…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.
PRESENT: Shri Manoj Jangra and Shri Hemender Tomar, counsel for the complainant.
Shri Anuj Gupta, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 21.12.2021.
ORDER:
The facts in brief of the complaint are that the complainant, his wife Smt. Krishna Tomar, his children were insured against the National Mediclaim Policy bearing its No. 361100/50/20/10005737/(361100502010005737) in the name of the complainant as hospitalization and domiciliary hospitalization benefit policy had been issued by the opposite party No.1 valid from 08.08.2020 to 07.08.2021 and the complainant had paid premium amount of Rs.19,263/- for sum insured of Rs.3,00,000/- + Rs.80,000/- (Rs.3,80,000/-) besides the wife of the complainant was covered to the tune of Rs. Rs.3,70,000/- while children were separately covered which were fully mentioned in the said mediclaim policy. The above said policy was renewed for the subsequent year under the name “National Parivar Mediclaim Policy” bearing mediclaim policy NO. 361100/50/21/10004109 in the name of the complainant and his family members being Floater Cover Hospitalization benefit policy which was issued by the opposite party No.1 and the same valid from 08.08.2021 to 07.08.2022. The complainant had already paid premium amount of Rs.28,965/- to the opposite party No.1 for basic cover sum insured of Rs.6,00,000/-. The complainant was associated with the opposite party No.1 company since long time as first mediclaim policy was taken by the complainant on 08.08.2001. The details of some previous policies wee as under:
i) Medaiclaim policy bearing its No. 36110050191000600 valid form 08.08.2019 to 07.08.2020.
ii) Mediclaim policy bearing its No. 361100501810006250 valid from 08.08.2018 to 07.08.2019.
iii) Mediclaim policy bearing its No. 361100501710006542 valid from 08.08.2017 to 07.08.2018.
iv) Mediclaim policy bearing its No. 361100501610001233 valid from 0808.2016 to 07.08.2017.
During the operation of the above said National Mediclaim policy bearing its No. 361100/50/20/10005737/(361100502010005737) the complainant had suffered from Syncope/CHB, CAG-Non significant CAD due to complaints od unconsciousness episode at around 4.30 pm, 2nd episode after 10 minutes and third episode after one hour on 07.06.2021 and the complainant was admitted with QRG Health City Hospital, Sector-16, Faridabad with above mentioned complaint on 07.06.2021. As per the report ECG Showed CHG, Echo revealed No. RWMA LEF 55-60%. Thereafter the doctors of the said hospital diagnosed the complainant as “Syncope/CHB, CAG-Non significant CAD” for which the complainant was remained admitted in QRG Health City Hospital, Sector-16, Faridabad from 07.06.2021 to 11.06.2021 and in which the complainant was diagnosed as mentioned above. The intimation in this regard was also communicated by the hospital authorities as well as the complainant to the opposite parties. Although at the time of admission it was told by the hospital authorities that the complainant had to pay nothing on account of bill as he was covered under cashless policy. It was also revealed by them that they had already got the approval from the opposite parties. In the said hospital firstly temporary packmaker insertion was done on 07.06.2021 thereafter, the complainant was taken up for CAG which revealed non significant CAD. Thereafter the complainant went underwent permanent pacemaker implantation, according pacemaker implantation was done under LA on 09.06.2021 Mode DDDR. Thereafter on the advise of doctor Rakesh Rai Sapra, M.d. Medicine D.M. Cardiology, Director Department of Interventional Cardiology and other Hospital Authorities of QRG Health City Hospital, Sector-16, Faridabad. The Medical Officer/authorized signatories of QRG health City Hospital, sEctor-16, Faridabad raised the final Bill NO. QHIR22/1694, I.P. No. 33-21/5214, UHID NO. 100150899 dated 11.06.2021 for Rs.3,06,660/- instead of total charges of Rs.3,06,660/- hence the complainant was compelled to pay the balance amount of Rs.43,340/- to QRG Health City Hospital, sEctor-16, Faridabad at the time of discharge of the complainant from the said hospital on 11.6.2021. As per the policy terms and conditions the complainant was insured for the amount of Rs.3,80,000/- as the same was reflecting in the policy effective from 08.08.2020 to 07.08.2021, accordingly as per contractual obligations the opposite parties were legally bound entire treatment charges of Rs.3,06,660/- at the time of discharge on 11.06.2021. But the opposite parties compelled the complainant to pay the balance amount of Rs.43,340/- to the said hospital. During course of treatment on the advise hospital authorities various tests like ultrasound, angiography, various blood tests, lever function test, ECHO test, multiple various ECG and other various tests etc. were conducted by the medical officer of QRG Health City Hospital, Sector-16, Faridabad. Thereafter the complainant was discharge don 11.0.6.2021 and as per the advise of medical officer/Dr. Rakesh Rai Sapra the complainant used to visit QRG Health City Hospital, Sector-16, Faridabad on various dates for routine checkups, tests, ultrasound, liver function test etc. In this regard posit hospitalization bill worth Rs.15,859.50 ps. Was submitted by the complainant to the opposite parties on 27.07.2021. However, the opposite parties made the payment of Rs.2800/- on 07.09.2021 through NEFT No KKBK0000958*KKBK212505504604 to the bank account of the complainant. Thus opposite parties had not paid balance amount of Rs.13,059.50 to the complainant on account of pre & post hospitalization charges, while the opposite parties were legally bound to make the payment of Rs.15,859.50 ps. to the complainant. In view of the above facts and circumstances the opposite parties had not made the balance of payment Rs.43,340/- (at the time of discharge of the complainant on 11.06.2021) plus Rs.13,059.50 Ps. (on account of post hospitalization charges) i.e. total amount of Rs.56,399.50 ps. to the complainant intentional and deliberately. 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) make the payment balance mediclaim amount of Rs.43,340/- (at the time of discharge of complainant) + Rs.13,059.50 ps. (post hospitalization expenses) i.e. total amount of Rs.56,399.50 ps. alongwith interest @ 18% p.a. from the date of due till the date of realization of the same jointly or severally..
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-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 the complainant, his wife and his children were insured with the answering opposite party under National Mediclaim policy vide Insurance Policy No.361100502010005737 w.e.f. 08.08.2020 to 07.08.2021 with insured amount for complainant Rs.3,00,000/=- and cumulative bonus of Rs.80,000/- subject to its terms and conditions, according to terms and conditions Coverage shall be maximum limit under section 2.1 for anyone illness 25% of the sum insured, maximum limit under section 2.2 for anyone illness 25% of the sum insured & maximum limit under section 2.1. was Rs.95,000/-, Section 2.2 was Rs.95,000/- and Section 2.3 was Rs.1,90,000/-. After receiving g the cashless approval request form QRG Hospital, Faridabad regarding CHB, CAG-Non significant CAD for admission 07.06.2021 to 11.06.2021 same was got processed by the team of the doctors of opposite party No.2 and cashless approval of Rs.02,63,320/- which was permissible and admissible under the terms and conditions of the insurance company was paid by the opposite party No.2 directly to aforesaid hospital on behalf of the answering opposite party, the payment of aforesaid amount was admitted by the complainant in his complaint under reply as detailed in Annexure C-11. It was pertinent to mention that under the insurance policy total sum insured was Rs.3,80,000/- less fixed price rate of procedure under PPN (73,320/- mentioned in final bill of hospital also) = 3,06,680/- (Balance sum insured.)
The complainant submitted claim form with opposite party No.1 on 27.07.2021 claiming post hospitalization bills of Rs.15,859/-. The aforesaid claim was also processed by opposite party No.2 on behalf of answering opposite party and it was found that complainant had claimed rs.2800/- towards OPD consultation, Rs.8491/- towards medicines, rs.250/- towards ECG, Rs.4,268/- towards lab tests, Rs.50/- towards registration, said claim was processed and found approved for Rs.2800/- towards OPD consultation, which was permissible and admissible under the terms and conditions of the insurance policy was paid by the opposite party No.2 on behalf of answering opposite party to complainant, the payment of aforesaid amount was admitted by the complainant in his complaint under reply. The complainant had not placed on record any claim form submitted by the complainant after discharge regarding hospitalization bill amount of Rs.43,340/- which was subject matter of present complaint, for this reason the present complaint was premature qua Rs.43,340/-. Further under the present policy the entitlement of complainant for the medical practitioner fee and other hospital expenses were also having cap limit of 25% and 50% respectively of the sum insured as mentioned in the terms and conditions of the policy, same was applied and the permissible amount as per terms of the policy had already been paid to the complainant, rather the permissible and admissible under the terms and conditions of the insurance policy was paid by the opposite party No.2 on behalf of answering opposite party to the complainant. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Notice issued to opposite party No.2 not received back either served or unserved. Tracking details filed in which it had been mentioned that item delivery confirmed. Case had been called several times since morning but none appeared on behalf of opposite party No. 2. Hence, opposite party No..2 was hereby proceeded against ex-parte vide order dated 21.12.2021.
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) make the payment balance mediclaim amount of Rs.43,340/- (at the time of discharge of complainant) + Rs.13,059.50 ps. (post hospitalization expenses) i.e. total amount of Rs.56,399.50 ps. alongwith interest @ 18% p.a. from the date of due till the date of realization of the same jointly or severally.. b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 22,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence,Ex.CW1/A – affidavit of Shri Deependra Pratap Singh Tomar,, Ex.C-1 – insurance policy, Ex.C-2 – insurance policy valid from 08.08.2021 to 07.08.2022, Ex.C-3 – 08.08.2019 to 07.08.2020, Ex.C-4 – insurance policy valid from 08.08.2018 to 07.08.2019, Ex.C-5 – insurance policy valid from 08.08.2017 to 07.08.2018, Ex.C-6 – insurance policy valid form 08.08.2016 to 07.08.2017, Ex.C7 – Interim Protection Note, Ex.C-8 & 9– identity cards, Ex.C-10 – Final bill of supply summary,, Ex.C-11 – total claimed of Rs.15,859/- towards post hospitalization, Ex.C-12 – discharge summary, Ex.C-14 to C-16 –OPD prescriptions, Ex.C-17 to 23– invoices, Ex.C-24 to 26 – receipts, Ex.C-27 to 31 – bills, Ex.C-32 – receipt, Ex.C-33 – OPD prescription, Ex.C-34 to C-37 – invoices, Ex.C-38 – test, Ex.C-39 – Final bill of supply, Ex.C-40 - OPD prescription,
On the other hand counsel for the opposite party No.1strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A – affidavit of shri Rameshwar Dass, A.O Cum Duly Constitute Attorney of National Insurance co. Ltd., NIT, Faridabad, Ex.R1 – insurance policy, Ex.R2 – terms and conditions, Ex.R3 – Cashless Authorization Letter (Part-D).
7. It is evident from insurance policy vide Ex.C1, the complainant, his wife Smt. Krishna Tomar, his children were insured against the National Mediclaim Policy bearing its No.361100502010005737 in the name of the complainant as hospitalization and domiciliary hospitalization benefit policy had been issued by the opposite party No.1 valid from 08.08.2020 to 07.08.2021 and the complainant had paid premium amount of Rs.19,263/- for sum insured of Rs.3,00,000/- + Rs.80,000/- (Rs.3,80,000/-) besides the wife of the complainant was covered to the tune of Rs. Rs.3,70,000/- while children were separately covered which were fully mentioned in the said mediclaim policy. As per final bill dated 11.6.2021 vide Ex. C-10 the opposite parties approved Rs.2,63,320/- instead of total charges of Rs.3,06,660/-. The complainant was compelled to pay the balance amount of Rs.43,340/- to QRG Health City Hospital, Sector-16, Faridabad at the time of discharge of the complainant form the said hospital on 11.06.2021. As per the advise of medical officer/Dr. Rakesh Rai Sapra the complainant used to visit QRG Health City Hospital, sEctor-16, Faridabad on various dates for routine checkups, tests, ultrasound, liver function test etc, it was post hospitalization treatment on account of OPD charges, medical bills, ECG charges, Gastro consultation OPD, Lab report of liver function profile, Hepatitis-B Test, HBV Viral Load by real time PCR etc.. As per Ex.C-11, the total amount claimed of Rs. 15,859/- towards post hospitalization submitted by the complainant to the opposite parties on 27.07.2021. The opposite parties made the payment of Rs.2800/- on 7.9.21 through NEFT No KKBK0000958*KKBK212505504604 to the bank account of the complainant. Thus opposite parties had not paid balance amount of Rs.13,059.50 to the complainant on account of pre & post hospitalization charges. The prayer of the complainant in the complaint is to make the payment balance mediclaim amount of Rs.43,340/- (at the time of discharge of complainant) + Rs.13,059.50 Ps. (hospitalization expenses) i.e. total amount of Rs.56,399.50 ps. alongwith intrest @ 18% p.a. from the date of due till the date of realization of the same jointly & severally.
8. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to pay to the complainant 50% of the balance amount i.e Rs.43,340/- (at the time of discharge of complainant) + Rs.13,059.50 Ps. (hospitalization expenses) i.e. total amount of Rs.56,399.50 ps alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith 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 order. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 05.08.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
