DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

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

(Behind Qutub Hotel), New Delhi- 110016

Case No.355/2010

DR. JAMES MASSEY

R/o Flat No.431, Rama Appartment

Plot No.2, Sector-11, Dwarka,

New Delhi-110075

….Complainant

Versus

 MEDSAVE HEALTHCARE (TPA) LTD.

 F-701, Ladoo Sarai,

 Mehrauli, New Delhi

UNITED INDIA INSURANCE COMPANY LIMITED

9, Transport Centre, New Rohtak Road,

Near Punjabi Bagh Circle,

Delhi-110035

        ….Opposite Parties

            Date of Institution    :    01.06.2010    

            Date of Order            :    22.04.2022  

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Sh. U.K. Tyagi, Member

ORDER

Member:   Sh. U.K. Tyagi

Complainant has requested for reimbursement of his medical expenditure from M/s Medsave Health Care Ltd. (TPA) (hereinafter referred  to as OP-1) as he alongwith his wife was insured for the currency of the period from 2009-2010 commencing from the date 15.09.2009 to 14.09.2010 for Rs.1,75,000/- . So he has requested to pay at least Rs. Rs.1,75,000/-  for which he was insured by the insurance company.

          Brief facts of the case are that the  Complainant was admitted in Jaipur Golden Hospital, Sector-3, Rohini, Delhi on 10.11.2009 for breathing problem and remained in Hospitals upto 05.12.2009 including one day hospitalization in Chanan Devi Hospital on 17.11.2009. It was averred that during this period, it was found by doctors a recent development of DM, HTN, CHF. On this, the Hospital was paid first Installment of Rs.26,000/- on 19.11.2009 as medical expenditure. The Chanan Devi Hospital sent a request on 14.11.2009 to Medsave Helath Care Ltd (TPA) for cashless access and it was taken up by the Jaipur Golden Hospital as well. The same was denied by the TPA. The ground for denial of the said expenditure and cashless access was being the pre-existing disease. The   Complainant also added that if the insurer had paid for policy for four years or more, in that case, even if there was an old disease, the same was still to be covered under the policy. It is noticed that the Complainant alongwith his wife is policy holder for last 5 years since 2005-06 with Medsave Card No. 5203020702496. The Complainant has given the complete details of the policy no’s with commencing date  since 2005-06, 2006-07, 2007-08, 2008-09 and 2009-10 in its complaint.

The Complainant also filed an application for impleadment of United India Insurance Limited. This Commission vide its order dated 22.02.2011 allowed the same (hereinafter may be referred to as OP-2).

          On the other hand, the OP-1 was proceeded exparte vide this Commission’s order dated 21.09.2010, hence, his defence was closed. The OP-1 was proceeded exparte vide this Commission’s order dated 21.09.2010, hence his defence was closed. The OP-1 did not cooperate with proceedings of this case here. OP-2 took some preliminary objection which are found of general nature and seems to have been taken for the sake of objections. The OP-2 also added that  no cause of action has arisen in favour of Complainant as Complainant was asked by the Medsave Health Care LImited –TPA of the OP-2 vide letter dated 02.09.2011 (copy enclosed as Annexure A) to submit the discharge summary and also break up of cardiologist charges mentioned in the bill of Rs.9,45,734/-. It was accepted by the OP-2 that they shall pay the claim as per terms & conditions of the policy issued to the Complainant. It was also averred by OP-2 that however, cashless facility was denied to the Complainant vide letter dated 19.11.2009 sent to Jaipur Golden Hospital (exhibited at Annexure ‘C’). It was further emphasized that the OP-2 shall process the claim only on receipt of the information as called for vide letter dated 02.09.2011 of TPA and subject to terms & conditions, of this mediclaim policy. As such, it is termed as pre-mature complaint.

          Both the parties i.e OP-2 & Complainant filed Written Submissions and evidences by way of affidavit. It is noticed from the proceeding – record that the Complainant was granted many opportunities to file rejoinder but the same is not found filed on record. The defence of the OP-1 was closed as mentioned above.

          This Commission has gone into the material on record carefully. The Complainant maintained that there was no indication of pre-existing disease on which his cashless access was denied. It was contended by the Complainant that even if any insurer has paid premium for the policy for the last four years or more, in that case, there is an old disease/pr-existing disease, the same shall be covered under the policy. It was carefully gone through the material of OP-2, it has not specifically denied the above mentioned averment. The Complainant also referred the ratio-decidendi of Hon’ble National Commission “where it was specifically held that the mere bald averments of pre-existing disease cannot be a ground for repudiation of claim.”  It was also emphasized by the OP-2 that the denial of cashless facility does not mean that claim is denied. Therefore he stated that it is a pre-mature claim as soon as the requisite documents are submitted, the claim shall be processed. But the Complainant has specifically denied this stating that the claim papers were submitted many times but the OPs are not acknowledging this fact.

          In nutshell, this Commission sincerely feels that there is no doubt about the claim of the Complainant. The Complainant has been able to prove his case successfully. It is not understood why the OP-1 did not join proceedings either way by rejecting his involvement or otherwise. Since, denial letter is sent by TPA, so, there appears no justification of leaving the proceedings in the beginning. To this effect, nothing is on record by which, this Commission let OP-1 off from its responsibility.       

In view of the facts & circumstances of the case as mentioned above, this Commission appreciates the averments of OP-2 to this extent that denial of cashless access, does not mean that the claim is rejected. In other words, the claim subsists and OP-2 accepts its liability. In view of this, this Commission, finding negligence and deficiency of service, directs OP-2 to allow the policy amount i.e Rs 1,75,000/- for which he was insured alongwith interest @6% per annum from the date of final payment of medical expenses within 3 months from the date of this order failing which rate of interest shall be charged @9% per annum. The OP-1 has not discharged its part even minimally, hence a cost of Rs.10,000/- is  inflicted and same shall be disbursed to the Complainant within two months, failing which rate of interest shall be levied @9% per annum till its realization.   

             File be consigned to the record room after giving a copy of the order to the parties.