District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.505/2019.

 Date of Institution: 18.10.2019.

Date of Order: 16.09.2022.

Jatin Gupta aged about 29 years son of Shri Devender Kumar Gupta R/o House No. 5/157, Mohalla Bassa Para, Old Faridabad, District Faridabad, Haryana.

                                                                   …….Complainant……..

                                                Versus

1.                M/s. National Insurance Company Limited, Divisional Office: 5-C/1 -2 BP, Railway Road, Neelam Chowk, NIT Faridabad- 121001 through its Divisional manager/principal Officer/Authorized Signatory.

2.                M/s. Safeway Insurance TPA Pvt. Ltd., House No. 815, Vishwas Sadan, District Center, Janakpuri, New Delhi – 110 058 through its C.E.O./Authorized Signatory/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.  Utpal Chaudhary,  counsel for the complainant.

                             Sh.  Sanjeev Bansal, counsel for opposite party No.1.

                             Opposite party No.2 ex-parte vide order dated 20.01.2020.

ORDER:  

             The facts in brief of the complaint are that the complainant was a regular mediclaim policy holder “Parivar Mediclaim Policy” since 2015 for himself, his wife and child.  The current Mediclaim policy No. was 361100/50/19/10002204 valid from 10.05.2019 to 09.05.2020 and sum insured was Rs.3,00,000/- .  After taking the policy form the opposite party, the complainant did not take any medical benefits under the said policy.  When the complainant suffered from pain in bilateral lower limb, upper limb and pain in abdomen and approached Sarvodaya Hospital & Research Centre, YMCA Road, Sector-8, Faridabad, where doctors of the said hospital examined the patient/complainant and advised for admission and acceding the advice of the doctor, the complainant got admitted in the said hospital vide IPD No. 177463 on 03.06.2019 and the doctors of the said hospital sent the information to the opposite party for providing cashless facility, but same was  declined by the opposite party.  The doctors of the said hospital managed and treated the complainant and discharged in symptomatically better accepting orally well on 08.06.2019 and charged Rs.76,805/- vide bill  No.1/19-20/S8006670 dated 08.06.2019 and the complainant had to pay the entire treatment amount of Rs.76,805/- to the hospital.  However, the complainant also spent a sum of Rs.20,000/- after discharging from the hospital on account of purchase of medicines and OPD.  The complainant submitted all required documents including discharges summaries and bills as demanded by the opposite parties form the complainant and lodged his claim with the opposite party vide reference ID No. N1-3-46218 and also answered the queries raised by the opposite parties and the

complainant lodge his claim.  The complainant contacted the concerned officers/officials of the office of the opposite parties and requested several times telephonically, as well as by personnel visits to disburse the claimed amount, but the opposite parties always avoided the matter one  pretext or the other and at last the opposite parties repudiated the claim of the complainant vide its letter dated 09.08.2019 on filmsy ground that “Parivar Medical Policy does not cover the expenses incurred primarily for diagnostic and evaluation purpose, hence claim not admissible. 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  the claimed amount of rs.96,805/-  alongwith interest @ 18% p.a. from the date of its due till actual payment.

 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 neither any cause of action nor locus standi to file the present complainant.  The claim of the complainant was not tenable as per clause 4.4.13 of the terms and conditions of the policy of insurance and the claim of the complainant had been duly considered and after observation of the documents, the opposite party No.2 given opinion that ”The conservative treatment involves just Inj. Pantodac, Magnex forte as per the presenting sheet further indicating that the initial intention to get hospitalized was to know the casuse for the paresthesia.  On subsequent days too major emphasis was given on  the lab

 investigations as suggested by the IPD as the IV treatment further invoices Inj. Optineuron (combinations of Vitamin B).  Moreover the IPD suggested patient to be hemodynamically stable on 05.06.2019 at the point of which the patient could have been discharged , but still this did not take place and the hospitalization was further continued and the investigations were a major part of it suggestive that the investigation of the cause of paresthesia was the reason behind the hospitalization.  The major charges incurred during hospital’s stay pertain to investigation only.  Out of build amount of Rs.86,805/-, Rs.56,000/- towards investigations).  Majorly, nebulization was done which did not require hospitalization on standalone basis.  The condition was not that grave which requires 5-6 days of hospitalization.  Hence, the claim was not payable as per clause 4.13 (hospitalization for the purpose of diagnosis and evaluation, irrelevant investigations charges expenses incurred at hospital primarily for diagnostic, x-ray or laboratory examinations or), hence the claim of the complainant was rightly repudiated by the company of the answering opposite party vide letter dated 09.08.2019.   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 received back served alongwith tracking details. Case called several times since morning but none appeared on behalf of opposite party No.2.  Therefore opposite party No.2 was proceeded against ex-parte vide order dated 20.01.2020.

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 Company Limited with the prayer to: a)  pay  the claimed amount of Rs.96,805/-  alongwith interest @ 18% p.a. from the date of its due till actual payment.  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 Shri Jatin Gupta, Ex.C-1 – insurance policy for the period from  06.05.2016 to 05.05.2017 Ex.C-2 (OSR) – insurance policy valid from  06.05.2018 to 05.05.2019, Ex.C3(OSR) – insurance policy valid from 10.05.2019 to 0.05.2020, Ex.C-4 (OR) – Discharge summary,, Ex.C5 (OSR) – Final bill, Ex.C-6 -  medicine bill, Ex.C-7 – bill of supply, Ex.C-8 (OSR) – prescription,, Ex.C-9 – invoice dated 08.06.2019,, Ex.C-10(OSR) – prescription,, Ex.C-11 (OSR)  - Invoice, Ex.C-12(OSR) – prescription, Ex.C-13(OSR) – Cash receipt, Ex.C-14 (OSR) – invoice,, Ex.C-15 – Adhaar card, Ex.C-16 – repudiation letter dated 09.08.2019.

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.RA – affidavit of Shri Rameshwar Dass, National Insurance Company ltd., Faridabad.

7.                It is evident from insurance policy vide Ex.C-3 that the complainant obtained Mediclaim policy No. was 361100/50/19/10002204 valid from 10.05.2019 to 09.05.2020 and sum insured was Rs.3,00,000/-.  When the complainant suffered from pain in bilateral lower limb, upper limb and pain in abdomen and approached Sarvodaya Hospital & Research Centre, YMCA Road, Sector-8, Faridabad, where doctors of the said hospital examined the patient/complainant and advised for admission and acceding the advice of the

doctor, the complainant got admitted in the said hospital vide IPD No. 177463 on 03.06.2019 and the doctors of the said hospital sent the information to the opposite party for providing cashless facility, but same was  declined by the opposite party.  The doctors of the said hospital managed and treated the complainant and discharged in symptomatically better accepting orally well on 08.06.2019 and charged Rs.76,805/- vide bill  No.1/19-20/S8006670 dated 08.06.2019  vide Ex.C5 (OSR). As per  repudiation letter dated 09.08.2019 vide Ex.C-16, opposite party has repudiated the claim of the complainant under condition No. 4.13 on the ground  that “Parivar Medical Policy does not cover the expenses incurred primarily for diagnostic and evaluation purpose, hence claim not admissible.”

8.                After going through the evidence led by the parties,  the Commission is of the opinion that the claim of the complainant has been repudiated under condition No.4.13 on the ground that “Parivar Medical Policy does not cover the expenses incurred primarily for diagnostic and evaluation purpose, hence claim not admissible.” But when the doctor advised  the patient to admit in the hospital, the patient is layman person he has to take the admission in the hospital on the advice of the doctor. He cannot deny and some of the  investigations are not possible  without the admission of the hospital because doctor need the patient for the observation. 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: 16.09.2022                                  (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.