District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.284/2023.
Date of Institution:20.04.2023.
Date of Order: 25.10.2024.
Sati Ram son of Shri Autar R/o House No. 106, Sector-21B, Faridabad – 121001.
…….Complainant……..
Versus
1. M/s. Group Mediprime TATA AIG, Plot No. 277, First Floor, Udhyog Vihar, Phase IV, Gurugram – 122016, Haryana.
2. The Authorized person, Family Health Plan (TPA) Limited, Srinitaya, Cyber Spazia, Suite, 101, 102, 109 & 110, Ground floor, Road No.2,, Banjara Hills, Hyderabad – 500 034.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma………..Member
Indira Bhadana………….Member.
PRESENT: Shri Yogesh Sharma, counsel for the Complainant.
Shri Rakesh Dabaas, counsel for opposite party No.1
Opposite party No.2 exparte vide order dated 4.7.2023.
ORDER:
The facts in brief of the complaint are that the complainant purchased a medical claim policy No. 023903813000 which was effected from 30.08.2021 till 29.08.2022. The said policy was a family term plan consisting three members i.e. Sati Ram, 2. Pinki – wife of Shri Sati Ram 3. Tanvi D/o Shri Sati Ram. The wife of the complainant smt. Pinki suffered chronic disease and was admitted in Verma Multispeciality Hospital, Main Kheri Road, Sector-87, Near Maharana Partap Chowk, Greater Faridabad for the purpose of her treatment on 27.07.2022 and was discharge don 1.8.2022. The hospital authorities obtained the permission from the opposite parties for paying the claimed amount of medical treatment and the wife of the complainant was got admitted in the hospital for treatment. Despite sending the documents, the opposite parties had not accepted the claim of the complainant rather rejected the same without any proper reason or rhyme which had caused great injustice to the complainant . Total bill was raised by the hospital authorities of Rs.69,711/- which was intimated to the opposite parties also. Thus, the opposite parties were liable to make the entire payment. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the amount of Rs.69,711/- alongwith interest @ 24% p.a. from the date the complainant had paid to the hospital authorities.
b) pay Rs.50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant
and submitted that tat the very threshold of the allegations contained in the complaint, the complainant had violated the conditions of the insurance policy by not submitting the requisite documents/informations to the insurance company, so as to process the claim, despite numerous correspondence at the end of the insurance company. 8 different query as well as reminder letters were sent to the complainant requesting for documents pending, but same were still not provided by the complainant. Query letters dated (29.08.2022, 07.10.2022, 03.01.2023) and reminder letters to these query letters dated (08.09.2022, 18.09.2022, 28.09.2022, 17.10.2022, 27.10.2022) were sent by the insurance company to the complainant. Thus, the insurance company had to repudiate the claim of the complainant for treatment of her wife Pinki as the same was in violation of Section 5 Clause5(i). The complainant neither had any cause of action nor locus standi to file the present complaint. It was submitted that the complainant had submitted the claim form dated 17.08.2022 to the insurance company as to indoor treatment of his wife Pinki in Verma Multi Speciality Hospital, Faridabad Betwixt company had got investigated the matter through an independent investigator PM Law Firm, in turn, after conducting the investigation, the said investigator had submitted his investigation report dated 10.09.2022 As pr available evidence and documents so mentioned hereunder:
- Patient was admitted in Verma Multispecialty Hospital from 27.07.2022 to 01.08.2022 with having C/o loose bowel motion since 3 days, burning micturition since 3-4 days. Fever with chills on and off since 2 days, nausa, vomiting, body ache, mild abdominal pain, decrease urine output since morning, mild pain abdomen 4-5 days.
- Patient diagnosed with Pyrexia with Urosepsis (Urinary Tract) + Age + Sever Dehydration.
- Patient was managed conservatively during hospitalization.
- Hospital visit done, ICP and other relevant documents collected and attached.
- No other chronic disease had been specified by the ICP.
- As per hospital authority written statement, patient was admitted in Verma Multispecialty Hospital from 27.07.2022 to 01.08.2022 with diagnosis Pyrexia with Urosepsis (Urinary Tract) + ACGE + Severe Dehydration. Patient was treated in their hospital under Dr. M.P.Sood’s supervision and patient discharge on satisfactory condition on dated 01.08.2022.
- Insured visit done, statement collected.
The following discrepancies were noted in the following manner:
- As per insured statement BP temp, pulse checked 3-4 times/day but as per nursing – noted it checked 7-8 times/day.
- As per patient statement, patient had c/o since 27.07.2022 and as per hospital ICP and DS, patient had c/o since 3-4 days so, they found that duration of complaint was mismatch.
- As per patient statement, X-ray, USG, ECG and Echo report was done but as per claim document there was no such report found.
- As per patient statement, patient was admitted in private room but as per hospital ICP and final bill, patient was admitted ICU room for 1 day then shifted to private room and hospital side taken charge of ICU & ICP doctor for 1 day. They found that hospital side bill inflation.
- As per patient statement, after discharge was patient F/UP visit on 04.08.2022 but in company side document no any follow up record like: Medicine bill and OPD papers found and patient side not provide post hospitalization papers.
- As per ICP, patient was treated with O2 support fir 1 days but as per patient statement, patient was not treated with O2 support.
- As per nursing note patient’s temp was continuously shows high after given inj. PCM, antibiotic dose. Clinically not justified.
- They had proper scrutiny of ICP and they found that daily higher antibiotic meroza 1 gm injection, paper 4.5 injection, inj. Levflox, inj. Metrogyl given but insured had continuously symptomatic and treating Dr. side refuse to give justification for why use higher authorities but never sustained, its seem like to inflate final bill amt.
- Pharmacy visit done but pharmacy authority person only verified bill but pharmacy authority person side not provide purchase invoice of pharmacy.
Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Registered notice issued to opposite party No.2 on 29.05.2023 not received back either served or unserved. Case called several times since morning but none had appeared on behalf of opposite party No.2. Learned counsel for the complainant had filed the tracking report in which the item delivered. Therefore, opposite party No. 2 was hereby proceeded against ex-parte vide order dated 04.07.2023.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties Grou Mediprime TATAAIG with the prayer to: a) pay the amount of Rs.69,711/- alongwith interest @ 24% p.a. from the date the complainant had paid to the hospital authorities. b)pay Rs.50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case, the complainant has led in his evidence Ex.CW1/A – affidavit of Sati Ram,, Ex.C-1 – legal notice,, Ex.C-2 – postal receipts,, Ex.C-3 – legal notice, Ex.C-4 to 6– terms and conditions,, Ex.C-7 – Form Part-A,, Ex.C-8 to 10 – receipts, Ex.C-11 & 12 – discharge summary, Ex.C-13 – breakup, Ex.C-14 & 15- break up, Ex.C-16 – FHPL), Ex.C-17 – discharge summary, Ex.C-18 - email dated 26.12.2022, Ex.C-19 - certificate of registration,, Ex.C-20 – progress notes,, Ex.C-21 - medication charge,, Ex.C-22 – Medication chart,
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A – affidavit of Amit Chawla, DVP (Legal), M/s. Tata AIG General Insurance Company Limited, Plot No. E-1, Ist & 2nd floor, Sector-8, Noida, Ex.R-1 - insurance policy, Ex.R2(colly) – Form Part A, Ex.R-3 – claim received dated 23.08.2022,, Ex.R-4- query to member, x.R-5 – first reminder, Ex.R-6 – second reminder letter, Ex.R-7 – third reminder letter, Ex.R-8 – investigation closure
report, Ex.R-9 – Query to member,, Ex.R-10 – first reminder, Ex.R-11 – second reminder, Ex.R-12 – claim rejection letter dated 1.3.2023.
7. In this case, the complaint was filed by the complainant with the prayer to pay the amount of Rs.69,711/- alongwith interest @ 24% p.a. from the date the complainant had paid to the hospital authorities. To prove his case, the complainant led in his evidence Ex.C-1 to C-22. On the other hand, opposite party NO.1 led in their evidence Ex.R-1 to Ex.R-12.
8. As per discharge summary vide ex.C-12, the wife of the complainant Pinki admitted in Verma Multispecialty Hospital, Main Kheri Road, Sector-87, Near Maharana Partap Chowk, Grater Faridabad on 27.07.2022 and discharge don 1.08.2022 On the other hand, opposite party repudiated the claim of the complainant vide letter dated 1.3.2023 on the ground that on review of the same with reference to the policy terms and conditions we find that the following documents/information were necessary for processing further. 1) Kindly provide contact details & registration certificate of treating doctor & pathologist. They should be under no obligation to make any payment under this policy (Section 5 clause 5), unless they had received all claim related documents in time and they had been provided with documentation and information they or their TPA had requested to establish the circumstances of the claim, its quntum or their liability for it and unless the insured person had complied with his obligations under this policy.
9. During the course of arguments, the counsel for the opposite party argued at length and stated at Bar that the complainant never filed the documents i.e medical bills and other investigations reports to the opposite party. Even the complainant has never submitted the photocopy of the bills to the opposite party. Opposite party argued that the complaint is premature. On the other hand, counsel for the complainant argued that he has already submitted all the relevant documents to the opposite party. During the course of arguments, counsel for the complainant has placed on record emails dated Oct.11,2022, Oct.12,,2022, Nov.8,2022,, 23.9.2022, 22.9.2022 & 30.09.2022. As per email dated 22.09.2022, in which it has been mentioned that “Sr Mi Satiram mera policy No. 023903813000 and uhid 1003/02/37 and employee I’d 1003 mea calem bill 22.08.2022 to FHPL offec mea mil gya tha or abhi tak na tho claem no nahi mila na tho mera bill ka 69711/- Rs. aya ha eek mahina ho gya..
10. After going through the evidence led by the parties as well as the emails, the Commission is of the opinion that if the complainant has already been given the documents to the company, then the insurance company will process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the claimed amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.5500/- as compensation for causing mental agony & harassment alongwith Rs.5500/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 25.10.2024 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
