Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No.97/10.11.2020
Mr. Prakash Chand son of Mr. Ram Phal
R/o House No. 11656, Karol Bagh, Sant Nagar,
Delhi-110005 …Complainant
Versus
Magma HDI General Insurance Co. Ltd.
through its Managing Director,
Unit 477, 4th Floor, Agarwal Cyber Plaza-II
Pitampura, North-West Delhi-110034. ...Opposite Party
Date of filing: 10.11.2020
Coram: Date of Order: 14.05.2024
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
ORDER [ex-parte]
Inder Jeet Singh , President
This case is scheduled today for Final Order.
1. (Introduction to consumer dispute) –The complainant has grievance of deficiency of services since despite having family health insurance policy, the complainant had episode hospitalisation for 15 days, there was total payment of bills of Rs. 4,24,359/- besides other medical expenses of OPD consultation, post-hospitalisation expenses. However, the OP1 considered partial claim of Rs. 2,22,327/- out of hospitalisation bills amount of Rs. 4,24,359/- and remaining amount of Rs. 2,24,843/- was disallowed. That is why the complaint for balance amount, other post discharge expense etc.
2.1. (Case of complainant) –The complainant had been availing health insurance from Liberty Videocon General Insurance Ltd. for the last about 7 years, however, later the complainant has ported his insurance policy to the OP by having family health insurance policy for himself and his family members vide policy no. P0020100021/6111/100021, under the nomenclature “One Health Policy” for sum insured of Rs. 10 lakhs per person for period of two years from 20.07.2019 to 19.07.2021 (hereinafter referred as “insurance policy” or ‘policy”). At the time of taking policy, the complainant was asked by OP to upload mobile app in his mobile contact no. 9278828267, the complainant installed the mobile app on his mobile handset, which was for quick search of hospitals, where OP is offering services on cashless basis.
2.2. During September-October 2019 the complainant was suffering, on or off, from fever for a few days and he was requiring urgent medical attention, he was feeling lower limb weakness and bilateral lower limb swelling, besides having shortness of breath, insidious onset, present on exertion.
The complainant searched the name of hospital on mobile app and it was showing name of Sir Ganga Ram Hospital, the complainant decided to approach Sir Ganga Ram Hospital for treatment. He went to hospital on 01.10.2019, he consulted at admission -desk for treatment since he was having insurance policy and entitled for cashless treatment. The hospital authority told the complainant that they are not attached with OP, however, the complainant confronted it by showing mobile app. The complainant also shocked to hear it being unfair trade practice and misinformation by the OP.
2.3 Since the complainant was requiring treatment, he was not keeping well and he had visited the Sir Ganga Ram Hospital, therefore, he decided to take treatment from Sir Ganga Ram Hospital, where he was admitted on 01.10.2019 and he was diagnosed for acute bronchitis, obstructive sleep apnea, diabetes, balanoposthisis. The complainant remained admitted in the hospital and he was discharged, after treatment, on 15.10.2019 while issuing him discharge summary. The complainant was handed over interim running bill of Rs. 4,24,359/- by Sir Ganga Ram Hospital on 15.10.2019, the interim bill is clearly showing that family health plan (TPA Limited) has share of Rs. 4,21,680/-. The complainant was denied cashless facility by the OP as Sir Ganga Ram Hospital is not in the list of panel hospital, the complainant was asked by the hospital to deposit the entire bill of treatment, which he had deposited of Rs. 4,40,459/- [vide payments of Rs. 30,000/- on 01.10.2019; Rs.30,000/- on 04.10.2019; Rs.1,80,459/- on 16.10.2014; Rs.100/- on 16.10.2019 and Rs.1,99,900/- on 16.10.2019] besides other expenses. There is also SMS received from the hospital for tender of amount.
2.4 The complainant lodged claim of Rs. 4,47,230/- for reimbursement to OP but after three months, the claim was partially settled for Rs. 2,22,387/- and it was paid by NEFT dated 29.01.2020, however, the remaining amount of Rs. 2,24,843/- was disallowed by the OP, which is without any justification.
The complainant had also incurred other expenses of Rs.15,392/- in 30 days post- discharge from hospital (viz. Rs. 1000/- as OPD consultation fee on 30.10.2019 + Rs. 9830.90/- medical expenses on 30.10.2019 +Rs. 500/- medicine expenses on 14.11.2019 + Rs. 3062/- medicine expenses on 01.11.2019 + Rs.1000/-as OPD doctor consultation fees on 14.11.2019). Moreover at the time of taking the policy, it was assured by the OP that in the eventuality of stay in hospital, there will be cash payment of additional amount of Rs. 1000/- per day; the complainant remained admitted in the hospital for 15 days and he is also entitled for Rs. 15,000/- under that heading of that expenses.
The complainant took the insurance policy by paying premium of Rs. 75,746/-, however, he was declined his valid claim, which caused him immense, mental tension and harassment, that is why he claims compensation of Rs. 1 lakh on account of mental harassment and financial losses and Rs. 25,000/- towards legal expenses, in addition to reimbursement of balance medical bills claim and other expenses.
2.5 The complaint is accompanied with copies of – Adhar card, insurance policy, discharge summary issued by hospital, interim running bill, final bill dated 16.10.2019, messages received on mobile phone, record of medical expenses and consultation fee receipt of Rs. 15,392/-, email record, legal notice dated 03.09.2020.
2.6. The OP was served with notice on complaint, however, for want of appearance, it was proceeded ex-parte vide order dated 19.07.2022. Moreover, on subsequent dates Ms. Rubina Khan, Advocate for OP and Sh. Aman, Advocate for OP had put appearance along-with memo of appearance to participate in the proceedings.
3. (Evidence)- The complainant Mr. Prakash Chand led his evidence by way of detailed affidavit coupled with documents, which are on the lines of complaint.
4. (Final hearing)- The complainant filed his written arguments followed by oral submissions by Shri Shresth Kumar, Advocate for the complainant. But there is no written argument or oral submissions on behalf of OP.
5.1 (Findings)- The contentions of complainant are considered by assessing the case of complainant, evidence including the documentary record and statutory provisions of law. The following conclusions are drawn from the material and evidence on record :-
(a) The complainant led its detailed evidence in the form of narration coupled with documentary record, which is on the lines of complaint by proving the episode of his health and admission in the hospital, where he remained admitted from 01.10.2019 to 15.10.2019. The complainant has also proved discharge summary dated 15.10.2019 for the treatment carried there.
(b) There are two limb of facts in the case of complainant that when he visited Sir Ganga Ram Hospital for treatment, he was apprised that its name is not in the panel of OP vis-à-vis the complainant opted for treatment in Sir Ganga Ram Hospital, being a constraint to undergo requirement of treatment. Later-on, he was reimbursed medical bills partly to the extent of Rs. 2,22,387/- on the basis of same documents of treatment and bills .
(c) The complainant has proved the interim running bills as well as detail of bill, which was for Rs. 4,40,459/- and the complainant had deposited the entire amount and in the running bill, the share of TPA is shown of Rs. 4,21,680/-, meaning thereby the Sir Ganga Ram Hospital has taken cognizance of insurance policy issued by OP in favour of complainant.
However, it is not disputed that the complainant was reimbursed part amount of Rs. 2,22,387/- and remaining amount of Rs. 2,24,843/- was disallowed by the OP.
(d) The complainant has also proved insurance policy while referring clause no. 2 point no. 23 (page no. 26) r/w page no. 32 of the paper book) that he would be entitled for enhanced daily cash benefit.
It establishes the case of complainant that he is entitled for Rs. 15,000/- being amount for 15 days at the rate of Rs. 1000/- per day.
(e) The complainant has also proved medical expenses and consultation charges post-discharge in 30 days and total amount spent was Rs. 15,392/-, it is within the prescribed time limit.
(f) The narration of facts, figures and circumstances narrated in the evidence (based on the complaint with document, already detailed in paragraph 2 above) are corroborating each other.
5.2 In view of conclusion drawn in paragraph 5.1 above, the complainant has proved medical record and bills related to his treatment during his hospitalization and other medical expenses post his discharge but he was reimbursed partly. The total medical bill of Rs.4,47,230/-is within the sum assured of Rs.l0 lakhs.
5.3. The conclusions drawn in aforementioned paragraph proved the circumstances and complaint against OP. Therefore, the complainant has succeeded establishing his case of reimbursement of balance medical bill amount of Rs. 2,24,843/- besides proof of his claim of Rs. 15,392/- (on account of other medical expenses and consultation fee) and Rs. 15,000/- (of other entitlement) which are covered within the insurance policy and sum insured.
5.4. Since the OP failed to reimburse the balance amount of Rs.2,24,843/- and other amount of Rs. 15,392/-, that is why the complainant claims interest at the rate of 18%pa. The complaint had spent amount from his own pocket, therefore, it makes out case for entitlement of interest on the amount spent by the complainant. Although, the interest may not have been mentioned in the insurance policy, but the complainant has been deprived of use amount of Rs. 2,40,235/- (i.e. 2,24,843/-+ Rs. 15,392/-) for his own because of payments for medical bills. Thus, interest at the rate of 6% from the date of complaint till realization of the amount in favour of complainant and against OP will justify both sides.
5.5. The complainant seeks compensation of Rs.1,00,000/- in lieu of mental harassment and financial losses suffered, besides cost of legal expenses of Rs. 25,000/- but no criteria for quantification is mentioned by complainant, therefore, it appears to be an estimate. However, the circumstances are manifesting that complainant had undergone inconvenience, trauma and harassment for want of settlement of valid claim. He was constraint to file the complaint under consideration. Therefore, compensation of Rs.10,000/- and cost of Rs. 8,000/- are appearing to be ideal in the situation of this case and accordingly it is determined in favour of complainant and against the OP1.
6. So, the OP is directed to reimburse/pay to complainant his balance medical claim and expenses of Rs.2,40,235/- (i.e. Rs.2,24,843+ Rs.15,392) with interest at the rate of 6% pa from the date of complaint till realization of the amount, besides other entitled amount of Rs.15,000/-; compensation of Rs. 10,000/- and cost of Rs. 8,000/-. These amount will be payable within 45 days from the date of this order, failing to pay the amount in that time, then rate of interest will be 8% pa on amount of Rs.2,40,235/- (in place of interest of 6% pa). The OP is at liberty deposit the amount by valid instrument in the name of complainant in the Registry of this Commission.
7. Announced on this 14th day of 2024 [वैशाख 24, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.
[Rashmi Bansal]
Member (Female)
[Inder Jeet Singh]
President
[ijs55]
***
Item no.23
CC- no.97/2020
14.05.2024 - [Proceedings]
Appearance –None for complainant today.
OP is also not present, it is ex-parte vide order dated 19.07.2022.
It is scheduled for final orders. Coram is also complete today. By separate reasoned order authored by the President of this Commission, announced and signed, the complainant is partly allowed in favour of the complainant and against OP as concluded in the final order. The parties are apprised of right of appeal. The file be consigned to record room after proper pagination.
[Rashmi Bansal] [Inder Jeet Singh]
Member (Female) President
