District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. .187/2020
Date of Institution:09.07.2020
Date of Order: 09.06.2023
Pooja P Kumar aged about 54 years W/o Shri Prem Prakash Kumar R/o House No. 9A, 1-Block, Sector-10, Faridabad.
…….Complainant……..
Versus
1. M/s. National Insurance Company Limited, Branch Office-II: SCO NO. 96, Ist floor, sEctor-16 Market, Faridabad – 121002 through its Branch Manager/Authorized Signatory.
2. Sarvodaya Hospital & Research centre, YMCA Road, Sector-8, Faridabad, through its Principal Officer.
…Opposite parties
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Mohd. Imran, counsel for the complainant.
Sh. Rakesh Dabaas counsel for opposite party No.1.
Sh. Yogender Singh, counsel for opposite party No.2.
ORDER:
The facts in brief of the complaint are that the complainant was regular medical policy holder of opposite party No.1 and the resent policy bearing
No. 361102501910000749 under National Parivar Mediclaim which was valid from 06.05.2019 to 05.05.2020 for herself and for her family members i.e her husband and son for a benefit value of Rs.5,00,000/- The son namely Devanshu Kumar of the complainant was suffering from severe headache, vomiting, vertigo, nausea, numbness in right leg and the complainant took her son to Sarvodya Hospital, Sector-8, YMCA Road, Faridabad/proforma opposite party No.2 on 17.07.2019, where the doctors examined him and advised for admission as indoor patient, acceding to the advise, the complainant got admitted her son in the said hospital 17.07.2019 vide IPD No. 181912 and he remained admitted in the said hospital upto 19.07.2019. The said hospital duly informed the opposite party No.1 in respect of hospitalization of Devanshu Kumar and requested to provide cashless facility but the opposite party No.1 did not provide the same, hence the complainant had to pay entire treatment/billing amount of Rs.39,404/- to the said hospital towards treatment expenses of her son. Thereafter, the complainant submitted the requisite documents regarding treatment/hospitalization of her son with opposite party No.1 and lodged the claim bearing No. NL-3-47295and the opposite party No.1 assured that after some quarries, the said claimed amount would be disbursed, Thereafter, the complainant started making many representation by personal visits to the opposite party No.1 to disburse the claimed amount but the opposite party No.1 always avoided the matter on one pretext or the other till date. Opposite party No.1 had not released the same and now opposite party No.1 in an illegal manner repudiated the claim of the complainant on flimsy ground vide its letter dated 20.08.2019, whereas the proforma opposite party opined that the indoor management of the patient was necessary to cure the disease of the patient. The complainant sent legal notice dated 23.01.2020 to the opposite party through registered post but all in vain. 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) disburse the claimed amount of Rs.39,404/- with interest @ 18% p.a. from the date of bill till actual realization.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 21,000 /-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 at the very threshold of the allegations contained in the complaint, it had been established form the submitted documents at the end of the complainant that the hospitalization of the complainant’s was done primarily for investigation and evaluation purposes with no active line of treatment given during the stay in Sarvodaya Hospital, Faridabad w.e.f 17.07.2019 to 19.7.2019 because most of the medicines were administered in the form of tablets & patients condition was stable at the time of admission. Further, as per the initial assessment sheet provided, the patient was ambulatory and did not require any supervision/assistance. All findings of the physical examination were normal & his genial condition was fair as per the records given. Therefore, the hospitalization of the complainant ‘son was not needed and the admission was done solely for the purpose of investigations. Not only this, the total final bill was of Rs.42404/- out of which the cost of medicines was only 2204/- (approx 5% of total bill) and the rest were the expenses for room rent, investigation, consultation etc. There was no active line of treatment as the condition of the patient was not that much acute for the management of which admission was required thus the claim of the complainant stands no payable as per exclusion clause 4.19 & 4.22 of the insurance policy so issued in this behalf hence, the insurance company had
traded the subject claim as repudiated by closing the file in terms of “letter of intimation” dated 20.08.2019. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No. 2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that the complainant had not come before the Hon’ble Forum with clean hands. The answering opposite party had performed its part of duty diligently and had sent the request for cashless hospitalization/treatment of the patient alongwith the estimate expenses summary and other required documents to insurance company/TPA on 17.07.2019 when the complainant was admitted with the answering opposite party. The insurance company i.e opposite party No.1, upon the intimation/request of the answering opposite party denied the said request for cashless treatment under the mediclaim policy giving reasons that “cashless denied under exclusion clause 4.19 and 4.22 of the policy, as the patient was admitted primarily for investigative and evaluative purpose. The patient could had been managed on OPD basis also. Hospitalization not justified. The answering opposite provided the complainant with all the services and provided all necessary certificate and clarifications etc. for the approval of his cashless claim. If opposite party No.1 had denied his mediclaim inspite of having all the information and clarifications received from the answering opposite party then the answering opposite party can’t be held liable to pay anything to the complainant. Opposite party No.2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
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– National Insurance Co. Ltd. with the prayer to: a) disburse the claimed amount of Rs.39,404/- with interest @ 18% p.a. from the date of bill till actual realization. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 21,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Pooja P Kumar, Ex.C-1 – insurance policy, Ex.C-2 – discharge summary, Ex.C-3 – Final bill, Ex. C-4 – note written by Sarvodya hospital, Ex.C-5 – NO claim letter dated 20.08.2019,, Ex.C-6 – legal notice.
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 Rameshwar Dass, Assistant Manager, M/s. National Insurance Co. Ltd., Branch Office-II, SCO-96, Ist floor, Shopping Complex, Sector-16, Faridabad, Ex.R-1 – insurance policy, Ex.R-2 – claim form, Ex.R-3 – discharge summary, Ex,R-4 – Final Bill, Ex.R-5 – Initial Nursing Assessment, Ex.R-6 – No claim letter dated 20.08.2019.
As per evidence of opposite party No.2, EX.DW2/A – affidavit of Saurabh Gahlote, duly authorized representative of Sarvodaya Hospital and Research Centre, YMCA Road, Faridabad, Ex.OP2/A – General Estimate of expenses under cashless admission, Ex.OP2/B – Denial of cashless access. Annx.D-2/C – Discharge summary.
7. In this case, the patient is a layman. When the doctor is admitting and issuing the certificate for the admission, it means the patients needs admission in the hospital. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are 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 parties are 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: 09.06.2023 (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.
