Haryana

Kaithal

400/19

Anil Kumar Sardana - Complainant(s)

Versus

ICICI Lombard Gen Insurance company - Opp.Party(s)

Sh.Gaurav Wadhwa

11 Apr 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.

                                                     Complaint Case No.400/2019.

                                                     Date of institution: 29.11.2019.

                                                     Date of decision:11.04.2023.

1. Anil Kumar Sardana S/o Late Sh. Ram Kishan Sardana (aged about 58 years) R/o House No.01, Sector-20, HUDA, Kaithal (Haryana)-136027.
2. Veena Kumari W/o Anil Kumar Sardana (aged about 57 years) R/o House No.01, Sector-20, HUDA Kaithal (Haryana)-136027.

                                                                        …Complainants.

                        Versus

1. ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, near Siddhi Vinayak Temple, Prabhadevi, Mumbai-400025.
2. ICICI Lombard General Insurance Company Limited, Gurgaon Branch, 12^th floor, Tower D, Global Business Park, Mehrauli Gurgaon Road, Gurgaon (Haryana)-122002.
3. ICICI Lombard Healthcare, ICICI Bank Tower, Plot No.12, Financial District, Nanakram Guda, Gachibowli, Hyderabad, Telangana-500032.
4. Smt. Vijay Rani Arora W/o Sh. Dinesh Arora R/o House No.301, Sector-19 Part-I, HUDA Kaithal; Authorized Agent of ICICI Lombard GIC Ltd. at Kaithal vide Agent Code No.118783.
5. Arya Multispecialty Hospital, Karnal-Kaithal Road, near Mini Secretariat, Rishi Nagar, Kaithal, Haryana-136027.
6. Fortis Hospital, Sector-62, Phase VIII, Mohali, Punjab-160062.

….Respondents.

        Complaint under Section 12 of the Consumer Protection Act

CORAM:     SMT. NEELAM KASHYAP, PRESIDENT.

                SMT. SUMAN RANA, MEMBER.

                SH. SUNIL MOHAN TRIKHA, MEMBER.

       

Present:     Sh. Jitender Sharma, Advocate, for the complainants.   

                Sh. Arvind Khurania, Advocate for the OPs No.1 to 3.

                OP No.4 exparte.

                Sh. Sudeep Malik, Adv. for the OP No.5. 

Sh. Vansh Malhotra, Adv. & Sh. Hans Raj Verma, Adv. for the OP No.6.

               

ORDER

NEELAM KASHYAP, PRESIDENT

        Anil Kumar Sardana and Veena Kumari-Complainants have filed this complaint under Section 12 of Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the respondents.

                In nutshell, the facts of present case are that the complainant No.1 is proposer/holder of health policy No.4128i/HP/155340548/00/000 alongwith Top-up policy No.4113i/XOL/73980304/06/000 of OP No.1 company insuring health of himself, his wife and son, valid for the period 20.09.2018 to 19.09.2019.  The complainant No.2 was insured vide Card No.100536284 under said policy suffered severe pain in the early morning of 3^rd July, 2019 and thus, was taken to OP No.5 for check-up, where after medical tests, OP No.5 reported “Chronic Cholecystitis with Multiple Small Gall Stones” and advised correlate clinically either at PGI Chandigarh or Fortis Hospital Mohali.  Complainant No.2 was taken to Fortis Hospital Mohali on 04.07.2019 and was diagnosed with “Acute, Chronic Calculous Cholecystitis with Bilary Pancreatitis”.  Thereafter, on 17.07.2019, after reinvestigation of medical tests, treating doctor at Fortis Hospital advised to get complainant No.2 admitted as IPD patient on 23.07.2019 for surgery/operation.  It is further alleged that complainant No.2 was taken to Fortis Hospital Mohali for admission on 23.07.2019 but at the time of admission, when complainants asked for AC Single Room Accommodation as per terms of AL Number 110100395417, the OP No.6 denied to provide the same on the ground that AC Single Room is not vacant/available, even though the admission of insured patient was pre-scheduled.  Upon denial of AC Single Room Accommodation, complainant No.1 complained about this inaction on the same day to OP insurance company vide e-mail dt. 23.07.2019.  Thereafter, in the morning of 24.07.2019, when complainant approached TPA of OP No.6 with the request to get allotted AC Single Room and if the same is unavailable, to allot AC Single Deluxe Room which was very well within the entitlement of insured under the policy but they did not do so.  On 25.07.2019, the patient-complainant No.2 was discharged and the attendant of OP No.2 provided a copy of Adhoc Bill to the complainant No.1 amounting to Rs.1,35,124/-.  Thereafter, OPs-insurance company sent copy of second authorization letter addressed to OP No6 (Fortis Hospital, Mohali) approving payment of Rs.1,30,015/- and deducting Rs.5109/- from the Adhoc Bill as non-admissible items via e-mail dt. 25.07.2019.  Furthermore, the concerned employee of OP No.6 illegally charged Rs.17,609/- (Rs.5109/- as disapproved by OP Insurance Company) + Rs.12,500/- stating that Rs.12,500/- is payable on account of package difference of AC Single Room & AC Single Deluxe Room, so, the complainants deposited the amount under protest.  It is further alleged that after discharge, complainant No.1 submitted Reimbursement Claim of Pre-Hospitalization expenses on 29.07.2019 alongwith requisite documents to OPs-insurance company for the period 03.07.2019 to 22.07.2019 amounting to Rs.33,963/-.  In reference to said Pre-Hospitalization Claim, OPs insurance company sent a text message to complainant No.1 without giving any reason as to why full claim has not been reimbursed and amount to the tune of Rs.809/- has been deducted, whereupon complainant No.1 sent a mail to OPs-insurance company to rectify the deficiency on their part & reimburse whole claim vide e-mail dt. 14.08.2019.  The Ops-insurance company in reply to said e-mail, sent settlement letter providing reasons for disallowed amount as charges for Apron, Camera Cover, Hand Rub, Trolley Cover are not payable.  So, it is a clear cut case of deficiency in service on the part of respondents and prayed for acceptance of complaint.     

2.            Upon notice, the Ops No.1 to 3, 5 & 6 appeared before this Commission, OP No.3 did not appear and opted to proceed against exparte vide order dt. 12.03.2020 of this Commission.  OPs No.1 to 3  contested the complaint by filing their joint written version raising preliminary objections with regard to locus-standi; maintainability; cause of action; that the complainant is guilty of suppression of material facts from this commission; that the complicated question of law and facts are involved in the present complaint; that there is no deficiency in service on the part of respondents.  On merits, the objections raised in the preliminary objections are rebutted and so, prayed for dismissal of complaint.

3.             Op No.5 filed the written version on the same line as followed by Ops No.1 to 3 and so, prayed for dismissal of complaint.

4.             OP No.6 did not file the written version rather ld. counsel for the OP No.3 made separate statement on 12.03.2020 to the effect that they are ready to refund the excess charged amount of Rs.12,500/- to the complainant within 7 days and the said aforesaid statement may be read as their reply to the complaint in question. 

5.             To prove his case, the complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C23 and thereafter, closed the evidence.

6.             On the other hand, the OP No.5 tendered into evidence affidavit Ex.RW1/A and thereafter, closed the evidence.  Whereas, OPs No.1 to 3 & 6 did not tender any evidence despite availing several opportunities, so, the evidence of Ops No.1 to 3 & 6 was closed vide court order dt. 16.11.2022. 

7.             We have heard the learned Counsel for both the parties and perused the record carefully.

8.             Ld. counsel for the complainants argued that the complainant No.1 is proposer/holder of health policy No.4128i/HP/155340548/00/000 alongwith Top-up policy No.4113i/XOL/73980304/06/000 of OP No.1 company insuring health of himself, his wife and son, valid for the period 20.09.2018 to 19.09.2019.  The complainant No.2 was insured vide Card No.100536284 under said policy suffered severe pain in the early morning of 3^rd July, 2019 and thus, was taken to OP No.5 for check-up, where after medical tests, OP No.5 reported “Chronic Cholecystitis with Multiple Small Gall Stones” and advised correlate clinically either at PGI Chandigarh or Fortis Hospital Mohali.  Complainant No.2 was taken to Fortis Hospital Mohali on 04.07.2019 and was diagnosed with “Acute, Chronic Calculous Cholecystitis with Bilary Pancreatitis”.  Thereafter, on 17.07.2019, after reinvestigation of medical tests, treating doctor at Fortis Hospital advised to get complainant No.2 admitted as IPD patient on 23.07.2019 for surgery/operation.  It is further argued that complainant No.2 was taken to Fortis Hospital Mohali for admission on 23.07.2019 but at the time of admission, when complainants asked for AC Single Room Accommodation as per terms of AL Number 110100395417, the OP No.6 denied to provide the same on the ground that AC Single Room is not vacant/available, even though the admission of insured patient was pre-scheduled.  Upon denial of AC Single Room Accommodation, complainant No.1 complained about this inaction on the same day to OP insurance company vide e-mail dt. 23.07.2019.  Thereafter, in the morning of 24.07.2019, when complainant approached TPA of OP No.6 with the request to get allotted AC Single Room and if the same is unavailable, to allot AC Single Deluxe Room which was very well within the entitlement of insured under the policy but they did not do so.  On 25.07.2019, the patient-complainant No.2 was discharged and the attendant of OP No.2 provided a copy of Adhoc Bill to the complainant No.1 amounting to Rs.1,35,124/-.  Thereafter, OPs-insurance company sent copy of second authorization letter addressed to OP No6 (Fortis Hospital, Mohali) approving payment of Rs.1,30,015/- and deducting Rs.5109/- from the Adhoc Bill as non-admissible items via e-mail dt. 25.07.2019.  Furthermore, the concerned employee of OP No.6 illegally charged Rs.17,609/- (Rs.5109/- as disapproved by OP Insurance Company) + Rs.12,500/- stating that Rs.12,500/- is payable on account of package difference of AC Single Room & AC Single Deluxe Room, so, the complainants deposited the amount under protest.  It is further argued that after discharge, complainant No.1 submitted Reimbursement Claim of Pre-Hospitalization expenses on 29.07.2019 alongwith requisite documents to OPs-insurance company for the period 03.07.2019 to 22.07.2019 amounting to Rs.33,963/-.  In reference to said Pre-Hospitalization Claim, OPs insurance company sent a text message to complainant No.1 without giving any reason as to why full claim has not been reimbursed and amount to the tune of Rs.809/- has been deducted, whereupon complainant No.1 sent a mail to OPs-insurance company to rectify the deficiency on their part & reimburse whole claim vide e-mail dt. 14.08.2019.  The Ops-insurance company in reply to said e-mail, sent settlement letter providing reasons for disallowed amount as charges for Apron, Camera Cover, Hand Rub, Trolley Cover are not payable.  There is deficiency in service on the part of OPs.

9.             Ld. counsel for the OPs No.1 to 3 argued that the claim was settled by the insurance company as per cashless policy.  During the course of arguments, ld. counsel for the Ops No.1 to 3 has drawn our attention towards the claim form as per Annexure-C6, wherein in the column of Room Type, it is mentioned that “Single”, so the insurance company had not agreed to provide AC Single Room to complainants.  He has further argued that during the pendency of present complaint, the complainants have received the amount of Rs.12,500/- from the OP No.6.

10.            We have considered the rival contentions of both the parties.  During the course of arguments, ld. counsel for the Op No.6 has stated that the amount of Rs.12,500/- was paid to the complainant during pendency of present complaint and the complainants have not denied the same.  There is no document on the file from which it could be proved that the complainants have received the amount of Rs.12,500/- from the OP No.6 (Fortis Hospital) under protest.  It is also clear from the record available on the file that the claim was settled by the insurance company as per cashless policy.  Hence, we are of the considered view that the complainants have failed to prove any deficiency in service on the part of OPs.  Mere allegations are not sufficient, those are necessary to be substantiated by cogent evidence.   

11.            Thus, as a sequel of aforesaid discussion, we find no merit in the present complaint and accordingly, the same is hereby dismissed.  There is no order as to costs.  A copy of this order be sent to both the parties free of cost.  File be consigned to the record room after due compliance.     

Announced in open court:

Dt.:11.04.2023.

                                                                (Neelam Kashyap)

                                                                President.

 

(Sunil Mohan Trikha),           (Suman Rana),          

Member.                            Member.

 

Typed by: Sanjay Kumar, S.G.