DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.353/2011
1. Sh. Rajinder Singh 90 years old
(senior citizen)
2. Smt. Vimla Singh
W/o Sh. Rajinder Singh
Both R/o:
A-169, New Friends Colony,
New Delhi-110065 ….Complainants
Versus
1. Max Super Speciality
1, Press Enclave Road, Saket
Delhi-110017
2. United India Insurance Co. Ltd.
4, Community Centre, 2nd Floor/Ph-1
(Near PVR Cinema) Narayana
New Delhi-110021
3. Primus Super Speciality Hospital
Chandragupta Marg, Chanakyapuri
New Delhi-110021
4. M/s E Meditek (TPA) Services Limited
Corporate Office Plot No.577 Udhyog Vihar
Phase-5 Gurgaon-122016 ….Opposite Parties
Date of Institution : 20.09.2011 Date of Order : 27.09.2017
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
Briefly stated, the case of the complainants is that the OP No.4 had issued a mediclaim policy No.221605/48/09/20/00001578 in their favour from the OP No.2. The policy was valid till 30th March, 2011. On 07.10.10 the complainant No.2 was admitted with the OP No.1 hospital and discharged on 10.10.10. A sum of Rs.92418/- was incurred by the complainant No.2 towards her treatment. Vide email dated 08.10.10 the complainants informed the OPs about the admission of complainant No.2 through the OP No.4. Thereafter, on 19.10.10 all the documents were filed with OP No.4 to process the complainants’ claim. It was shock to the complainants that they were informed vide letter dated 27.10.10 that their claim was repudiated on the ground of delay in information of the complainant No.2’s admission in the hospital. On 29.10.10 the complainant No.1 was admitted in the OP No.3 hospital and discharged on 30.10.10. A sum of Rs.134754/- was incurred towards his treatment. It is submitted that on 08.11.10 all relevant documents of the admission of complainant No.1 were submitted to the OP No.4 to process the mediclaim but to the shock of the complainants it was informed by the OP No.4 vide letter dated 15.11.10 that the claim was repudiated on the ground of delay in information about his admission in the hospital. It is stated as follows:-
“8. That both the complainants i.e. Mr. Rajinder Singh, aged about 87 years and his wife Mrs, Vimla Singh, aged about 83 years are not keeping well and there is nobody to look after them. In the present case when the complainant no.2 i.e. Vimla Singh was hospitalized, on the very next day, opposite party no. 4 was duly informed through e-mail as the complainant no.1 was to look after his wife it was not possible for him to visit the opposite party’s office. Moreover when complainant no.1 was admitted in the hospital, his wife Vimla Singh, the complainant no.2 herein had no option but to take care about his health despite the fact she herself was not physically fit as she was just discharged from the hospital. Therefore under these circumstances it was not possible for both the complainants to inform the opposite parties no.4 & 2 immediately but as soon as the complainants found themselves able to intimate they immediately notified their admission at hospital to the opposite parties. It is not in dispute that for the period and ailment as intimated in the claim form, complainants were indeed hospitalized and were treated therein. Therefore the delay as claimed by the opposite parties is not so inordinate and fatal that they invoke repudiation.
9. That as per the terms of policy opposite parties were required to affirm the breach and violation of any of the terms of the policy. They could have visited the hospital and confirmed the information of admission through searching and inspecting the relevant documents are available with opposite party No.3 & 1 but opposite parties no.4 & 2 did not do so.”
Legal notices dated 24.03.2011 were duly served upon the OPs but neither the reply was received nor any amount as claimed has been made to them. Hence, pleading deficiency in service on the part of the OPs the complainants have filed the present complaint for issuing following directions to the OPs:
a. to pay to the complainants a sum of Rs.99,754/- and Rs.92148/- with bank interest @ of 18% p.a. from 10.11.10 till realization on account of deficiency in service,
b. to pay Rs.5,00,000/- each to both the complainants on account of mental pain, harassment and mental agony,
c. to pay to the complainants cost of the complaint.
OP No.1 in its written statement has inter-alia stated that the complaint is liable to be dismissed as there is no cause of action against OP No.1 since the complaint pertains to the medical insurance claim between the complainants and the OP No.2. It is submitted that despite being informed about presence of Third Party Assurance counter at OP No.1 premises the complainants did not avail the services of OP No.1 to apply for the insurance claim through the OP No.1. Instead the complainants opted to settle the medical charges by cash and by credit card payment only. The total bill amount of the treatment of the complainant No.2 was 92418/- which was cleared by the complainants by cash and credit card facility. OP No.1 has prayed for dismissal of the complaint.
OP No.2 & 4 in their written statement have inter-alia stated that the OP No.4 is the TPA of OP No.2. The policy was issued by the OP No.2 and OP No.4 is not necessary party to the present complaint. The OP No.2 had issued Individual Health Insurance policy No. 221605/48/09/20/00001578 in favour of complainant No.1 for the period from 31.03.10 to 31.03.11. One of the salient conditions of the policy (which is also implied condition of a contract of indemnity) is that the claim should be intimated within 24 hours of admission. The complainants lodged a claim with E-Meditek (TPA) OP No.2 with regard to hospitalization and treatment of complainant No.2 Smt. Vimla Singh. The complainant’s wife was admitted on 07.10.10 and discharged on 10.10.10 while the information was given to the TPA of the OP No.2 on 19.10.10 and the insured failed to explain the reasons of delay in giving information to the OP No.2 & 4. Thus, the claim of the complainant was repudiated. After scrutinizing the claim form it was found that the complainant No.1 was admitted in hospital on 29.10.10 while the information was given to the TPA on 08.11.10. Therefore, they did not commit any deficiency in service or negligence. OP No.2 & 4 have prayed for dismissal of the complaint with exemplary cost.
OP No.3 in the written statement has inter-alia stated that the complaint filed by the complainant pertains to medical insurance claim made by the OP No.2 through OP No.4 and the case filed against OP No.3 is without any justifiable reason but simply with a view to harass and extort illegal sum from the OP No.3. It is submitted that the complainant No.1 opted to settle all the medical expenses by way of cash and credit card only and the total bill amount of the treatment of the complainant No.1 was cleared by the complainant against receipt at the time of the discharge. Prayer is for dismissal of the complaint.
Complainants have filed separate rejoinders to the written statements of OPs inter-alia denying the averments made in the written statements and reiterating the averments made in the complaint.
Complainant No.2 has filed her own affidavit in evidence. On the other hand, affidavit of Dr. Sonali Vatsa, Deputy Medical Superintendent on behalf of the OP No.1, affidavit of Sh. Shyam Nandan Thakur, Assistant Manager on behalf of the OP No.2 & 4 and affidavit of Dr. N. D. Khurana, Chief Operating Officer on behalf of OP No.3 have been file in evidence.
Written argument have been filed on behalf of the parties.
We have heard the oral arguments on behalf of the complainant and OP No.1 & OP No.3 and have also gone through the record very carefully.
We are pained to record that despite specific directions issued in this behalf by us neither the complainants nor the OPs have marked exhibit nos. as per the exhibit nos. given to them in their respective affidavits. Parties must also understand their duties. Everything should not be left to be done by the Forum.
Complainants have filed the insurance policy valid from 31.03.2010 to 30.03.2011 (copy Annexure-A). Annexure-B relates to the discharge summary of complainant No.2 including the bills summary of Rs.92418/-. Vide email dated 08.10.10 (copy Annexure-C Colly) it was informed on behalf of the complainants to the OP No.2 regarding the admission of complainant No.2 in the hospital of OP No.1. Admittedly vide repudiation letter dated 27.10.10 OP No.2 & 4 repudiated the claim on the following ground:-
“… We are in receipt of the claim form & associated documents of Vimla Singh. On scrutiny of the same, we observe that he/she was admitted in Max Super Speciality Hospital. Delay in intimation (date of admission was 07/10/10 while date of intimation was 19/10/10).
In view of the above, we are left with no option but to repudiate your claim.”
Complainant No.1 was admitted in OP No.3 hospital on 29.10.10 and discharged on 30.10.11. He submitted final bill of Rs.99754/- with OP No.4 (Ann. D). The OP No.4 vide letter dated 15.11.10 repudiated the claim of the complainant No.1 on the ground that “the patient got admitted in the hospital on 29/10/10. The date of intimation was 08.11.10. There was late intimation, so the claim cannot be settled for violation of condition of claim procedure clause no.7. In view of the above we are left with no option but to repudiate your claim.”
One Sh. Vikram Khosla on behalf of the complainants sent an email dated 05.12.2010 to the OP No.2 (Annexure-F) regarding late/delayed intimation and filing the documents and requested for condonation of the delay and release of the claim amount. The complainants sent a legal notice dated 24.03.11 to OP No.2 & 4 [(Annexure-F (Colly)].
The OP No.2 & 4 repudiated both the claims of the complainants vide their letters dated 27.10.10 and 15.11.10 respectively on the ground that there was delay in intimation to the OP No.2 & 4. OP No.2 & 4 have filed the certified true copy of the policy in question which we mark as R1 for the purposes of identification. The same does not contain any stipulation regarding time limit for sending information regarding admission of the policyholder or beneficiary/ies thereunder to OP No.2 & 4.
The OP No.2 & 4 have not filed any other document regarding terms and conditions in this regard. It is evident from the email dated 08.10.10 that Sh. Vikram Khosla on behalf of the complainants had informed the OP No.2 & 4 regarding admission of complainant No.2 in the OP No.1 hospital. He again sent email dated 05.12.10 after repudiation and requested the OP No.2 & 4 regarding submission of the documents and explained the delay and requested for condonation of the delay. Relevant portion of email dated 05.12.10 which is not in dispute reads as under:-
“ Sir,
This is reference to medical claims filed for my parents Mr Rajinder Singh, aged 87 years and my mother Mrs Vimla Singh, aged 83 years under the said policy.
01. Mr. Rajinder Singh was admitted on 29.10.2010 and discharged on 30.10.2010. The documents were filed on the 8.11.2010 at your office in Gurgaon.
02. Mrs. Vimla Singh was admitted with a stroke which nearly paralysed her right side, on 07.10.2010 and discharged on 10.10.2010 and the documents were filed on 19.10.2010.
Till Mrs Vimla Singh was admitted she was the one who was keeping all the policy papers and following up with the insurance companies etc. and it can be clearly seen that people of that age will find it difficult to inform the company of the illness of the seriousness that they suffered.
Under these circumstances it is requested that any delay in informing and or submission of the documents be condoned and the claim amount be released at the earliest
In case of any information needed from our side please let us know
Thanks
For Mr. Rajinder Singh and Mrs Vimla Singh
Vikram Khosla
9563289304”
The same is Annexure F (Colly).
Ages of the Complainants are not in dispute. The Complainants have assigned sufficient reasons in para 8 of the complaint which is not disputed. The same averments have been reiterated in the email dated 05.12.10 which is reproduced hereinabove. Therefore, in the special facts and circumstances of the present case the Complainants have shown sufficient cause for not sending the intimation regarding their admission in the hospitals within time, if any, to OP No. 2 & 4. Therefore, OP No.2 & 4 ought not to have rejected /repudiated the claims of the complainants on such flimsy grounds. Hence, we hold OP No.2 & 4 guilty of deficiency in service.
Therefore, we allow the complaint and direct the OP No.2 insurance company to pay Rs.99,754/- and Rs.92418/- being the amount incurred by the complainants on their treatments alongwith interest @ 6% p.a. from the date of filing of complaint till realization, Rs.25,000/- as compensation for causing mental agony and harassment to the complainants and Rs.10,000/- towards cost of the litigation.
The order shall be complied within 30 days of receipt of copy of this order failing which OP No.2 shall become liable to pay interest @ Rs. 9% per annum on the amounts of Rs.99,754/- and Rs.92418/- from the date of filing of the complaint till realization.
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 27.09.2017.
