District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.299/2019.
Date of Institution: 11.06.2019.
Date of Order: 23.12.2022
Jamil S/o Shri Ishak R/o H. NO. 577, Prem Nagar, Sector-17, Kheri Road, Faridabad.
…….Complainant……..
Versus
Cigna TTK Health Insurance Company Ltd., 32-B, 3rd floor, Rajinder Nagar, Pusa Road, Near Pillar NO. 122 of Metro Station, Karol Bagh, New Delhi – 110 005 through its Servicing Officer.
Also at:- NH-28, 2nd floor, Old DLF, Sector-14, Gurgaon, Haryana – 122001through its Branch Manager.
Also at: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai – 400 063 through its Authorized Signatory.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Net Ram Tanwar counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant was holder of Family Floater Pro Health-Project Policy bearing policy No. PROHLR990028530 valid from 15.10.2018 to 14.10.2019 ID No.1000577800 . The wife of the complainant namely Amina aged 50 years was admitted in Metro Heart Institute with Multispecialty Hospital, Sector-16A, Faridabad with complaints of severe headache since 3 days, severe vertigo, nausea, pain right upper limb since then, on dated 22.11.2018 with IPD No. 18/32907 and remained admitted there upto 27.11.2018. Prior the admission of wife of the complainant, the said hospital had sent the intimation to the opposite party for taking the pre-approval of cashless treatment of the wife of the complainant. It was submitted that the same was accepted by the opposite party and gave pre-approval for the treatment of the wife of the complainant vide claim NO. 18494764 dated 18.12.2018. After getting the approval from the side of the opposite party, the said hospital had admitted the wife of the complainant with them on 22.11.2018 and started their treatment. Copy of pre-approval for treatment was also enclosed herewith for the kind perusal of this Hon’ble Forum.
The insurance company was cleared/paid the medical bill of Rs.44,385/- vide bill NO. IB18004536 dated 16.05.2018, IPD No. 18/13357 in respect of admission date i.e. 13.05.2018 and discharged on 16.05.2018 from Metro Heart Institute, Sector-16A, Faridabad.
Thereafter the said hospital had given that best treatment to the wife of the complainant and conducted various other tests in this regard. Prior to the relieve the wife of the complainant, the said hospital had sent the final bill of Rs.94,400/- alongwith treatment record of the wife of the complainant for approval of the same for cashless purpose. Upon which the opposite party did not give its approval in this regard by taking the plea that at present the complainant should make the payment out of his own pocket and assured the complainant that as and when the complainant would claim of the said amount by reimbursement process, the opposite party would make the same payment to the complainant. Thereafter, alongwith complete treatment record and other necessary documents, the complainant approached to the opposite party for the reimbursement of the treatment expenses of his wife, which was paid by the complainant to the above said hospital out of his own pocket. But the complainant got shocked and surprised when the complainant received the letter dated 18.12.2018 issued by the opposite party in the said letter the opposite party had declined the claim of the complainant by taking false plea. The complainant sent legal notice dated 16.03.2019 to the opposite party but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay an amount of Rs. 94,400/- alongwith interest @ 24% p.a. as compensation besides costs in the interest of justice.
b) Any other relief which this Hon’ble Forum deems fit and proper may kindly be awarded in favour of the complainant and against the opposite party.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that at the very threshold of the allegations contained in the complaint, from the relied upon documents, particularly discharge summary, by the complainant it was established that the complainant’s wife Amina was treated in Metro Hospital Faridabad w.e.f. 22.11.2018 to 27.11.2018 and where he was diagnosed as “Acute Prolapse of Intra-vertebral Disc. (PIVD) (C5-C6) with right upper limb weakness & vertigo and was managed conservatively hen so, in view of the policy inception since 28.08.2017, the claim of the complainant as to treatment of his wife stands non payable in view of the exclusion clause V.3 (iii) Two years waiting period of the insurance policy so issued in this regard. The complainant neither had any cause of action nor locus standi in lodging the present complaint, reason being, as a matter or record the complainant had lodged mediclaim towards hospitalization of his wife Amina vide claim form dated 03.12.2018 by enclosing entire treatment papers including discharge summary, wherein diagnosis was as “Acute PIVD (C5-C6) with Right Upper Limb Weakness & Vertigo with summary of illness as complaint of severe headache since 3 days, severe vertigo, nausea, pain right upper limb since then, by alleging indoor treatment w.e.f. 22.11.2018 to 27.11.2018 therein with Metro Hospital, Faridabad, so received by Medi Asist Insurance TPA Pvt. Ltd., being the third party administrator of the opposite party so as to process the claims , on 11.12.2018. During processing of the claim at the end of the said TPA, it had been observed that the claim was not payable since a waiting period of 24 months applies to the said ailment/disease for which the treatment was received. Therefore, the company rejected the claim vide rejection letter dated 1812.2019.Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– Cigna TTK Health Insurance Company Ltd. with the prayer to: a) pay an amount of Rs. 94,400/- alongwith interest @ 24% p.a. as compensation besides costs in the interest of justice. b)Any other relief which this Hon’ble Forum deems fit and proper may kindly be awarded in favour of the complainant and against the opposite party.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Jamil,, Ex.C-1 & 2 – postal receipts, Ex.C-3 – policy, Ex.C-4 – Final Bill,, Ex.C-5 – Bill settlement receipt, Ex.C-6 to 12– Final Bill Break up, Ex.C-13 – Discharge summary,, Ex.C-14 – final Bill,, Ex.C-15 – Bill settlement receipt, Ex.C-16 & 17 – final bills, Ex.C-18 to 23 – Final Bill break up, Ex.C-24 – Admission Advance receipt, Ex.C-25 – Discharge summary, Ex.C-26 – adhaaar card, Ex.C-27 – legal notice,, Ex.C-28 – Acknowledgement card.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri Jaswinder Singh, Shekhawat, Manager (Legal) M/s. Manipal Cigna Health Insurance Company Limited, 401/402,Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai,, Annx.A – policy, Annx B – policy schedule,, Annx.C – Claim Form – Part A, Annexure ‘D’ – Discharge summary, Annx.E – Final Bill, Annx.F – repudiation letter.
6. In this complaint, the complainant was holder of Family Floater Pro Health-Project Policy bearing policy No. PROHLR990028530 valid from 15.10.2018 to 14.10.2019 ID No.1000577800 . The wife of the complainant namely Amina aged 50 years was admitted in Metro Heart Institute with Multispecialty Hospital, Sector-16A, Faridabad with complaints of severe headache since 3 days, severe vertigo, nausea, pain right upper limb since then, on dated 22.11.2018 with IPD No. 18/32907 and remained admitted there upto 27.11.2018. Prior the admission of wife of the complainant, the said hospital had sent the intimation to the opposite party for taking the pre-approval of cashless treatment of the wife of the complainant and the same was accepted by the opposite party and gave pre-approval for the treatment of the wife of the complainant vide claim NO. 18494764 dated 18.12.2018. After getting the approval from the side of the opposite party, the said hospital had admitted the wife of the complainant with them on 22.11.2018 and started their treatment. The insurance company was cleared/paid the medical bill of Rs.44,385/- vide bill NO. IB18004536 dated 16.05.2018, IPD No. 18/13357 in respect of admission date i.e. 13.05.2018 and discharged on 16.05.2018 from Metro Heart Institute, Sector-16A, Faridabad. Prior to the relieve the wife of the complainant, the said hospital had sent the final bill of Rs.94,400/- alongwith treatment record of the wife of the complainant for approval of the same for cashless purpose. The opposite party did not give its approval in this regard by taking the plea that at present the complainant should make the payment out of his own pocket and assured the complainant that as and when the complainant would claim of the said amount by reimbursement process, the opposite party would make the same payment to the complainant. Opposite party repudiated the claim of the complainant vide letter dated 18.12.2018 vide Annx.F on the ground that “on scrutiny of the documents it has been observed that claimant admitted at Metro heart Institute on 22 Nov. 2018 with Acute PIVD with rt upper limb weakness, vertigo, Managed conservatively and discharged on 27 Nov.2018. Claimant is covered under Cigna TTK Pro-Health Insurance protect Mediclaim policy since 28 August 2017. As per the policy expenses related to treatment of all Vertibrae Disorders, including but not limited to spondylitis, Spondylosis, Spondyloisthesis are not admissible during first two years from the date of inception. Hence the claim stands repudiated under the policy Exclusion V.3. We regret our inability to admit this liability under the present policy conditions. We also reserve the right to repudiate the claim under any other grounds available to us subsequently.
7. After going the evidence led by the parties, the Commission is of the opinion that it is evident form Ex. C-20 to C-22 once opposite party has paid the medical bill of Rs. 44,385/- vide bill No.IBI8004536 dated 16.05.2018, IPD No. 18/13357 in respect of admission dated i.e 13.5.2018 and discharged on 16.5.2018 from Metro Heart Institute, Sector-16A, Faridabad to the complainant, the question of rejection of claim of the complainant amounting to Rs.94,400/- does not arise. It is evident from final bill dated 27,11,2018 I Sl. NO.3 i.e. Neuro Procedure amounting to Rs.4200/-, the Commission is of the opinion that opposite party can be deducted for Rs.4200/- from the final bill of the complainant. Hence the complaint is allowed.
8. After going through the evidence led by the parties, the Commission
is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite party is also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 23.12.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
