District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.59/2021.
Date of Institution: 02.02.2021
Date of Order: 09.09.2022.
Chander Prakash Goel, S/o Amichand Goel, R/o H.No. 80, Sector-18A, Faridabad.
…….Complainant……..
Versus
1. M/s. National Insurance Company Ltd., through its Manager, Division No. Xii, 3rd floor, 6/90, Padam Singh road, Karol Bagh, New Delhi – 110 005.
2. M/s. National Insurance Company Ltd., Regd. Office at; 3 Middleton Street, Kolkata – 700 071.
3. Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, New Delhi.
…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. Kranti Singh, counsel for the complainant.
Sh. Rakesh dabaas, counsel for opposite parties Nos.1 & 2.
Opposite party No.3 ex-parte vide order dated 19.10.2021.
ORDER:
The facts in brief of the complaint are that the complainant purchased a health Insurance Policy for uncertain health risks and much needed financial backup at the times of medical emergencies from the opposite party bearing policy No. 351200501910001339. The complainant was admitted in a emergency situation in Inderprastha Apollo hospital on 04.09.2020 with a severe pain the left shoulder and neck, caused by falling on 31.08.2020. The complainant before going to hospital tied well to overcome from the injury by taking oral pain killers for three days, but the efforts were futile and pain keeps on increasing. The complainant was treated in the Apollo Hospital by Dr. Harsh Bhargava and after treatment he was discharged with a bill of Rs.83,856/-. The whole country was facing a pandemic situation at that time, and the complainant was severely ill due to unbearable pain in the shoulder and neck, there was no other option left other admission in the emergency, The complainant had applied for claim , by filling claim form for cashless treatment, as per the terms of insurance policy and submitted the same with concerned department. The opposite party had rejected the legitimate request of the complainant, though a letter addressing the complainant dated 13.11.2020 with a illegitimate baseless reason stating “We are in receipt of recommendation from TPA M/s. Safewat Insurance TPA Pvt. Ltd. Wherein he was admitted in Indraprastha Apollo Hospital from 04.09.2020 to 06.09.2020 with the diagnosis of Soft Tissue Injury Left Shoulder and under Intraarticular Injection Left Shoulder. It was not payable if hospitalization was done only for the administration of Intra Articular Injection. On the basis of the above his lain was not admissible if hospitalization was done only for administration of this therapy this procedure was not listed under the Day Care Procedure. As per clause 4.22 stay in hospital which was not medically necessary was not payable”. Hence, competent authority had decided and regret to inform him that claim was hereby repudiated and closed as “No Claim”. The complainant severally called the opposite party via telephone and requested for this claim settlement, but the results were futile at the end. The complainant had sent several mails requesting them to return the original documents, but the opposite party had deliberately with fraudulent intention ignored the requests. 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 hospital bill of Rs.83,856/- and Rs.1343/- for medicines alongwith the pendent lite and future interest @ 24% p.a. against the opposite parties and in favour of the complainant.
b) pay Rs. 3,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 20,000 /-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, as a matter of record, the complainant was treated/hospitalized in Apollo Indraprastha Hospital w.e.f 04.09.2020 to 06.09.2020 for the administration of Intra Articular Injection for the treatment of soft tissue injury left shoulder but the expenses as Rs.83,866/- incurred thereon were not payable in view of exclusion clause 4.22 of the insurance policy so issued in this regard. The complainant neither had any cause of action nor locus standi in lodging of the present complaint before this Hon’ble Commission, reason being, as a matter or record, the complainant was treated/hospitalized in Apollo Indraprastha Hospital w.e.04.09.2020 t o 06.09.2020 for the administration of Intra Articular Injection for the treatment of soft tissue injury left shoulder but the expenses as Rs.83,866/- incurred thereon were not payable in view of exclusion clause 4.22 of insurance policy os issued in this regard. As such, the opposite parties had treated the subject claim as repudiated by closing the file in terms of respective “ letter of intimation” dated 13.11.2020, which decision could not be termed unconscionable at all. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Case called several times since morning but none appeared on behalf of opposite party No.3 despite availing several effective opportunities. Hence, opposite party No.3 was hereby proceeded against ex-parte vide order dated 15.12.2021.
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) pay hospital bill of Rs.83,856/- and Rs.1343/- for medicines alongwith the pendent lite and future interest @ 24% p.a. against the opposite parties and in favour of the complainant. b) pay Rs. 3,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 20,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Shri Chander Praksh Goel S/o Ami Chand Goel, Ex.C1 – insurance policy from 11.01.2020 to 10.01.2021, Ex.C-2 (colly)– Discharge summary, Ex.C-3 – repudiation letter dated 13.11.2020.
On the other hand counsel for the opposite parties Nos.1 & 2 strongly
agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Shri Rameshwar Dass, administrative Officer, (Legal) M/s. National Insurance co. Ltd., Divsional Officer-1, 5C/1-2, Neelam Chowk, NIT, Faridabad, Ex.R-1 – insurance policy valid from 11.01.2020 to 10.01.2021, Ex.R-2 – Claim form, Ex.R-3 – Discharge summary, Ex,R-4 - Final Interim Bill, Ex.R-5 - Recommendation to insurer dated 31.10.2020, Ex.R-6 – letter dated 13.11.2020.
7. It is evident form Ex.C-1,the complainant purchased a health Insurance Policy for uncertain health risks and much needed financial backup at the times of medical emergencies from the opposite party bearing policy No. 351200501910001339. The complainant was admitted in a emergency situation in Inderprastha Apollo hospital on 04.09.2020 with a severe pain the left shoulder and neck, caused by falling on 31.08.2020. The complainant before going to hospital tried well to overcome from the injury by taking oral pain killers for three days, but the efforts were futile and pain keeps on increasing. The complainant was treated in the Apollo Hospital by Dr. Harsh Bhargava and after treatment he was discharged with a bill of Rs.83,856/- (vide Annexure C2 (colly) in which page No.37 that Interven Pain Management Proceed Injection for Nerve 0 Entrapment /Post OP/Trauma Keloid/Scar Tissue/Intravenous XYLOCARD Infusion Pewr Session/Trigger Point Injection – Single Group has been mentioned on 05.09.2020 for Rs.4500/-. The claim of the complainant has been repudiated vide letter dated 13.11.2020 (Ex.C3) on the ground that “We are in receipt of recommendation from TPA M/s. Safewat Insurance TPA Pvt. Ltd. Wherein he was admitted in Indraprastha Apollo Hospital from 04.09.2020 to 06.09.2020 with the diagnosis of Soft Tissue Injury Left Shoulder and under Intraarticular Injection Left Shoulder. It was not payable if hospitalization was done only for the administration of Intra Articular Injection. On the basis of the above his lain was not admissible if hospitalization was done only for administration of this therapy this procedure was not listed under the Day Care Procedure. As per clause 4.22 stay in hospital which was not medically necessary was not payable”. Hence, competent authority had decided and regret to inform him that claim was hereby repudiated and closed as “No Claim”.
8. After going through the evidence led by the parties, the Commission is of the opinion that the patient cannot forced not to admit when the doctor advised him to take admission. The patient has to follow the instructions of the doctors. In the interest of justice, the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the T&C of the policy 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.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- 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: 09.09.2022 (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.
