District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 335/2021.
Date of Institution: 15.07.2021.
Date of Order:07.03.2023.
Smt. Sushma Kocher, aged about 57 years wife of Shri Rakesh Kochar, R/o H.NO. 780, Sector-16, Faridabad (Haryana) having Aadhar card No.
…….Complainant……..
Versus
M/s. IFFCO Tokyo General Insurance Co. Ltd., Delhi Retail FAT (Nehru Place) IFFCO House, 2nd floor, 34, Nehru Place, New Delhi – 110 019.
Branch Office:
2nd floor SSR Corporate Park, Unit 209, 13/6, Mathura Road, Sector-27, Faridabad through its Manager.
…Opposite party
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: Ms. Anita Shehrawat , counsel for the complainant.
Sh. O.P.Gaur, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant alongwith her husband Shri Rakesh Kochar and son namely Manav Kochar had taken the mediclaim policy No. H0081454 Member ID No. H0081454/20 namely “Family Health Protector” valid from 10.04.2019 to midnight of 09.04.2020 for the total insured mediclaim benefit of Rs.5,00,000/-. The complainant was suffering from high grade fever and also complaint of burning maturation pain abdomen and high grade with Chills etc. for the last 4-5 days Hence the complainant was admitted in QRG Medicare Limited, Plot No.1, Sector-16, Faridabad on 07.03.2020 in night hours but she was discharged at about 11.00p.m on the same day. The complainant had paid the amount of Rs.6,000/- to the said hospital in emergency. Complainant was under impression that she would recover soon after getting treatment. But unfortunately in the morning itself complainant was feeling uneasy and hence on 08.03.2020 complainant was again admitted QRG Medicare Limited, Plot NO.1, Sector-16, Faridabad with the complaint of Burning maturation pain abdomen and high grade with chils etc. The file of the complainant was sent by the hospital authorities for cashless scheme but the opposite party rejected the claim of the complainant straight away on the same day i.e. 08.03.2020 rejection of claim of complainant on false reason of detected of pregnancy. The complainant was discharged was discharged from said hospital namely QRG Medicare Limited, Plot No.1, Sector-16, Faridabad on 09.03.2020. Complainant paid the total medical expenses of Rs.17,747/- to the hospital authority due to rejection of claim of complainant on false reason of detected of pregnancy. The complainant was discharged from the hospital with the advice to
have injections twice a day for a week and the cost of the injections was Rs.2000/- per day including service charges of the attendant to inject the injunctions. In this complainant spent total amount of Rs.30,000/- on her treatment which she was entitled to recover from the opposite party. The complainant was not pregnant and the file was again taken up for the reimbursement of the amount incurred by the complainant. The complainant was communicating with the opposite party through email letters regarding the reimbursement of the amount but the claim was repudiated twice. On 09.06.2020 the opposite party sent email to the complainant thereby rejecting/repudiating the claim of the complainant. On 07.07.2020 the opposite party again sent email to complainant in which the opposite party disclosed that the claim had been rejected on the false ground claim had been processed for denial on its merits within the purview of the policy, as the vitals at the time of admission were within normal limit, except mild grade fever 99.6, as the patient in this case could have been managed on OPD tests which was not covered in the policy. The rejection of the claim was highly unsustainable in the eye of law as the patient was admitted twice in hospital once in the morning on 07.03.2020 in night hours and discharged at about 11.00p.m. and again when the condition could not be recovered she again admitted on 08.03.2020 in the hospital and treatment was given by the doctors as per their opinion complainant was not supposed to know treatment which was given in that circumstances/situation, hence the rejection of the complainant was highly unjustified by the opposite party. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay an amount of Rs.30,000/- with interest @ 24% p.a. since date of due till the date of realization of the amount in full to the complainant jointly and severally.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 5500 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that Shri Rakesh Kumar Kochhar purchased a Family Health Protector policy bearing No. H0081454 wherein he and his spouse Mrs. Sushma Kochhar and son Manav Kochhar were covered. The said insurance policy was valid from 10.4.2019 to 09.04.2020 having sum insured amount of Rs.10,00,000/- and cumulative bonus amount of Rs.25,000/-. It was submitted that the opposite party insurance company received a claim request with respect to patient Mrs. Sushma Kochhar. On scrutiny of the submitted documents, the said cashless request was denied vide letter dated 09.03.2021 with the following observations:
“As per submitted documents patient admitted with complaint of high grade fever with burning micturition, all vitals were within normal limits and all investigation also within normal attempt was made to treat patient on OPD basis. In view of available documents patient can be managed on OPD basis & hospitalization also not justified for investigation & evaluation purpose hence this cashless was denied.”
It was submitted that the complainant submitted his claim for reimbursement. On security of the submitted claim documents it was revealed that the patient was admitted in QRG Hospital, Faridabad with the complaint of burning micturition, pain in abdomen and high grade fever with chills, diagnosed with febrile UTL. It was also noted that the vitals at the time of admission were within normal limit, except mild grade fever 99.6. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– Iffco Tokio General Insurance Co. Ltd. with the prayer to: a) pay an amount of Rs.30,000/- with interest @ 24% p.a. since date of due till the date of realization of the amount in full to the complainant jointly and severally. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .c) pay Rs. 5500 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A - affidavit of Smt. Suhma Kochar,, Ex. C-1 – Family Health Protector, Ex.C2 – Emergency Discharge Instructions, Ex.C-3 – Discharge summary, Ex.C-4 – Auth. Denial letter, Ex.C-5 – letter dated 09.06.2020, Ex.C-6 – email dated 07.07.2020, Ex.C-7 – Final bill, Ex.C-8 – legal notice,, Ex.C-9 – postal receipt.
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Mridul Ranjan, General manager of the IFFCO Tokio General Insurance Co. Ltd. Iffco Tower II Plot NO.3, Sector-29, Gurugram, Annx.R1 – insurance policy alongwith terms and conditions, Annx.R/2 – denial letter, Annx.R/3 – Emergency Discharge instructions dated 07.03.2020, Annx.-R/3A – Hospital’s triage sheet dated 08.03.2020, Annx. R/4 – Discharge summary date d09.03.2020, Annx.R/5 – Repudiation letter dated 09.06.2020, Annx.R/6 - email dated 07.07.2020.
6. In this case, the complainant alongwith her husband Shri Rakesh
Kochar and son namely Manav Kochar had taken the mediclaim policy No. H0081454 Member ID No. H0081454/20 namely “Family Health Protector” valid from 10.04.2019 to midnight of 09.04.2020 for the total insured mediclaim benefit of Rs.5,00,000/-. The complainant was suffering from high grade fever and also complaint of burning maturation pain abdomen and high grade with Chills etc. for the last 4-5 days Hence the complainant was admitted in QRG Medicare Limited, Plot No.1, Sector-16, Faridabad on 07.03.2020 in night hours but she was discharged at about 11.00p.m on the same day. The complainant had paid the amount of Rs.6,000/- to the said hospital in emergency. Complainant was under impression that she would recover soon after getting treatment. But unfortunately in the morning itself complainant was feeling uneasy and hence on 08.03.2020
complainant was again admitted QRG Medicare Limited, Plot NO.1, Sector-16, Faridabad with the complaint of Burning maturation pain abdomen and high grade with chils etc. Opposite party has repudiated the claim of the complainant on the false reason of detected of pregnancy. Claim has been processed for denial on its merits within the purview of the policy, as the vitals at the time of admission were within normal limit, except mild grade fever 99.6, as the patient in this case could have been managed on OPD tests which is not covered in the policy.
7. After going through the evidence led by the parties, the Commission is of the opinion that the complainant is a layman. As per the advice of the doctor she admitted in the hospital. Reason for rejection of the claim of the complainant by the opposite party is not justified. Hence, the complaint is allowed. Opposite party is directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due 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.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- 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. File be consigned to the record room.
Announced on: 07.03.2023 (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.
