DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.384/2014

Mr. Kaushal Kumar Mishra

H. N. 238, Main Market,

Maharajpur, Shahibabad,

Gaziabad, U.P.-201010                                                                                                                                                                                                                                                                         ….Complainant

Versus

M/s United India Insurance Co. Ltd.

UI, BO-Bahadurgarh, 8/30, Dharampura,

Delhi-Rohtak Raod,

Bahadurgarh-124507 (Haryana)

Medsave Healthcare (TPA) Ltd.

F-701A Lado Sarai (behind Gold Course)

New Delhi-110030

Rapid Healthcare Pvt. Ltd.

506 KirtiMahal, 19 Rajendra Place,

New Delhi - 110008                                                ….Opposite Parties

       Date of Institution    :         07.10.2014

       Date of Order            :         13.12.2021

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Sh. U.K. Tyagi, Member

ORDER

President: Ms. Monika A Srivastava

The present complaint has been filed by the complainant for seeking compensation and damages of Rs.1,42,410/- along with costs and has been preferred against M/s United India Insurance i.e. OP No. 1, Medsave Healthcare OP No. 2 and Rapid Healthcare Pvt. Ltd. OP No. 3.  The case of the complainant is that he had purchased a medical claim insurance policy bearing number 111205/48/12/06/0000 1580 from OP No.1 through OP No.3 and was provided card number 5200 1311 3006840 A in 2012 by paying a one time premium of Rs.6,566/- for a cover of rupees two lakhs in 2012 and was later on renewed on  2013.

It is the case of the complainant that he suffered from fever, vomiting and diarrhoea and was admitted to the Gupta Multispecialty Hospital Vivek Vihar, Delhi. He was diagnosed with Enteric fever and due to his condition; he was hospitalized for the next five days from 12.06.2013 to 17.06.2013. OP No.2 was informed by the hospital itself on 12.06.2013 and a reference number 2013 0613 B009 and 2A 405 was issued by OP No. 2 and is annexed as Annexure A 2. The investigation officer of the OP No. 2 visited the hospital on 13.06.2013 and took the details of the complainant. On 17.06.2013 the complainant was discharged and the total bill of the hospital was Rs.42,410/-. Annexure A5 is the medical claim form of the complainant. On 10.07.2013 the complainant received a mail stating that his medical claim has been rejected as fraudulent and when the complainant inquired further he was told that there were no papers in the hospital which indicated that he was actually admitted in the hospital.

The complainant wrote letters to OP No.2 and 3 attaching all his medical records and bills obtained by the hospital on 13.07.2013 and the same are annexed as annexure A 7 and A 8.

Thereafter on 26.9.2013, the complainant received a request from OP No.2 to fill up his claim form and share his NEFT particulars along with a copy of cancelled cheque.  OP No.1 was also copied in the same mail. The requisite details were shared by the complainant with OP No.2 on the same day and also on 30.09.2013 and is annexed as Annexure ‘A-9’.

It is the case of the complainant that he had duly intimated OP No.2 regarding his hospitalization and in fact the investigation officer from OP No.2 had also visited the complainant in the hospital and took details of his Medicare policy and card and thereafter issued a reference number. The complainant has filed his evidence as also his written submissions in support of his claim.

The opposite parties have failed to appear and were proceeded ex parte on  and resultantly have not filed any document in support of their claim that the claim filed by the complainant is fraudulent. On the other hand the complainant has filed all the documents pertaining to his hospitalization. And it is also on record that the after the complainant had provided all the documents to the OP No.2. The OP No.2 had requested for his bank details. We find no reason to disbelieve the complainant’s version as per record available.

Therefore, the complaint of the complainant is allowed and the OP No.1is directed to pay to the complainant a sum of Rs.42,410/- with interest at the rate of 6% p.a. from the 17.06.2013 till its realization within a period of two months from the date of this order failing which all the OPs are liable to give an additional amount of Rs. 15,000/- to the complainant.

File be consigned to the record room after giving/sending copies of the order to the parties. The office is directed to upload the order on the website.