2. Before coming to the facts, it is necessary to mention here that the complaint was originally filed by the complainant against the insurance company with which it was insured by making the competent authority/Consumer Affairs Department as OP2 as a necessary party but at the stage of admission itself the Commission removed OP2 as a necessary party and directed the complainant to file amended memo of parties and issued notice to the OP/Insurance company only. It is also necessary to mention that initially the complaint was filed against the Apollo Munich Health Insurance Co. Ltd., but subsequently the OP had filed an application for substituting the name of Apollo Munich Health Insurance Co. Ltd. to HDFC ERGO Health Insurance Limited which application was also allowed and thereafter amended memo of parties was filed & accordingly the name of the parties in the cause title is being mentioned as Brahma Dutt Sharma Vs. HDFC ERGO Health Insurance Limited.
3. Now coming to the facts of the complaint case, it is submitted that complainant had health insurance policy from the OP under Family Floater Scheme where his wife was duly covered and she fell ill and had to be treated in Indra Hospital, Delhi where she was admitted on 11.05.2015 and was discharged on 12.05.2015 and he spent an amount of Rs.50341/- on the medical treatment whereafter he submitted all the original bills/documents relating to the treatment and also completed all other formalities through agent of the OP and all the related documents have also been annexed alongwith complaint as Annexure P-I(colly) and another letter was received by complainant on 14.07.2015 and the same was responded properly and later on one Mr. Sharma also came to the residence of the complainant and recorded the statement of the patient/his wife, but despite that reimbursement of medical bill was not done and despite writing several times and also despite various phone calls to different officials of OP no reimbursement was made and he even got his policy renewed from OP itself by paying Rs.12372/- as a premium for next year for continuation of policy despite previous claim amount not been reimbursed which amounts to deficiency in service by the OP. He sent a legal notice to the OP dated 15.09.2015 which was not complied with and therefore he has filed the present complaint thereby seeking directions to the OP to pay Rs.50341/- to the complainant alongwith compensation of Rs.2 Lakh towards mental pain and  agony and Rs.55000/- towards litigation charges.
4. The OP has filed reply interalia submitting that the complaint is an abuse of the process of law and has been filed with the sole purpose of harassing and pressurising the answering respondent. Complaint is devoid of any material facts or merit and same is false, malicious, incorrect and malafide which is barred by Section 3 of the Consumer Protection Act, 1986 and the same is liable to be relegated to the Civil Court which is the competent Court of jurisdiction, complaint is not maintainable either on questions of fact or on question of law and insurance policy is a contract of indemnity which is governed by the principles of Indian Contract Act and since there is no merit in the complaint, the same be dismissed. The facts as submitted by the OP are that that the decision of the insurance company to grant insurance cover to the applicant depends upon the various facts, i.e. disclosure of material fact, declarations made by the proposer, premium amount or maturity amount, aliment which are to be covered on the basis of information, the contents of the proposal form and on having all such information the policy was issued to the complainant for the period of 22.06.2012 to 21.06.2013, 22.06.2013 to 21.06.2014, 22.06.2014 to 21.06.2015, 22.06.2015 to 21.06.2016, 24.06.2016 to 23.06.2017 and 24.06.2017 to 23.06.2018 and it was renewed from time to time and on the date of the ailment the policy was valid & then detailed procedure is mentioned as to how the claims is received and how the claims are settled. It is submitted that on 05.06.2015 the complainant submitted claim for reimbursement of expenses incurred by him w.r.t. the hospitalisation of the wife at Indira Infertility Clinic and Test Tube Baby Centre with date of admission 11.05.2015 and date of discharge 12.05.2015 with the final claim amount of Rs.50341/- and vide letter dated 12.06.2015 the OP demanded certain documents from the complainant;

-     All the investigation reports.

-     Attested copies of indoor case papers of hospitalization including admission notes and daily progress notes.

-     Cancelled cheque copy with the payee nane(Brahma Dutt Sharma)/bank passbook statement of proposer/payee in the policy to get claim paid electronically.

-     Histopathology report of the excised part.

-     Original cash paid receipt of final bill.

-     Original consolidated Final bill with breakup details on hospital letterhead.

-     Registration certificate of hospital with registration number.           

5. Apart from demanding all these documents the investigation report was also called and it was observed that the hospital, where complainant’s wife was admitted was a 20 bedded Infertility Healthcare provider in Delhi and it had applied for registration but the registration was still pending and insured did not verify the fact on two occasions & the complainant had denied to meet the claim examiner after giving appointment and admittedly she stopped responding. The non-cooperative attitude of the wife of the complainant for the verification process and not making the document available & despite writing another letter but the documents were not completed/supplied & therefore the claim was treated as closed due to non-cooperation. The response was subsequently received from the said complainant in which the complainant submitted the cancelled cheque and registration certificate of the hospital only, and rest of the required documents were not submitted and the claim was accordingly closed on 28.03.2016 for non submission of documents, copy of which was sent to complainant and it is further stated that insured undertakes to compensate the loss suffered by the insured on account of the risk cover by the insurance policy on providing the documents. Then the detail of various judgments has been mentioned as to how the insurance policy has been dealt with by various Court/Commission. In the present matter since complainant has violated the terms & conditions of the insurance policy and showed her inability to provide documents, the claim was closed and therefore complaint is liable to be dismissed and be dismissed.
6. As far as merits are concerned all these facts are reiterated and it is denied that complainant submitted all the original documents related to the treatment or completed all the formalities through Agent Mr. Gian Singh. It is further submitted that the official of OP had contacted the complainant and his wife but they did not meet despite giving appointment twice and therefore the contents of the preliminary objections be read as part of the reply on merit and complaint case of the complainant be dismissed. Prayers is stated to be exaggerated and liable to be dimissed.       
7. Complainant thereafter has filed replication thereby denying the contents of the written statement and reaffirming the content of the complaint and it is submitted that complainant sent claim form/application duly filled as prescribed by the OP on 05.06.2015 alongwith all the document and also such documents were duly supplied but OP has erroneously closed the claim of the complainant and it is prayed that complaint case of the complainant be allowed.
8. Complainant has filed his own evidence by way of affidavit whereas the OP has filed evidence of Ms. Deepti Rustogi duly constituted Attorney of OP. Both the parties have also filed written argument. The Commission has heard the argument and perused the record.
9. The policy, the ailment of the wife of the complainant, payment of bill of Rs.50341/-, statement of claim alongwith various documents was submitted, all are admitted facts.
10. The issue is only as to whether complete documents as required by the OP to allow the reimbursement after following the procedure were supplied or not.
11. The required documents which the OP has required are the prior investigation report, attested copies of indoor case papers of hospitalisation including admission notice, cancelled cheque alongwith passbook statement, histopathology report, original cash paid receipt of the final bill/consolidated bill and registration certificate of hospital.
12. During the argument it was informed that as far as all previous investigations are concerned these cannot be filed as there is no previous history of the complainant w.r.t. the ailment for which she was admitted and imaging report/lab report chromosomal study reports also cannot be filed and as far as other documents are concerned have already been supplied. So much so, during the argument it is also specifically contended by the Ld. Counsel for OP that all the documents which were required have been received but the registration certificate of the hospital with registration number is still pending which is mandatory whereafter the complainant who is appearing in person countered the argument of Ld. Counsel for OP stating that these documents have been filed by the OP himself alongwith his evidence and therefore there is no more document required by the OP from the complainant to pass the mediclaim bill. It is quite surprising that when the complaint was filed all these documents were filed by the complainant alongwith complaint and apparently while fling the reply by OP, the OP has not demanded any other document after filing of the complaint. The contention of OP to some extent can be presumed that some document might not have been supplied with the claim form, yet after filing the complaint case there is nothing on record which may show that any more document was required by the OP to assess the claim. There is not even single averment in the entire written statement that some of the documents have not been supplied or filed on the Commission’s record so far and therefore it appears that OP may not be assessing/reimbursing the medical claim before the filing of the complaint, but after filing of the complaint, OP could not have stopped the reimbursement once it has received all the documents from the Commission’s record. Writing detailed & lengthy written statement thereby stating various judgments and various detailed procedure of the insurance policy and then incorporating the various portion of the policy in the written statement by itself could have been appreciated in much better way if alongwith written statement it could have been specifically averred that the complainant has not filed the particular required documents alongwith the complaint. Therefore it appears that all such lengthy written statement is devoid of any merit once no further documents was sought from the Commission alleging deficiency of supplying the document even to the Commission/Court, therefore it may be a ground that claim be not awarded to the complainant from the date of lodging claim by the complainant but in any case once the claim has been filed before this Commission alongwith entire set of documents then the deficiencies on the part of OP stand established. Accordingly OP is directed to make reimbursement of claim amount from the date of filing the complaint as in any case it was not a ground to close the claim. As far as registration certificate is concerned the same has been filed by the OP itself.
13. The Commission therefore holds that complainant has been able to prove deficiency in not reimbursing the claim of the complainant and accordingly complaint of the complainant is allowed with following directions;

• OP is directed to pay/reimburse the amount of Rs.50341/- to the complainant alongwith interest @6% p.a. from the date of filing the claim till realisation within 30 days of receiving the copy of the judgment.
• The OP would comply the order of this Commission within 30 days of having received the copy of judgment & if the order is not complied with as directed here-in-above then the rate of interest would be @9% p.a. from the date of filing the complaint till actual realisation on the whole amount i.e. including the compensation & litigation charges.
• OP is also directed to pay Rs.15000/- towards compensation and litigation cost of Rs.5000/-.                 
• Copy of the judgment be supplied/sent to both the Parties free of cost as per rules.

Announced on 05.07.2024.

File be consigned to Record Room.