CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No. 529/2011
Sh. Vibhu Goyal
R/o A-76, Ramte Ram Road,
Ghaziabad, U.P. ……Complainant
Versus
1. Incharge/Head of the Deptt.
Claim Department
MD India Health Care Services,
(TPA) Pvt. Ltd.
Regional Office:-
E-98, 2nd Floor, Lajpat Nagar,
New Delhi-110024
Also at:
18/13 WEA Ganga Plaza, Ground Floor,
Pusa Lane, Karol Bagh, New Delhi
2. MD India Health Care Services
(TPA) Pvt. Ltd. (Regional Office)
18/13 WEA Ganga Plaza, Ground Floor,
Pusa Lane, Karol Bagh, New Delhi
And also at:
Head Office Claims Department
M.D. India Head Care Services,
(TPA) Services
S.No. 46/1, E-Space,
A-2 Building, IIIrd floor,
Pune Nagar Road, Vadgaonsheri,
Pune, Maharashtra
3. The Oriental Insurance Company
Registered Office Oriental House,
A-25/27, Asfa Ali Road
New Delhi-110002 ……Opposite Parties
Date of Institution : 23.12.2011 Date of Order : 10.08.2015
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
Brief facts of the case are that the OP No.3 through its marketing representative approached Complainant and introduced various medical policies and represented to him that the Mediclaim Policy offered was completely cashless and the best policy in the market. On believing the lucrative offer given by the representative of the OP No.3, he availed/took the cashless Mediclaim Policy bearing No.252100/48/10/01035 which was being timey renewed by him. On 14.03.10, he suddenly felt palpitation alongwith excess sweating and uneasiness. He was taken to emergency department of Narinder Mohan Hospital & Heart Centre, Ghaziabad where he was admitted in ICU. After admission all the necessary tests were done and medical treatment was given and he was discharged on 15.03.10. The hospital charged Rs.10,954/- from him. After discharge he was advised to come back for review of his health and recovery but after one week on 24.03.10 he again felt unconsciousness and after consultation Doctors of Narinder Mohan Hospital advised him to approach the Medanta the Medicity, Gurgan (in short, Medanta) for the treatment as only few hospitals including Medanta were equipped for treatment of such diseases. On 25.03.10 he went to Medanta and was admitted in the hospital where necessary tests were conducted. After verifying the reports of the tests he was informed that WPW syndrome, palpitation and sweating were diagnosed. After going through the reports the ‘EPS + RFA’ procedure was to be conducted and accordingly on 26.03.10 the recommended procedure was done. He spent a total amount of Rs.54,410/- on the test conducted and the treatment undergone by him. During the time of treatment necessary documents were supplied to OP No.2 for availing the cashless facility but instead of extending cashless facility, the OP No.1 & 2 started harassing him by creating one problem or the other. His family was made to run from pillar to post to arrange the papers which were already submitted to them. Even after submitting the papers OP No.1 & 2 did not provide the cashless facility which they were contractually bound. After discharge from the hospital, he again submitted all the relevant papers and documents to OP No.1. After one week when he contacted OP No.1 they stated that all the papers had been sent for consideration and approval and he would be paid his claim shortly. On 06.05.10 the OPs sent two unsigned letters to him that the claim of Rs.10,000/- was rejected on the ground that:
- as per the terms and conditions of the policy insured should be admitted atleast for 24 hours for the claim to be payable hence the claim is repudiated,
- As per policy terms and conditions, claim is not payable under clause 2.3.
The other claim of Rs.54,410/- was rejected on the ground that:
- “Policy coverage for Mr. Vibhu Goyal is for 4 year/years
- Current illness WPW syndrome + palpitation and sweating is since - as per-
- As per claim documents it is observed that the patient was treated with EP and RFA for WPW syndrome (Wolf Parkinson white syndrome) which is non invasive procedure and does not require admission in hospital. As per policy terms unproven treatment is excluded from the scope of policy hence the claim is repudiated.
- As per policy terms and conditions, the claim is not payable”.
Complainant has stated that he was hospitalized at Narinder Mohan Hospital on 14.03.10 at 4:03pm (as per medical record) and was discharged on 15.03.10 at 3.59 p.m. and he remained hospitalized for 23 hours and 56 minutes. According to him, it was only on the advise of the specialized doctors of the hospital the complainant had undergone the treatment at hospital. Complainant has further stated as under:
“Even otherwise a person who is ill and unwell approaches any hospital or any Doctor is always under a bonafide trust. That he will be guided properly for the treatment, being a layman a person cannot challenge the recommendation of the well specialized Doctors. If a patient is advised to be admitted in the hospital, he has to believe the advice given by the Doctor, and has to follow the instructions given to him. The complainant believing and acting upon the advice of the Doctors got admitted on 23.3.2010 in the medanta the medicity hospital, where he took the treatment for his illness. Wherein the complainant underwent various tests and the treatment procedure advised by the specialized Doctors and only on 27.3.2010 the complainant was discharged from the hospital.
That the TPA and the insurance company have graciously failed to provide the service to the Complainant and have been harassing the poor Complainant. This kind of behaviour of the TPA of the insurance company rejecting the claim of the complainant without any valid reason and considering the claim of the complainant as in a routine manner is a great deficiency in service by the Opposite Parties”.
He sent a legal notice dated 18.06.10 to OPs but OPs failed to comply with the said notice. Complainant has filed the present complaint and prayed as under:
- to direct the OPs to pay Rs.65,410/- spent by the Complainant on his treatment.
- to directthe OPs to pay the damages/compensation as Rs.1,50,000/- and Rs.50,000/- towards the mental pain and agony, litigation charges and other costs on account of deficiency of service.
- Direct the OPs to pay pendentelite and future interest @ 18% per annum from the date of filing of this complaint till the date of payment.
- Direct the OPs to pay the cost of the complaint.
OPs No.1 & 2 were proceeded exparte vide order dated 12.07.12.
OP No.3 in its written statement has stated that the Complainant had not explained circumstances as per the law. The treatment was taken by him first time in Narinder Mohan Hospital where he was admitted for less than 24 hours and as per the terms and conditions of the policy insured should be admitted atleast 24 hours for the claim to be payable and second time he was treated at Medanta but the treatment which was given to the Complainant does not require the admission in the hospital being “non-invasive procedure”. Hence, under the terms, condition and exclusions of the policy the claim of the Complainant was held to be not payable and he was informed accordingly by the TPA. There is no deficiency of service on the part of OP No.3 under the Mediclaim insurance policy. No claim can be entertained for the loss of profits and earnings. Now to hide his own act of negligence and conduct he has filed this complaint by making false and fabricated allegations on flimsy grounds. OP No.3 has prayed for dismissal of the complaint with costs.
Complainant filed replication to the written statement submitted by OP No.3.
Complainant has filed his own affidavit in evidence while affidavit of Sh. Satish Chander, Dy. Manager has been filed in evidence on behalf of OP No.3.
Written arguments have been filed on behalf of the contesting parties. We have heard the Counsel for Complainant. We have gone through the file very carefully.
Admittedly, the Complainant had a Mediclaim policy bearing No. 252100/48/2010/1035 of OP No.3 for the period from 21.10.09 to midnight on 20.10.10 as an individual medical policy (copy annexure OP-3/A). He was admitted in Narender Mohan hospital on 14.03.10 at 4.30 p.m. (sic) for the treatment of palpitation, excess sweating and uneasiness and was discharged on 15.03.10 at 3.59 a.m. On 24.03.10 he again felt unconsciousness and he consulted Doctors of Narinder Mohan Hospital and they advised him to approach Medanta Gurgoan for the treatment as only few hospitals including Medanta are equipped for treatment of such diseases. On 25.03.10 he was admitted in Medanta Hospital with illness as WPW syndrome + palpitation and sweating and discharged on 27.03.10. The Complainant submitted all the bills and relevant documents with the OP No.3. Regarding bill of Rs.10,000/- of Narinder Mohan Hospital OP No. 3 stated that he was admitted for less than 24 hours and as per the terms and conditions of the policy he should be admitted atleast for 24 hours for the claim to be payable. Second time, the Complainant was treated at Medanta but the treatment which was given to the Complainant does not require the admission in hospital being “non-invasive procedure” and OP has not made the payment to the Complainant.
In view of the above, it transpires from the record and the discussions that the first time the Complainant was admitted in Narinder Mohan Hospital on 14.03.10 at 4.03 p.m. and discharged on 15.03.10 at 3.59 p.m. i.e. 23 hours and 56 minutes (it is approximate 24 hours). No doubt, according to clause 2.3 of the terms and conditions governing the policy in question expenses on hospitalization are admissible only if hospitalization is for a minimum period of 24 hours. However, in the present case the complainant remained admitted in Narinder Mohan Hospital for 23 hours and 56 minutes which can very safely be treated as 24 hours. We do not appreciate the anxiety of the officer/official concerned of the OP-3 who had very meticulously calculated the time of admission of the complainant in Narinder Mohan Hospital and preferred to reject the claim on a very untenable ground that the hospitalization period was less than 24 hours. His act is highly condemnable. Instead of finding such negligible faults in the claims submitted by the insured persons, the officers of the Insurance Companies and the TPAs must consider the case with a liberal approach and in such a case must pass the claim instead of rejecting the same. Therefore, we hold that while rejecting the first claim of Rs. 10,000/- of the complainant, the OPs committed deficiency in service.
The second time the complainant with the advice of the doctors of Narinder Mohan Hospital got himself admitted in the Medanta on 25.3.2010 where he underwent certain examinations, procedure and ultimately he was discharged from the Hospital on 27.3.2010. A patient is not an expert in the field of medicines. He/she solely depends upon the pious and expert advice of the doctors. If a doctor advises a patient to get himself/herself admitted in the hospital for the purposes of further management and treatment, the patient is left with no option but to accept the advice of the doctor. If he/she does not do so, he/she does so at his/her own peril and risk. This had also happened to the complainant in the present case. Since the complainant was advised by the doctor at Medanta Hospital to get himself admitted in the hospital, the complainant did so. At the time of his admission in Medanta he did not know whether he had to undergo any surgery or any other medical procedure. It must be the doctors who had conducted the tests on him and made him to undergo EPS + RFA procedure. Whether it was a non-invasive procedure or invasive procedure was not a matter to be taken care of by the complainant. It was the sole discretion of the doctor concerned. Therefore, in our considered opinion the OPs again committed deficiency in service while rejecting the claim of the complainant for the second time.
In the complaint, the complainant has stated that earlier he had filed CCNo.640/10 regarding the claims in question before this Forum which was dismissed in default on 8.11.2011 and, hence, he has filed the present fresh complaint. In view of the law laid down in New India Assurance Company Ltd. Vs. R. Srinivasan, 2000 II AD (SC) 180, we hold that the present complaint is maintainable. There is nothing on the record which can make the complainant disentitled from filing the present complaint.
In view of the above discussion, we allow the complaint and direct the OPs, jointly and severely, to pay Rs. 10,000/- + Rs. 54,410/- = Rs. 65,410/- towards claim amount, Rs. 25,000/- as compensation for mental pain and agony and Rs. 5,000/- towards cost of litigation to the complainant within 30 days from the date of receipt of copy of this order failing which the OPs shall, jointly and severely, become liable to pay Rs. 65,410/- along with interest @ 9% p.a. from the date of filing of the complaint till the date of realisation.
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 10.08.15.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
10.08.2015
Present – None
Vide our separate order of even date pronounced, the complaint is allowed and the OPs are directed, jointly and severely, to pay Rs. 10,000/- + Rs. 54,410/- = Rs. 65,410/- towards claim amount, Rs. 25,000/- as compensation for mental pain and agony and Rs. 5,000/- towards cost of litigation to the complainant within 30 days from the date of receipt of copy of this order failing which the OPs shall, jointly and severely, become liable to pay Rs. 65,410/- along with interest @ 9% p.a. from the date of filing of the complaint till the date of realisation. Let the file be consigned to record room.
(NAINA BAKSHI) (N. K. GOEL) MEMBER PRESIDENT
