District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.210/2021
1.
Date of Institution: 08.04..2021.
Date of Order: 12.09.2022.
Mehar Chand son of Shri Ram Chand resident of House No. D-74, Village Ajronda, Sector-15A,Faridabad.
…….Complainant……..
Versus
1. Health Insurance TPA of India Limited, 2nd floor, Majestic Omina Building, A-110, Sector-4, Noida, U.P.- 201301 through its Director/Manager.
2. M/s. United India Insurance Company Limited, 5R/5, Above Aastha Eye Centre, Neelam Chowk, NIT, Faridabad through its Branch Manager.
…Opposite parties……
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. Manoj Arora, counsel for the complainant.
Opposite party No.1 ex-parte vide order dated 24.03.2022.
Sh. L.S.Perswal, counsel for opposite party No.2.
ORDER:
The facts in brief of the complaint are that in the year 2011, the complainant had taken a mediclaim policy form opposite party No.2 for himself as well as his above said family members and since then he was getting the policy renewed form time to time, presently complainant had a family mediclaim policy bearing its No. 228002818P111509942 which was issued by opposie party No.2 w.e.f. 15.12.2018 to 14.12.2019 for a total sum of Rs.5,00,000/- and the complainant had paid a sum of Rs.20,360/- as premium and as per the above said policy complainant, his wife Radha Rani and children namely Kirti Sharma, Sandeep Sharma and Harsh Sharma were covered and renewed his mediclaim policy to till time. On 13.08.2019, the wife of the complainant approached to the Metro Hospital with complaint of increased bleeding during menses. The attending doctor of the Metro Hospital, DRctor-16A, Faridabad after seeing the ultra sound of the Radha Rani observed that as he w shaving large fibroids with uterus size extroverted and advised for total Laparoscopic Hysterectomy (TLCH) with Bilateral Salpingo Oophorectomy (BSO) and as per the advice of the doctors of the Metro Hospital the treatment of the said Radha Rani was done by the said doctors. Therefore, she was admitted with the Metro Hospital, Sector-16A, Faridabad from 13.08.2019 to 16.08.2019 being IPD NO. 19/19933 and UHID No. 518654. Accordingly on 13.08.2019, as per the procedure adopted their atby the officials of the opposite party No.2 had sent a request for cashless hospitalization for mediclaim insurance policy in the requisite format alongwith estimate for treatment of Radha Rani to opposite party No.1, wherein the officials of the hospital had duly mentioned the procedure/treatment the officials of the opposite party No.1 after seeing the request and estimate had given an initial approval of Rs.61,000/- with the condition that for further enhancement final bill alongiwth discharge summary may required to be deposited. The said Raha Rani got admitted on 13.08.2019 and after getting treatment from the hospital got discharged on 16.08.2019. The final bill raised by the hospital was Rs.91,769/-. The official of opposite party hospital then asked the complainant for depositing the amount of Rs.51,769/-. The complainant got shocked as there was an initial approval for Rs.61,000/-. The concerned officials of the hospital then informed that the opposite aprties Nos.1 & 2 had made a sum of Rs.40,000/- only and effused to make the payment for Rs.51,769/- therefore, the complainant made the balance payment of Rs.51,769/- after deducted the amount of Rs.40,000/- which was paid by opposite parties Nos.1 & 2. After discharge the complainant approached to the opposite parties Nos.1 & 2 for clearance of the balance amount of the bill i.e. Rs.51,769/- then the opposite parties asked the complainant to submit the claim form for reimbursement, therefore, as per their advice, complainant submitted the claim form for reimbursement with all the formalities mentioning therein to pay the balance amount of Rs.51,769/- but the opposite parties Nos.1 & 2 had not paid the same till date and not given any reply to the complainant to till date intentionally and deliberately. The complainant feeling cheated with the unfair trade practices of the opposite parties Nos.1 & 2 as the opposite parties were giving contradictory statements and complainant was suffering from mental and financial loses. The complainant sent legal notice dated 05.08.2020 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 parties to:
a) pay the claimed remaining amount of Rs.51,769/- alongwith interest @ 18% p.a. from the date of due till actual payment.
b) pay Rs. 20,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Registered notice sent to opposite party No.1 on 04.02.2022 not received back served or unserved. Case called several times since mo ring. But none appeared on behalf of opposite party No.1. More than one month had elapsed. Therefore, opposite party No.1 was proceeded against ex-parte vide order dated 24.03.2022.
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that the complainant neither had any cause of action nor locus standi in lodging the present complaint before this Hon’ble Commission. It was submitted that claim No. 191100117495 was registered with opposite party No.1 being the Third Party Administrator for and on behalf of the answering opposite arty/insurance company on account of hospitalization of the wife of complainant/insured namely Smt. Radha Rani on 13.08.2019 in Metro Heart Institute, Sector-16, Faridabad. In reference to cashless facility intimation at the end of the hospital, the opposite party No.1 vide its reference dated 16.08.2019, so addressed to the hospital, authorized the hospital for hospitalization of the insured/complainant on account of ailment being Fibroid for the period 13.08.2019 to 16.08.2019 for sum Rs.40,000/- inclusive TDS. Opposite party No.1 had already paid the maximum amount payable for the diagnosed Fibroid which was 20% of the sum insured by taking the sum insured as Rs.2,00,000/- in view of the coverage clause 1.2.F as well as relying upon the exclusion clause No.4.3, since the insured and earlier the sum insured was Rs.2,00,000/-. As per clause 4.3 of the policy, it was stated that “unless the insured has 24 months of the continuous coverage, the expenses on treatment of diseases such as cataract, benign, gall bladder stone removal, gout and rheumatisum, calculus disease etc. are not payable. The complaint of the complainant was liable to be rejected on the ground that the complainant had concealed the true and material fact from this Hon’ble Commission because the insured had recently obtained the enhancement of the sum insured, therefore, the relying upon the clause 4.3, the earlier sum insured which was Rs.2,00,000/- had been taken as a base for computing 20% of the sum insured as payable under the clause 1.2F. Since the maximum amount payable under the terms and conditions of the insurance policy had already been paid by the opposite parties to the complainant which was admitted by the complainant in complaint. Opposite party No. 2 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 parties– United India Insurance Co. Ltd. & Anothers with the prayer to: a) pay the claimed remaining amount of Rs.51,769/- alongwith interest @ 18% p.a. from the date of due till actual payment. b) pay Rs. 20,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000/- as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Mehar Chand, Ex.C-1 – insurance policy for the period 15.12.2018 to 14.12.2019, Ex.C2 – insurance policy for the period 15.12.2019 to 14.12.2020, Ex.C3 – insurance policy for the period 15.12.2020 to 14.12.2021, Ex.C4 – pre- authorization approval letter, Ex.C5 – Final bill,, Ex.C6 – Discharge summary, Ex.C7 – pre authorization approval letter, Ex.C-8 – claim form, Ex.C-9 – legal notice, Ex.C10 to C12 - postal receipts, Ex.C-13 – reply to legal notice.
On the other hand counsel for the opposite party No.2 strongly
agitated and opposed. As per the evidence of the opposite party No.2 Ex.RW-1/A – affidavit of Shri Ashok Kumar, administrative Officer, United India Insurance Company Limited, D.O.28, NIT, Faridabad. , ExṚ-1 – insurance policy valid from 15.12.2016 to 14.12.2017, Ex.R-2 – insurance policy valid from 15.12.2017 to 14.12.2018, Ex.R-3 – insurance policy valid from 15.12.2018 to 14.12.2019.
6. The complainant has filed the complaint with the prayer of remaining amount of Rs.51,769/- alognwith interest @ 18% p.a.f rom the date of due till its actual payment.
7. It is evident from discharge summary vide Ex.C6 the wife of the complainant namely Radha Rani got admitted on 13.8.2019 and after getting treatment from the hospital got discharged on 16.8.2019. The final bill raised by the hospital was Rs.91,769/- vide Ex. C5. The official of opposite party hospital asked the complainant for depositing the amount of Rs.51,769/- The complainant got shocked as there was an initial approval for Rs. 61,000/- vide Ex.C4. The concerned officials of the hospital then informed that the opposite parties Nos.1 & 2 had made a sum of Rs.40,000/- only and refused to make the payment for Rs.51,769/-, therefore, the complainant made the balance payment of Rs.51,769/- after deducted the amount of Rs.40,000/- which was paid by the opposite parties No.1 & 2.
8. The complainant has submitted the claim form vide (Ex.C-8) for reimbursement with all the formalities mentioning therein to pay the balance amount of Rs.51,769/-. Opposite party No.1 had already paid the maximum amount payable for the diagnosed Fibroid which was 20% of the sum insured by taking the sum insured as Rs.2,00,000/- in view of the coverage clause 1.2.F as well as relying upon the exclusion clause No.4.3, since the insured and earlier the sum insured was Rs.2,00,000/-. As per clause 4.3 of the policy, it was stated that “unless the insured has 24 months of the continuous coverage, the expenses on treatment of diseases such as cataract, benign, gall bladder stone removal, gout and rheumatisum, calculus disease etc. are not payable.
9. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are 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 parties are 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: 12.09.2022 (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.
