DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.30/2012
Sh. Harjeet Singh
A-119, Gujra Wala Town Part-1
Delhi-110033 ….Complainant
Versus
1. Future Healthcare and Health Management Services
1796 A, 1st Floor, Prasadi Lane, Kotla, South Extension-I
Delhi-110003
2. Paramount Health Services (TPA) Pvt. Ltd.
D-39, Okhla Industrial Area, Phase-1,
New Delhi-110020
3. Oriental Insurance Co. Ltd.
TP HUB, F-14, United Life Insurance Building
Connaught Place, New Delhi ….Opposite Parties
Date of Institution : 19.01.12 Date of Order :30.08.17
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
The case of the complainant, in nutshell, is that the complainant had bought a mediclaim policy namely, “Life Care Silver Plan” valid from 20.02.2010 to 19.02.2011 from OP No.1 for Rs.1 lac and paid premium of Rs.8545/. He was admitted in the hospital for treatment of NIDDM (detected on admission) CAD – acute anterior wall MI single vessel disease primary ptcap from 06.11.10 to 09.11.10 at Ridge Heart Centre, Sunder Lal Jain Hospital, Phase-III, Ashok Vihar, New Delhi. As there was no cashless facility in that hospital, he had to spend about Rs.2 lacs for the treatment; he deposited five cases with original documents [angiography report, lab inv. Report, ECG, discharge summary, hospital bills, medicine receipts/bills] with the OP No.2 for payment amounting of Rs.2 lacs but till today he has not received the payment despite the fact that he has visited the office of the OP several times and sent emails. The complainant has requested to solve his problem.
OP No.1 & 2 have been proceeded exparte vide order dated 04.09.2012 passed by our predecessors.
OP No.3 i.e. Oriental Insurance Co. (Insurer of OP No.2) was impleaded as a necessary party vide order dated 06.09.2013.
The OP No.3 has inter-alia submitted that the policy bearing No.254003/48/2010/1958 was issued by the OP No.3 in the name of OP No.2 as a group policy. The policy was taken on the basis of group as defined by IRDA. However, it was found that the group formed by the OP No.2 was not conforming to the norms set out for the formation of the group. Some other information provided by the OP No.2 for taking out policy was found to be false. Hence, this policy was taken on the basis of wrong and false information and was not valid. There are other irregularities in the policy. Therefore, a large number of cases are pending due to irregularities. Moreover, this case is under vigilance enquiry of the Company and the said enquiry is still pending. Hence, the OP No.3 is not liable for any claim arising out of the present policy as the policy is not valid as per IRDA guidelines, OP No.2 is responsible for the payment of claim, if any, arising out of the present policy. It is submitted that the documents with the TPA are also matter of record. The complainant is entitled for only maxium of Rs.1 lac as the total sum assured was Rs.1 lac. Hence, the amount incurred in the present treatment of Rs.2 lacs is not payable in any circumstances. The OP No.3 has prayed for dismissal of the claim.
The complainant has filed a rejoinder to the written statement OP No.3. It is stated that the complainant has been waiting for the settlement of his claim for the last 4 years and the main OP No.3 has caused deficiency in service to the complainant in not reimbursing the genuine claim of the complainant. The complainant has requested that the OP No.3 be directed to reimburse the medical expenses alongwith litigation cost and compensation.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. S. S. Yadav, Deputy Manager has been filed in evidence on behalf of the OP No.3.
Written arguments have been filed on behalf of the complainant.
We have heard the arguments on behalf of the complainant and have also gone through the file very carefully.
It is not in dispute that the complainant remained hospitalized from 06.11.2010 to 09.11.2010 at Ridge Heart Centre, Sunder Lal Jain Hospital, Phase-III, Ashok Vihar, New Delhi. The complainant submitted the bills to the OP No.1 for reimbursement of the claim. The OP No.2 applied from OP No.3 as a group policy wherein the complainant took the insurance policy for Rs.1 lac and paid premium of Rs.8545/-. The OP No.3 in its written statement and in affidavit in evidence has stated that the policy was taken on the basis of group as defined by IRDA. However, it was found that the group formed by the OP No.2 was not conforming to the norms set out for the formation of the group. Some other information provided by the OP No.2 for taking out policy was found to be false. Hence, this policy was taken on the basis of wrong and false information and was not valid. There are other irregularities in the policy. Therefore, a large number of cases are pending due to irregularities. Moreover, this case is under vigilance enquiry of the Company and the said enquiry is still pending. Hence, the OP No.3 is not liable for any claim arising out of the present policy as the policy is not valid as per IRDA guidelines, OP No.2 is responsible for the payment of claim, if any, arising out of the present policy.
The complainant filed the provisional receipt dated 24.11.09 regarding the insurance issued by the OP No.2 and paid a sum of Rs.8545. We mark the document as Annexure-A for the purposes of identification.
It is clear from the documents submitted by the complainant that the insurance papers were issued by the OP No.2. The OP No.2 issued Life Care Silver Plan to the complainant covering the four members of his families i.e. the complainant, his wife and two sons. We mark the document as Annexure-B for the purpose of identification. The Annexure-C relates to the hospitalization insurance risk covered by the OP No.2. Vide this document OP No.2 agreed to give discount on the diseases mentioned in the said document alongwith the mediclaim from OP No.3 and the hospitalization insurance of Rs.1 lac family floater basis from OP No.3. OP No.3 had to give 50% of the sum assured in case of cardiac surgery to the insured. Therefore, we see that there was no privity of contract between the complainant and the OP No.3 Co. and the complainant had to seek redressal of his grievances from OP No.2. Vide letter dated 12.11.10 (copy Mark D for the purposes of identification) the complainant had sent the documents alongwith claim form to OP No.2 for processing of his claim. He wrote a letter received in the office of OP No.1 and OP No.2 on 21.05.11 which we mark as Mark E. From a perusal of these letters it appears that in response to a letter dated 22.11.10 received from the office of OP No.1 & 2 the complainant had submitted some papers to them on 07.12.10. However, the complainant has not placed the copy of the letter dated 22.11.10 stated to be received by him from the office of OP No.1 & 2, the copy of his reply dated 07.12.10 which could show that the complainant had complied with any such requirement raised by the OP No.1 & 2. In order to prove that the complainant had completed all the formalities for processing his clam the complainant ought to have filed the copy of the letter dated 07.12.2010. Therefore, we are not inclined to believe that the OP No.2 did not deliberately process his claim. Therefore, in our considered opinion, the complainant has failed to prove any deficiency in service on the part of the OPs. Accordingly, we dismiss the complaint with no order as to costs.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 30.08.17.
