DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.557/2013
Vijay Choudhary
S/o Shri Hukum Chand Choudhary
Naya Bazar, Narnaul
Mahendergarh, Haryana-123001. ….Complainant
Versus
- Medsave Healthcare (TPA) Ltd.
F-701A, Lado Sarai, Behind Golf Course
New Delhi-110030.
- Paras Hospital
C-1, Sushant Lok 1, Sector-43
Gurgaon, Haryana-122002
- United India Insurance Co. Ltd.
24, Whites Road, Chennai-600014
….Opposite Parties
Date of Institution : 21.11.2013 Date of Order : 01.12.2017
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
Briefly stated, the case of the complainant is that he had purchased an insurance policy bearing No. 110300/48/12/14/00000327 from OP-3 who promised to provide cashless facility in the hospital on panel. The said policy was valid from 22.06.2011 to 21.06.2013. OP-1 issued a card bearing No. 52010309047287A to the complainant. In the month of March, 2013 complainant felt sick. OP-2 hospital prepared an estimate of Rs. 53,700/-. The same was intimated to OP-1 and OP-3 by the complainant. Complainant was granted permission by OP-1 to avail cashless facility. Accordingly complainant was hospitalized from 12.03.2013 to 15.03.2013 in OP-2 hospital. The complainant was asked by OP-2 to pay a sum of Rs. 5,000/- on 12.03.2013 rather providing cashless facility. He was directed by OP-2 to deposit a sum of Rs.15,000/- on 13.03.2013, Rs. 34,174/- on 15.03.2013 at the time of discharge. OP-1 allowed the claim to the tune of Rs. 39,994/-. After discount of Rs.10,000/-, OP (sic) raised the net bill amount of Rs. 94,168/- out of which OP-1 paid a sum of Rs. 39,994/- and the remaining amount of Rs. 54,174/- was paid by the complainant. Thereafter, complainant deposited the original bills with the OP-1 and also deposited a bill of Rs.1,921/-. Rs. 1721/- was paid out of Rs. 1921/- and Rs.200/- was deducted by saying that the said SOL spray is not permissible as per the policy. It is submitted that OP-1 and OP-3 did not pay the claim and therefore the complainant paid the said bill from his pocket to OP-2. It is submitted that no policy documents were ever sent to the complainant and only the card was sent by the TPA. The non-payment of the amount of Rs.54,174/- is illegal, arbitrary, malafide and wrong in the eyes of law. It is submitted that OP-2 made an estimate of Rs.53,700/- and therefore OPs were under the obligation not to charge more than Rs. 53,700/-. Hence OP-2 is also liable for the same. Complainant has prayed for issuing directions to the OPs as follows:-
- To pay the claim of Rs.54,174/- with interest @ 18% per annum till the disposal of the complaint;
- To pay Rs.200/- deducted by the OPs from the amount of Rs.1,921/-;
- To pass order against the OP no. 2 to refund the excess amount of Rs. 40,468/- charged by the OP no. 2 above than estimate;
- Allow compensation of Rs. 50 thousand in favour of the complainant;
- Allow litigation cost of Rs. 20,000/- in favour of the complainant.
OP-2 in its reply has inter-alia stated that the complainant wants to pay only for one service while he had taken two services from OP-2; that OP-1 and OP-3 had not given approval for another service to the complainant. It is stated that estimate of Rs.53,700/- was only for the one treatment and the total bill of Rs.1,04,168/- was for two treatments. Complainant has not mentioned this fact in the present complaint and hence has concealed facts. It is prayed that the complaint be dismissed with costs of Rs. 1,00,000/- for making false and frivolous complaint with ulterior motives and Rs. 10,000/- for Advocate’s fee.
OP-3 in its reply has inter-alia stated that “it is on records of the case that the complainant is holding a AROGYA HEALTHCARE POLICY bearing No. 110300/48/12/14/00000327 issued by OP No. 3 for the period of 02.07.2012 to 04.07.2013.” It is submitted that the complainant submitted the bill of Rs.94,168/- to the OP-1 out of which Rs.39,994/- has already been paid. The amount of Rs.2,559/- is not payable because expenses towards mask, nebulizer kit, hand rub, drops, ECG Electrode, non sterile gloves, apron, sterillium handrub, brand aid wash proof, tegaderm are not payable as per exclusion clause of the policy. It is stated that the balance amount of Rs.51,615/- was never denied by OP-3 which is under consideration and the complainant has filed the present complaint before completion of scrutiny. OP-3 has prayed for dismissal of the complaint.
No separate reply has been filed on behalf OP-1.
Complainant has filed a joint rejoinder to the replies of OP-2 and OP-3. It is stated as follows:-
“There is no explanation to this effect that why the said claim is not paid or declined yet. This shows deficiency in services on behalf of the OP no. 1-2.”
“It is denied that the present complaint is a premature complaint. It is submitted that when a part of claim has been paid then on what basis the remaining claim was not paid. It is submitted that the complainant has taken mediclaim policy which covers all medical expenses so the OP cannot pay claim of one expense and decline for the other. This itself proves deficiency in services on behalf of OP.”
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. Kapil Chaudhary, authorized representative has been filed in evidence on behalf of OP-2.
OP-1 and OP-3 have been proceeded exparte. No affidavit in evidence has been filed on their behalf.
Written arguments have been filed on behalf of the complainant and OP-2.
We have heard the counsel for the complainant and OP-2 and have also gone through the file.
The facts of the case are peculiar. According to the case of the complainant made out in the complaint, denial of the claim of Rs.54,174/- by OP-1 and OP-3 is illegal, arbitrary, malafide and wrong in the eyes of law. In response to the plea taken by OP-3 in the reply that the claim of Rs.51,615/- was/ is under consideration by OP-3 and has never been denied to the complainant and the complainant has filed the present complaint before waiting for the completion of the scrutiny of his claim by OP-3, the case of the complainant in the rejoinder has been put in the reverse gear to say that there is no explanation as to why the claim for this amount has not been paid or declined so far which act itself amounts to deficiency in service on behalf of OP-1 and OP-2 and that the acceptance of part claim in the mediclaim policy for one claim and non-payment of the remaining amount of claim for another claim also amounts to deficiency in service.
In view of the fact that in the written statement, OP-3 has not denied the claim of the complainant for the remaining amount, we do not want to go into the question whether the complainant had taken one treatment or two treatments from OP-2 hospital because the OP-3 has not taken any such plea in its reply.
We have very carefully gone through the order sheets and nowhere it has been mentioned whether the claim of the complainant for remaining amount of Rs.54,174/- or Rs.51615/- has since been denied or has been accepted or whether it is still pending adjudication before the OP-3.
It is correct that the non passing of an order on the claim papers of the claimant covered under the mediclaim policy within reasonable time may also amount to deficiency in service. However, at the same time the complainant must specifically disclose this fact in the complaint. In the present case, the complainant did not do so and suppressed a very material fact from this Forum and has not dared to deny this fact in his rejoinder.
Therefore, we do not hold either of the OPs guilty of deficiency in service. However, at the same time we issue the directions to OP-3 to deal with the claim of the complainant for the remaining amount at the earliest if the same is still pending for consideration or if OP-3 has already passed some order of the said amount to communicate the same to the complainant.
Complaint stands disposed off accordingly.
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 01.12.2017.
