DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Complaint No. CC/15/222 of 5.10.2015

                                      Decided on:        12.5.2016

Varinder Bansal S/o Late Sh.S.P.Bansal aged about 36 years resident of H.No.307, Ajit Nagar, Near Sant Peter’s School, Patiala 147001.

                                                                   …………...Complainant

                                      Versus

1.      Bharti AXA General Insurance Co.Ltd., Backside Narain Continental Hotel, Chhoti Baradari, Patiala through its Authorized Signagory/Branch Manager.

2.      Bharti Axa General Insurance Co.Ltd., Ist Floor, Ferens Icon, Survey No.28, Doddanekundi, Banglore-560037 through its Managing Director.

3.      E-Meditech.TPA Services Ltd. Plot No.577, Udyog Vihar, Phase-5, Gurgaon, Haryana-122016 through its Authorized Signatory/Director.

4.      Paramount Health Services TPA Pvt. Ltd., Plot No.A-422, Road No.28 MIDC , Industrial Area, Wagal Estate, Ram Nagar, Vithal Rukhmani Mandir, Thane (West),Maharashtra-400604 through its Authorized Signatory/Director.

                                                                   …………….Ops

                                      Complaint under Section 12 of the

                                      Consumer Protection Act.

                                      QUORUM

                                      Sh. A.P.S.Rajput, President

                                      Smt.Neelam Gupta, Member

                                      Smt.Sonia Bansal,Member

Present:

For the complainant:     Sh.Chamandeep Mittal , Advocate

For Ops No.1&2:          Sh.Jaspreet Singh,Advocate

For Ops No.3&4:           Ex-parte.          

                                         ORDER

NEELAM GUPTA, MEMBER

1. The complainant got himself insured with Ops no.1&2 vide policy No.BIH/Q0071467/2C/11 , policy named as ‘Smart Insurance Policy of Bharti AXA General Insurance Co.’ and the policy was duly valid from 13.11.2014 to 12.11.2015.The said policy was purchased by the complainant through the credit card of HDFC Bank, Patiala. It is averred that in the 2^nd week of September,2015, the complainant was admitted in Daya Nand Medical College & Hospital,Ludhiana on 14.9.2015 due to some medical problem. The complainant immediately informed the hospital authorities about the medical insurance of the complainant with Bharti Axa and also told the hospital authorities to contact and take approval of his treatment as the DMC,Ludhiana is empanelled with the Ops No.1&2 and is recognized network provider  of Ops no.1to4.It is further averred that DMC Hospital Ludhiana intimated Ops no.3&4 through e-mail for getting approval for the cashless medical claim for the medical treatment expenses through its  corporate cell on 15.9.2015 at about 9.32 AM and the said intimation was also given to Op no.4 through intimation No.08330854 and the hospital authorities also attached some documents for the purpose of getting the claim of the complainant but the corporate cell of hospital authorities did not receive any reply or approval from the ops. The hospital authorities explained the complainant regarding the conduct of the Ops and further directed the complainant to pay all the medical bills of his treatment to the hospital and so under the compelling circumstances, the complainant had to pay a sum of Rs.24710/-  to the hospital authorities of DMC and got discharged from the hospital on 17.9.2015.
2. It is further averred that on 18.9.2015, the complainant sent an e-mail to Op no.2 regarding the harassment undergone by the complainant at the hands of the service providers i.e. Ops no.3&4 of Bharti AXA GIC Ltd. but till the date of the filing of the complaint, no reply was given by the Ops.
3. It is further averred that the complainant availed the service of the Ops as per rule/term 2.5 of the terms and conditions of the policy and the DMC, Hospital, Ludhiana is net work provider as well as empanelled hospital of the Op’s as per term/rule 2.26 of the terms and conditions of the policy. By not allowing the claim of the complainant, the Op’s indulged in unfair trade practice as well as this act amounted to deficiency of service on the part of the Ops. The complainant underwent a lot of harassment and mental agony at the hands of the Op’s. Ultimately he approached this Forum under Section 12 of the Consumer Protection Act,1986( for short the Act).
4. On notice, Ops no.3&4 failed to appear despite service and were thus proceeded against exparte whereas Ops no.1&2 appeared through counsel and filed there reply to the complaint. It is an admitted fact that the complainant got himself insured under policy ‘Smart Insurance Policy of Bharti AXA GIC’ vide policy No.BIH/Q0071467/2C/11 for the period 13.11.2014 to 12.11.2015.It is also an admitted fact that the claim of the complainant was duly registered by the Op’s vide claim No.100091508361. It is submitted that after preliminary scrutiny of documents by Op no.3, certain query was raised by Op no.3 vide letter dated 16.9.2015 for the processing of the claim. Vide their letter dated 16.5.2015, certain documents were  called by Ops for processing of the claim and the same were not supplied by the DMC, Ludhiana due to which the claim of the complainant was closed by the Ops on 29.9.2015. It is the DMC, Ludhiana who did not send the required documents for processing the claim of the complainant. After denying all other allegations mentioned in the complaint, it was prayed to dismiss the complaint.
5. The complainant produced in evidence Ex.CA, his sworn affidavit alongwith documents Exs.C1 to C14 and his counsel closed the evidence.Whereas the counsel for Ops no.1&2 tendered in evidence Ex.OPA, the sworn affidavit of Smt.Shivali Sharma, legal manager Bharti AXA, GIC alongwith document Exs.OP1 and closed the evidence.
6. Parties failed to file the written arguments. We have heard the counsel for the parties and gone through the evidence on record.
7. Ex.C3 is the policy document dated 15.11.2014, sent by Bharti AXA, GIC to the complainant relating to the purchase of Smart Health Basic Policy No.BIH Q00714672C/11 by the complainant vide which the complainant was duly insured with the Ops for the period 13.11.2014 to 12.11.2015.In the second week of September,2015, the complainant fell ill and was admitted in DMC & H,Ludhiana Ex.C4 is the letter written by DMC & H , Ludhiana to Op no.3 for approval of cashless / further approval at the earliest and also  mentioning of the room eligibility  or room limit amount of the complainant so that they can easily provide such facility.But Ops failed to provide the cashless facility to the complainant . Ex.C11 is the e-mail dated 18.9.2015 sent by the complainant to Bharti AXA GIC regarding the complaint against Bharti AXA Health insurance for not giving him cashless facility as a result he had to pay Rs.29000/- from his pocket on getting discharge from the hospital on 17.9.2015.
8. Ex.C12 is the policy terms and conditions. As per clause 2.26 of Ex.C12 , ‘Network provider’ means “Hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to provide  medical services to an insured on payment by a cashless facility”.As per clause 2.5 of the same ‘cashless facility’means ‘a facility extended by the insurer to the insured where the payments of the costs of treatment undergone by the insured in accordance with the policy terms and conditions are directly made to the Network provider by the insurer to the extent pre-authorization approved”.
9. In the present case the complainant was a holder of insurance policy issued by Op as per Ex.C3, and was entitled for cashless facility as per the terms and conditions of the policy, the fact has not been rebutted by the Ops. But the Ops failed to provide the cashless facility though the DMC & H, Ludhiana had written a letter to Op no.3 ( i.e. Ex.C4) for availing the facility. But the Ops failed to provide the cashless facility and the complainanrt had to pay Rs.24710/- from his pocket on 17.9.2015 on getting discharged from the hospital.The only plea taken by Op no.3 in its written statement is that it had written a letter to DMC Hospital, Ludhianaon 16.9.2015 vide which certain information or documents were called by the Ops for processing the claim and the same were not supplied by DMC & H Ludhiana, due to which the claim of the complainant was closed by the Ops on 29.9.2015.Ex.OP1 is the copy of the letter written by Op no.3 to DMC & H, Ludhiana but no evidence in support of this letter being sent by Ops to the DMC & H Ludhiana has been placed on record. Thus, we see that the act of the Ops by not allowing the claim of the complainant amounted to deficiency of service as well as unfair trade practice on the part of Ops. and the complainant underwent  a lot of harassment and mental agony at the hands of the Ops.
10. In view of the aforesaid discussion, we accept the complaint with a direction to Ops no.1&2 to make the payment of Rs.24,710/- with interest @ 8% per annum from the date of repudiation i.e. 29.9.2015 till final payment . The Ops no.1&2 shall also make the payment of Rs.5000/- by way of compensation on account of harassment and mental agony experienced by the complainant. In view of the facts and circumstances  of the complaint, the same is accepted with litigation cost assessed at Rs.5000/-.The order be complied by the said Ops within a period of 45 days from the date of receipt of the certified copy of the order.

Pronounced

Dated:12.5.2016

               Sonia Bansal           Neelam Gupta                        A.P.S.Rajput

        Member                Member                                  President