DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 1250/2016
D.No._________________________ Dated: _________________
IN THE MATTER OF:
RAKESH RATHOR,
S/o SH. HARPAL SINGH RATHOR,
R/o 294/1, GALI No.1,
AMBEDKAR NAGAR,
HAIDERPUR, DELHI-110088.… COMPLAINANT
Versus
HDFC ERGO GENE. INS. CO. LTD.,
THROUGH ITS MANAGER,
1st FLOOR, 165-166,
BACKBAY RECLAMATION,
H T PARIKH MARG, CHURCH GATE,
MUMBAI-400020.
ALSO AT: STELLAR I T PARK,
TOWER-1, 5th FLOOR, C-25,
SEC.-62, NOIDA-201301. … OPPOSITE PARTY
CORAM:SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 30.11.2016
Date of decision: 23.12.2019
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against OPunder
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Section 12 & 14 of the Consumer Protection Act, 1986 therebyallegingthat the complainant purchased the Mediclaim Insurance Policy vide policy no. 2825100719-49400000 through online of OP for a sum insured to the tune of Rs.3,00,000/- on 10.08.2015 for a period of one year. At the time of purchasing the policy, the complainant was assured by the official of OP that the said policy is a very good policy and helpful to the medically expenses bill and on the assurance given by the official of OP, the complainant bought the said Medical policy and the official of OP assured the complainant got “Pre hospitalization medical expenses incurred 30 days prior to hospitalization” & post hospitalization medical expense incurred within 60 days from date of discharge from the hospital.” The complainant further alleged that the complainant was assured by OP that the complainant got “any hospital day care centre or other provider that is not part of the network” and on the assurances the complainant purchased such policy & OP also assured that the complainant got Daily Cash Benefit for Rs.500/- per day upto maximum 20 days & also ambulance charge. Thereafter, the complainant was hospitalized at Santom Hospital, Prashant Vihar, Delhi on 21.07.2016 due to urinal problem and the hospital approached to OP telephonically for Mediclaim at the time of hospitalization and the complainant admitted in the hospital as per the assurance gave by OP i.e. the claim has been cleared and proceed for surgery and at the time of discharge i.e. 28.07.2016,
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the complainant was shocked when the hospital said that the claim has been rejected from insurance company. The complainant further alleged that the complainant again approached to OP to send the approval of the claim to the hospital before surgery and it has been approved then why rejected the claim and the complainant was shocked when the official of OP said that it is totally the fault of the hospital. The complainant again approached to the hospital and the hospital said that it is fault of OP and they keep on avoiding the matter on the matter on one pretext or other. The complainant further alleged that the hospital held the patient till the bill was paid and the hospital again sent all documents to OP on 28.07.2016 and the complainant was shocked and surprised when the claim repudiated saying that “Patient was admitted on 21.07.2016 with the diagnosis of Urinary tract infection. Heamaturia, Stricture urethra and was managed surgically with Cystoscopy. OIU BNI. As per Section 9A ii b of the policy, a waiting period of two years is applicable for the Genito-Urinary surgery. The complainant further alleged that the repudiation of the legitimate claim by OP is malafide, arbitrary, wrong, illegal and totally unjustified and it is not mention earlier before surgery, if it would have been intimated earlier that the claim may or may not be rejected, we would have proceeded accordingly. On 30.07.2016, the complainant paid the bill of Rs.88,115/- against invoice no.
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IBL/16-17/002232 to the hospital. The complainant further alleged that OP has failed to provide proper service and claim amount for which the complainant has taken the hospitalization benefit policy for himself and his family and OP is liable to pay the same on account of deficiency in service and unfair trade practice.
2. On these allegations the complainant has filed the present complaint praying for direction to OP to pay a sum of Rs.88,115/-alongwith interest @ 18% p.a. from the date of payment to till the realization of the amount as well as compensation of Rs.1,50,000/- for causingdamages, mental agony and harassment and has also sought Rs.5,500/- towards cost of litigation.
3. OP has been contesting the complaint and has filed written statement. In its written statement, OP submitted that the complaint is absolutely false, frivolous, misconceived and is not maintainable andis liable to be dismissed and there is no deficiencyin service on the part of OP. OP further submitted that a Health Sureksha (Silver Plan) bearing no. 282510071949400000 valid from 10.08.2015 to 09.08.2016 was issued in the name of Rakesh Rathore and his wife for a sum of Rs.3,00,000/- and the liability of the company, if any, is subject to terms & conditions of the policy and a pre-authorization letter was received from the complainant through Santom Hospital, however, an inquiry was raised which
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was replied by the hospital and on going through the reply to the queries, pre-authorization was denied vide letter dated 28.07.2016. Thereafter, a claim was lodged with OP/insurance company for re-imbursement of expenses and from the treatment papers it was observed that the insured patient was admitted on 21.07.2016 with the diagnosis of Urinary Tract Infection (UTI), Heamaturia, Stricture Urethra and was managed surgically with Cystoscopy, OIU BNI. And on going through the documents submitted by the complainant for re-imbursement of his claim the competent authority found that the claim was not payable, as the treatment with respect to Genitourinary Surgery is not covered for the first two years of the policy. OP further submitted that as the first inception date of the policy was 10.08.2015 and the claim falls under the said clause and the claim was repudiated and a letter dated 18.11.2016 was sent to the complainant informing him about the rejection of the claim.
4. The complainant filed rejoinder and denied the submissions of the OP and further submitted that OP has taken a misleading plea.
5. In order to prove his case, the complainant filed his affidavit inevidence and also filed written arguments. The complainant also placed on record copy of insurance policy issued by OP, copy of request for cashless hospitalization for medical insurance policy, copy of claim form part-B, copy of Final Bill (detail) no. 11037 dated 28.07.2016 of Rs.88,115/- issued by Santom Hospital, Delhi and copies of treatment documents. The complainant also placed on
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record copy of estimated expense of Rs.83,600/- issued by Santom Hospital, Delhi, copy of ultrasound report dated 22.07.2016 issued by Santom Hospital, Delhi, copy of Health Claim Services, copy of letter dated nil sent by the complainant to Santom Hospital, Delhi and copy of claim repudiation letter without prejudice,
6. On the other hand, Sh. Pankaj Kumar,Manager (Legal) ofOP filed his affidavit. OP also filed copy of Claim Repudiation Letter without Prejudice, copy of 1st reminder letter for deficiency without prejudice, copy of deficiency letter without prejudice, copies of Claim Form Part-A, Claim Form Part-B, copy of Guidance for filling claim for-Part-B, copy of request for cashless hospitalization for medical insurance policy, copy of additional information request letter to Pre-Authorization, copy of letter dated nil sent by the complainant to Santom Hospital, Delhi, copy of Health Claim Services, copy of discharge card issued by Santom Hospital, copy of Ultrasound Whole Abdomen, copy of Laboratory Report, copy of letter dated 10.08.2016 sent by OP to the complainant and copy of Health Suraksha Policy “Silver Plan”. OP also filed written arguments.
7. This forum has considered the case of the complainant as well as OP in the light of evidence and documents placed on record by the parties. The documents and evidence of the parties shows that the complainant was admitted in Santom Hospital, Delhi on 21.07.2016 due to Heamaturia, Stricture Urethra and was discharged from the
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hospital on 28.07.2016. OP has not disputed about the disease for the treatment of which the complainant was hospitalized. The complainant being a layman while taking the Mediclaim Insurance policy is not expected that he will be suffering from a disease and will be hospitalized for the treatment of such disease. OP has failed to prove any documents that such disease is not covered in the policy in the 1st year of taking the policy and thus we are of opinion that OP has failed to prove its defence and is not available to the OP and we are of opinion that OP has wrongfully repudiated the claim of the complainant. Thus, OP is held guilty of deficiency in service.
8. Thus, holding guilty for the same, we direct OP as under:
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ii) To pay to the complainant an amount of Rs.40,000/- as compensation for harassment and mental agony suffered.
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9. The above amount shall be paid by OPto the complainant within 30 days from the date of receiving copy of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of receiving copy of this order till the dateof payment. If OPfails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may
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approach this Forum u/s 25/27 of the Consumer Protection Act, 1986.
10. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 23rd day of December, 2019.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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UPLOADED BY : SATYENDRA JEET
