Delhi

East Delhi

CC/275/2014

MADHUSUDHAN - Complainant(s)

Versus

MEDICARE TPA - Opp.Party(s)

07 Apr 2014

ORDER

           DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.       275/2014

                                                                                                   Date of Institution               19/03/2014

                                                                                                   Order reserved on               09/11/2017        

                                                                                                   Date of Order                        13/11/2017                                                                                     

 

In matter of

Mr Madhusudan Tiwari, adult   

s/o- Sh R K Tiwari                                                                                                                                                                                                   

R/o- 352/1, Ambedkar Marg,  

Mandawali, Delhi 110092..………………….……………...…………….Complainant

                             

                                                                             Vs

1-M/s Medicare TPA Pvt Ltd. 

E-1, Jhandewalan Extn.,

Rani Jhansi Road, Nr Videocon Tower,

New Delhi – 110055

 

2-Royal Sundaram Alliance Insurance Co. Ltd.

Sundaram Towers,

45 & 46 Whites Road, Chennai 600014 ..……………..….…………..Opponents

 

Quorum   Sh Sukhdev  Singh        President

                  Dr P N Tiwari                 Member

     Mrs Harpreet Kaur       Member                                                                                      

 

Order by Dr P N Tiwari Member  

Brief -                                                                                                

Complainant / Policy holder had filed this complaint u/s 12 of the Consumer Protection Act, 1986 for deficiency in service of OP for nonpayment of hospital bills of insured under mediclaim policy by OP2 through OP1.

Facts of the case -

Complainant had a mediclaim policy from OP2 21/01/2013 to 20/01/2014 under Family Floater Policy no. GL121835319A for sum assured 2 lakh with mediclaim card vide no. (Ex CW1/1A). It was stated that complainant had Multiple Myeloma disease and was admitted at Malik Radix Healthcare from 15/07/2013 to 19/07/2013 (Ex CW1/2, 2A & 2B).

It was stated that cashless was denied, so complainant paid hospital bill of a sum of Rs 23,000/-. Thereafter complainant filed his claim with OP1, but it was rejected. Thereafter complainant again got admitted in the same hospital from 18/12/2013 to 26/12/2013 and paid treatment cost a sum of Rs 87,000/-(Ex. CW1/3 & 3A).

The complainant got admitted at BLK Hospital in Karol Bagh, Delhi from 02/01/2014 to 07/01/2014 and paid a sum of RS 55,000/-. The complainant again got admitted again at same hospital from 11/02/2014 under day care and incurred treatment bill of Rs 18,000/-. He got admitted on 14/01/2014 for day care and had treatment bill Rs 19,000/-(Ex. CW1/4, 4A, 6, & 6A). When hospital bills were not paid, complainant sent legal notice on 16/01/2014 (Ex CW1/7). No reply was received, thus filed this complaint on 06/03/2014 and claimed sum assured value of the policy (2lakh) with compensation Rs one lakh for mental agony and physical harassment.  

It was also stated by the complainant that the said complaint was dismissed due to non appearance of complainant before this Forum at the time of admission hearing, so filed First Appeal before Honble State Commission, Delhi vide FA no. 492/2014 decided on 15/07/2014 where order of this Forum was set aside and directed complainant to appear on 19/08/2014 and original complaint was restored and be decided on merit (Ex CW1/8).      

After receiving notice, OP1 did not put appearance as notices sent were not received due to none existing of OP1 address given by complainant. Neither fresh memo of party was filed nor OP1 were declared Ex Parte. Though being TPA a subsidiary of OP2, onus falls on OP2/insurer to defend their stand.

OP2 submitted written statement. All the contentions of deficiency in the services alleged by complainant were denied. OP2 submitted that the present complaint be dismissed as complainant had not filed complete claim documents pertaining to rest of claims and first claim was proved as fraud because complainant was not present on the bed in the hospital at the time of visit by the investigator, so was rejected on the basis of facts from the treating hospital though other papers were with OP. It was must to get the spot verification of insured whether he had been admitted in the said hospital. As he was away at the time of visit by surveyor, it amounts to fraud and documents were fabricated, but as such it could not be said that claim was rejected or not, so this was not deficiency on part of OP1.

 

It was further stated that policy was in first year from 21/01/2013 vide policy no. GL00011447000100 for sum assured two lakh with CB zero (Ex.OPW1/1, 1A) and complainant got admitted at Malik Rodex Hospital for ‘Enteric fever’, but complete discharge papers were not submitted by complainant though hospital bill was of Rs 23,000/- which was paid. As the complainant was not present at the time of spot visit by the investigator when cashless intimation was sent by the hospital, claim was not entertained and put under ‘Fraud ‘category and was duly intimated to the complainant it was mandatory to verify the genuine admission in the hospital (Ex OPW1/3, 3A & 4). So this complaint was based on the first ‘claim’ had no merit and may be dismissed.   

 

Complainant filed his evidences on affidavit where he himself affirmed on oath that all the facts were correct and true as per his complaint were correct and true and on record.

OP2 also submitted their evidence on affidavit through Mr. Aneesh Bhaskaran, AR with OP2 and affirmed on oath that all the procedures adopted by them were as per the IRDA guidelines and putting the claim as ‘Fraud’ was based on the information received from their investigator. All the relevant evidences were correct and on record.

Arguments were heard from both the party’s counsels and after perusal of file, order was reserved.

Before coming to the conclusion of this case, we framed three issues as under –

1. Whether case was ‘Fraud’ as declared by OP genuine?
2. Whether claim was filed properly before OP?
3. Whether non claimed ailment ‘Multiple Myoloma’ is payable as per policy terms and conditions by OP?

1-Whether case was ‘Fraud’ as declared by OP, genuine ?

As per the IRDA guidelines, spot verification of all admissions are mandatory for giving cashless or denying and any insured if got admitted in the hospital and after receiving the information from insured or treating hospital, spot verification is must to get the correct status of insured and validity of mediclaim policy. Here in this case, insured was not present on the bed as he was admitted for ‘Enteric Fever’ and was away from the ward at that time.

It is very difficult for any non medical (allopathic) person to say or give his opinion on genuineness of ailments or treatment documents (ICPs) and many non payable cases are directed for payments.

Here in this case, though complainant was not present on bed and was calling from elsewhere, proves fraud claim. It has also seen by scrutinizing the discharge summary and treatment advised (Ex CW1/1), lots of irrelevant medicines were advised. But there was no concrete evidence by OP to prove that case was to be put as Fraud except investigator’s own report and not supported by any affidavit or hospital’s indoor record.

 2-Whether claim was filed properly before OP –

By seeing claim (Ex CW1/1, 2 &3), complainant has not filed complete and proper treatment documents which were neither observed by OP nor during the proceeding of case. It is compulsory to have all the required claim documents before OP for deciding the claim. In addition to this, complainant has annexed additional treatment documents as Ex CW1/ 4 to 6, which are incomplete and without being claimed before OP. Hence, it is evident that complainant has not filed complete and proper treatment documents for claim under policy terms and conditions.

3-Whether non claimed ailment ‘Multiple Myoloma’ is payable as per policy terms and conditions by OP?

It is evident that complainant was suffering from Multiple Myelomas, a type bone marrow cancer and patient suffers from various symptoms related to the ailment. No such detail history or earlier treatment documents were on record except for Enteric Fever treatment which is an acute ailment shown, but Multiple Myoloma is a very chronic ailment. All treatment documents are incomplete on record.

The other discharge summaries and day care treatment documents are incomplete and prove for Multiple Myoloma. After going through the terms and conditions of the policy under Exclusion clause 3(b), this ailment is payable after two years of policy. So, we cannot proceed against the terms and conditions set by the OP in the policy.

Hence, after seeing entire facts and evidences on record and properly analyzing medical facts, neither OP1 nor OP2 were at fault or had done any deficient services towards complainant, this complaint deserves to be dismissed so dismissed  without any order to cost.   

 

Copy of this order be sent to the parties as per the Section 18 of the Consumer Protection Regulations,2005 (in short CPR) and file be consigned to Record Room under Section 20(1) of the CPR.

 

(Dr) P N Tiwari  Member                                                                         Sukhdev Singh  President