District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.003/2020.
Date of Institution:03.01.2020.
Date of Order:27.09.2022.
Vijender Kumar Garg aged about 51 years S/o Sh. Ram Narayan Garg, Resident of House No. 1173, Sector-37, Faridabad (Haryana).
…….Complainant……..
Versus
1. M/s. National Insurance Company Limited, Branch Office: 5-C/1 & 2, BP, Railway Road, NIT, Faridabad- 121001, Haryana through its Manager/principal Officer.
2. M/s. Park Mediclaim TPA Pvt. Ltd., 702, Vikrant Tower, Rajendra Place, New Delhi – 110 008 through its Director/Principal Officer.
3. M/s. Indraprastha Apollo Hospital, Sarita Vihar, Delhi – Mathura Road, New Delhi – 110 076 through its Director/Principal Officer.
…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: Sh. Narinder Singh Kang, counsel for the complainant.
Sh. Neeraj Kumar Gupta, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 24.01.2020.
Sh. Hem Chandra Gupta, Manager Legal on behalf of Opposite party No.3.
ORDER:
The facts in brief of the complaint are that Opposite party No.1 was the insurance company and opposite party No.2 was the TPA of opposite party No.1 and the complainant was regular insurance policy holder of the opposite parties from last so many years continuously. The present/current “National Parivar” policy bearing NO. 361100/501810000485 valid from 18.4.2018 to 17.4.2019 for himself, his wife Smt. Sneh Garg, sons- Subhanshu Garg & Deepanshu Garg issued by the opposite parties and the sum assured was Rs.15,00,000/- and for which the complainant had paid a sum of Rs.64,346/- as premium to opposite party No.1 and the previous policy was valid from 18.4.2017 ato 17.4.2018 and sum assured was Rs.15,00,000/- and before its , the complainant an dhis family members were insured vide policy No. 361100/48/16/8500001189 valid from 29.04.2016 to 28.04.2017 and sum assured was Rs.8,00,000/- and the complainant and his above said family members were covered.
The complainant suddenly suffered from breathlessness and immediately approached Sarvodaya Hospital, Sector-8, Faridabad on 25.12.2017, whereas the doctors checked and suggested the complainant for proper heart check up and prescribed the medicines and also done X-Ray on same day and after taking medicine, the complainant approached Indraprastha Apollo Hospitals, New Delhi for second opinion on 28.02.2018. Whereas , the doctors examined and checked through stipulated tests like ECHO on 01.03.2018 and angiography on 30.03.2018. The doctors prescribed the medicines and advised for follow up. On 05.05.2018, the complainant felt huge breathlessness and the family members took time to opposite party No.3, whereas the doctors managed the patient and Aortic Valve Replacement surgery was done and he was discharged on 16.05.2018. The hospital raised the bill bearing NO. DEL-1CR-81455 dated 16.05.2018 for Rs.8,83,556.43. However, the Hospital Administration/opposite party No.3 intimated the opposite parties regarding hospitalization of the complainant and requested for providing cashless facility and the opposite parties disbursed only Rs.3,30,000/- with a flimsy remark “No further grant since the maximum available sum insured limit + CB limit had exhausted” instead of 8,83,556.43 and hence, the complainant had to pay the remaining billing amounting to the hospital. . After discharge from the hospital, the complainant lodged his claim and submitted all the requisite documents as demanded by the opposite parties vide claim NO. NHICDR2/189202/121. The officials of the opposite parties assured the complainant that after some quarries, the claimed amount would be disbursed shortly. Despite of completing each and every formalities by the complainant, the opposite parties did not pay even a single panny to the complainant till date, whereas the complainant approached several times to the opposite parties for the same, but always the opposite parties avoided it on one pretext or the other and finally on the opposite party No.1 vide its letter reference No. 361100/MOD/2018 dated 17.07.2018 declined the claim of the complainant in an illegal manner.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 Rs.5,53,556/- alongwith interest @ 18% p.a. from the date of its due till realization of whole amount to the complainant..
b) pay Rs. 1,00,000/- 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 the complainant had no locus standi to file the present complaint. Earlier the complainant had filed vide complaint No. 497/20.11.2018 which was later on withdrawn on 29.11.2019 at the time of arguments because no balance had become due against opposite party No.1. he also admitted that the opposite party No.1 had already paid the sum insured amount to the complainant and the complainant was not liable for balance treatment amount. Now the complainant filed this present complaint with the same parties and same cause of action, hence the complaint of the complainant was liable to be dismissed. The complainant had no cause of action to file the present complaint. The opposite parties had rightly repudiated the claim of the complainant vide letter dated 10.07.2018 the maximum available limit of total applicable sum insured that Rs.3 lacs had been already exhausted during the settlement of hospitalization claim. Hence, this claim was not admissible.
3. Registered notice was sent to opposite party No.2 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 filed the tracking report in which the “Item Delivery Confirmed”. Therefore, opposite party No.2 was proceeded against exparte vide order dated 24.01.2020
4. Opposite party No.3 put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that the Hon’ble Forum did not had any jurisdiction to entertain the present complaint against the answering opposite party No.3 as no part of the cause of action against the answering opposite party had arisen within the jurisdiction of this Hon’ble Forum. The registered office of the answering opposite party was situated at Delhi Mathura Road, Sarita Vihar, New Delhi. The cause of action to file the present complaint had accrued within the jurisdiction of the hospital which was situated at Sarita Vihar, NewDelhi. Hence, the present District Forum did not had the jurisdiction to entertain the present complaint on territorial grounds. Opposite party No. 3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
7. In this case the complaint was filed by the complainant against opposite parties– National Insurance Co. Ltd. & Ors. with the prayer to: a) pay Rs.5,53,556/- alongwith interest @ 18% p.a. from the date of its due till realization of whole amount to the complainant.. b) pay Rs. 1,00,000/- 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 Vijender Kumar Garg, Ex.C1 – insurance policy valid from 29.04.2016 to 28.04.2017 for sum insured Rs.8,00,000/-, ex.C2 – insurance policy valid from 18.4.2017 to 17.4.2018, Ex.C-3 – insurance policy valid from 18.4.2018 to 17.4.2019,, Ex.C-4 & C5 – doctor prescription, Ex.C5/A – Cardiac Catheterisation report, Ex.C5/B – OP Cash Bill – Bill of supply,, Ex.C5/C – Duplicate bill, Ex.C6 – Discharge summary,, Ex.C7 – In patient bill dated 16.5.2018, Ex.C-8 – letter, Ex.C-9 – repudiation letter dated 17.07.2018,, Ex.C-10 – identity card,.
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 Shri Rameshwar Dass, Administrative Officer, National Insurance Co. Ltd., Faridabad.
Evidence on behalf of opposite party No.3 not filed after availing several opportunities. No ground for further adjournment had been made out. Hence, evidence on behalf of opposite party No.3 was hereby closed by court order. Accordingly, evidence on behalf of opposite party NO.3 had been closed vide order dated 28.09.2021.
8. The complainant has filed the complaint with the prayer to pay Rs.5,53,556/- alongwith interest @ 18% p.a. from the date of its due till realization of whole amount to the complainant.
9. It is evident from Ex. C3 the complainant obtained “National Parivar Mediclaim Plus” policy bearing NO. 361100/501810000485 valid from 18.4.2018
to 17.4.2019 for himself, his wife Smt. Sneh Garg, sons- Subhanshu Garg & Deepanshu Garg issued by the opposite parties and the sum assured was Rs.15,00,000/- and for which the complainant had paid a sum of Rs.64,346/- as premium to opposite party No.1 and the previous policy was valid from 18.4.2017 to 17.4.2018 and sum assured was Rs.15,00,000/- vide Ex.C2 and before its , the complainant and his family members were insured vide policy No. 361100/48/16/8500001189 valid from 29.04.2016 to 28.04.2017 and sum assured was Rs.8,00,000/- and the complainant and his above said family members were covered vide Ex.C1. Opposite party repudiate the claim of the complainant vide letter dated 17.07.2018 vide Ex.C9 on the ground that “Maximum available limit of sum insured had already exhausted during settlement of hospitalization claim.” Counsel for the complainant has argued that as per National Parivar Mediclaim Plus Policy in clause 2.3.1 Enhancement of sum insured stating that “i) Sum insured can be enhanced only at the time of renewal, to the next slab.
ii) For the incremental portion of the sum insured, the waiting periods and conditions as mentioned in exclusion 4.1., 4.2. 4.3 shall apply. Coverage on enhanced sum insured shall be available after the completion of waiting periods.
iii) Change of plan by enhancement of sum insured is allowed only at the time of renewal, subject to four years of continuous coverage with the company and any insured person is not suffering from any disease.
iv. For change of plan, medical reports as per section 2.8 iii are required to be submitted with respect to each insured person aged forty years and above.
On the other hand, counsel for opposite party No.1 argued that as per clause 4.3 of National Parivar Mediclaim policy, First 30 days waiting period (Excl.03) stating in column( b) “This exclusion shall not ,however, apply if the insured person has continuous coverage for more than twelve 12 months. Counsel for opposite party No.1 further argued that as per clause 4.1 of the National Parivar Mediclaim policy i.e Pre existing disease (Excl 01) in c) column stated that “if the insured person in continuously covered without any break as defined under the portability norms of the extant IRDA (Health Insurance) Regulations then waiting period for the same would be reduced to the extent of prior coverage.” This is the reason that opposite party No.1 has rightly repudiated the claim of the complainant vide letter dated 17.07.2018 “the maximum available limit of total applicable sum insured limit Rs.3 lacs had already exhausted during the settlement of hospitalization claim. Hence, the claim is not admissible.”
10. During the course of arguments, Shri Narender Singh Kang, counsel for the complainant has made a statement that “I tender policy NO. 361100/48/15/8500001597 of the year 29.4.2015 to 28.4.2016 as Ex.C1/A.”
11. After going through the evidence led by the parties, the Commission is of the opinion that the complainant has got the policy since 2015. As per inpatient bill dated 16.5.2018 vide Ex. C-7 the opposite parties disbursed only Rs.3,30,000/- instead of Rs.8,83,556.43. As per repudiation letter dated 17.07.2018 vide Ex.C9 the claim of the complainant was repudiated on the ground “the maximum available limit of total applicable sum insured limit Rs.3 lacs had already exhausted during the settlement of hospitalization claim. Hence, the claim is not admissible.. The Commission is also of the opinion that after 48 months of the policy it was the duty of opposite party to verify everything from the complainant . Details of the policies are as under:
1. Policy bearing No.361100/48/15/850000/597 valid from 29.04.2015 to 28.04.2016 for Rs.3,00,000/-.
2. policy bearing No.361100501710001159 valid from 18.04.2017 to 17.04.2019 for Rs.15,00,000/-.
3. policy bearing No. 361100/501810000485 valid from 18.4.2018 to 17.4.2019 was Rs.15,00,000/-
4. policy No. 361100/48/16/8500001189 valid from 29.04.2016 to 28.04.2017 and sum assured was Rs.8,00,000/-
12. Keeping in view of the above, the Commission is of the opinion that deficiency in service on the part of the opposite party has been proved. Resultantly, the complaint is allowed.
13. Opposite parties Nos.1 to 3 are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay
Rs.3300/- as compensation on account of mental tension, agony and harassment alongwith Rs.3300/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 27.09.2022 (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.
