BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.22 of 2019
Date of Instt. 21.01.2019
Date of Decision: 05.08.2019
Sanjay Kainth aged about 44 years S/o Sh. Tarlok Chand R/o 438, Shastri Nagar, Jalandhar Mob.9814088556.
..........Complainant
Versus
1. M/s New India Assurance Co. Limited, 8th Floor, New India Centre, Cooperage Road, Mumbai-400001 through its General Manager/Officer In-charge/MD.
2. M/s MDINDIA Health Insurance TPA Private Limited, Head Office S. No.46/1-E Space, A-2, Building 4th Floor, Pune Nagar Road, Vadgaonsheri-Pune-411014. E-mail:info@mdiindia.com through its General Manager/Officer Incharge/MD.
….….. Opposite Parties
3. Life Insurance Corporation of India, Unit-3, Pucca Bagh, Jalandhar through its Branch Manager/Officer Incharge.
….…..Performa Opposite Party
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Vikas Sharma, Adv Counsel for the Complainant.
OPs No.1 & 2 exparte.
OP No.3 not summoned.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainant, wherein alleged that he is working as Development Officer in Life Insurance Corporation of India i.e. OP No.3 since 1996 and he is permanent employee of OP No.3. OP No.1 is also known as General Insurance Company, whereas OP No.2 is acting as mediator between the OP No.1 and OP No.3 and its employees for the settlement of the medical insurance claims of the ensured employees of OP No.3.
2. That being the permanent employee of the OP No.3, the OP No.3 had purchased a group medical health insurance policy for all its employees bearing Master Policy No.120700/34/17/04/00000003 known as “Tailor made Group Medi Claim Cashless Policy” from OP No.1, vide which all the employees of LIC of India i.e. OP No.3 has been insured medically from the date of their appointment. The complainant being permanent employee of OP No.3 has also become the beneficiary and insured under the said medical policy of the OPs to the tune of Rs.10,00,000/-. The said policy is still in force and the same is being got renewed annually, by the OP No.3 from OP No.1. Earlier in the year 2017, the total sum assured under the said policy was Rs.10,00,000/- only and the same was enhanced from Rs.10,00,000/- to Rs.20,00,000/- in the year 2018.
3. That unfortunately on 16.12.2017, during the insured period, the complainant felt severe pain in his abdomen and he was immediately taken to M. K. Hospital, Jalandhar, where he was medically examined by Dr. M. K. Arora, M. D. and he remained admitted in the said hospital from 16.12.2017 to 23.12.2017. The complainant was kept under medication for about one week by Dr. M. K. Arora, but since no major improvement was seen in the health of the complainant, as such the complainant was referred to D. M. C. Hospital, Ludhiana by Dr. M. K. Arora and at that time, a bill to the tune of Rs.65,075/- was generated by hospital, but since the said hospital was not empanelled hospital of the OP No.1 for cashless facility, as such, the entire bill of Rs.65,075/- was paid by the complainant from his own pocket with the impression that the same would be duly reimbursed by the insurance company i.e. OP No.1. On the same day i.e. 23.12.2017, the complainant was immediately got admitted in D. M. C. Hospital, Ludhiana, where he was diagnosed that he has been suffering from GB Calculi, Type-2 DM, Peripancreatic collection-Moderately severe and acute Pancreatitis as such, the complainant remained hospitalized for about 19 days w.e.f. 23.12.2017 to 11.01.2018 for his treatment and was discharged on 11.01.2018 when the condition of the complainant became stable. Even at the time of bill of Rs.2,52,037/- was generated by the D. M. C. Hospital, Ludhiana, but since the D. M. C. Hospital, Ludhiana was an empanelled hospital of OP No.1 hence the cashless facility was available to the complainant, as such, no amount was to be payable by the complainant towards his medical treatment expenses, as the same was to be paid by the OPs No.1 and 2 directly to the D. M. C. Hospital, Ludhiana. Copy of the bills and discharge card are attached.
4. That after few days of his discharge i.e. on 20.01.2018 the complainant suffered from problem of regular vomiting and non digestion of food as such, he was again admitted to D. M. C. Hospital, Ludhiana on 20.01.2018 and was diagnosed that he has been suffering from Acute Emphysematious Severe Necrotising Pancreatitis-Bilary-Clonic and Small Ball Fistula with history-HDBT 2 Days, when patient started C/o Pain Abdomen, acute in onset, severe in intensity, Radiating, not relieved with Medication and this time, the complainant remained hospitalized for about 48-49 days w.e.f. 20.01.2018 to 12.03.2018 and during the said period, he has to undergo for two operations of pancreatitis and was thus operated twice by the doctors DMC Hospital on 06.02.2018 and 11.02.2018 and was discharged on 12.03.2018. During the said hospitalization, the complainant requested to DMC Hospital to give him cashless treatment as being provided by him during his earlier treatment, but the hospital authorities told to the complainant that the OPs No.1 and 2 has refused to provide cashless facility to the complainant, vide their letter dated 10.02.2018. The complainant was also disclosed that even the earlier cashless bill of Rs.2,52,037/- of the complainant has been refused to be paid by the OPs No.1 and 2 and as such, the complainant has to pay the entire treatment expenses from his own pocket. The complainant immediately talked to the OPs No.1 and 2 in this regard, but they told to the complainant that as present they had not denied the claim of the complainant and they have only denied cashless facility to the complainant, however, the complainant can get reimbursement of his claim. Thus, the complainant was compelled to pay the entire hospital treatment charges including medicine and lab. Hence the complainant was bound to pay the entire amount of Rs.9,95,737/- to D. M. C. Hospital, Ludhiana from his own pocket before his discharge from the hospital.
5. That after discharge from D. M. C. Hospital, Ludhiana, the complainant applied for reimbursement of his claims of Rs.65,075/- and Rs.9,95,737/- with the OPs No.1 and 2 through proper channel, vide two claim ID No.MD13949920 and ID No.MD13842240 and after receiving all the documents from the complainant through proper channel, the OPs assured for the early settlement of the case of the complainant. After submission of the entire documents, the complainant number of times approached to the OPs No.1 and 2 either personally or through emails, but nothing was heard from the side of the OPs inspite of repeated requests and reminders of the complainant and they continue to dilly delay the matter and proclaimed that the complainant will be informed through his own office i.e. OP No.3, but nothing was heard from OP No.3 also. Thus, the complainant has been running from pillar to post for the settlement of his claim. In the meantime, the complainant remained continue under the treatment and medication of the doctors of D. M. C. Hospital, Ludhiana and during his treatment, the doctors of D. M. C. Hospital, Ludhiana conducting the MRCP Test of the complainant on 06.08.2018 and after conducting the test, the doctors advised and disclosed to the complainant that he has to undergo for an operation of removal of his Gallbladder Stones after medication of about 5-6 months and also started medication of the complainant in this regard. As per the advice of doctors, the complainant after taking medicinces for about six months again visited to D. M. C. Hospital, Ludhiana on 27.08.2018, for the removal of Status Diversion Loop Ileostomy. Even at that time, the doctors of DMC hospital diagnosed that the complainant is suffering from “F/U/C/ Gall Stones Induced Acute Necrotizing Pancreatitis With Status Diversion Loop Ileostomy” and advised the complainant to undergo for operation of his Gallbladder and as such, the operation of the gallbladder/gallstone of the complainant was also conducted and for that purpose, the complainant was again hospitalized at D. M. C. Hospital, Ludhiana from 27.08.2018 to 03.09.2018. During that period, the complainant was operated by the doctors of D. M. C. Hospital, Ludhiana. This time again no cashless facility was provided to the complainant by the OPs No.1 and 2 and again the complainant was compelled to pay a sum of Rs.1,14,313/- as expenses for his treatment. As such, the complainant, inspite of having cashless policy, had already incurred a total amount of Rs.65,000/- + Rs.9,95,737/- + Rs.1,14,313/-= Rs.11,75,250/- from his own pocket for his entire treatment. After discharge from the D. M. C. Hospital, Ludhiana, the complainant again applied for reimbursement of his third claim to OPs No.1 and 2 through respondent No.3, vide Claim ID No.MD14429241. The complainant even thereafter number of times approached to the OPs No.1 and 2 through various emails and requested for early settlement of his claims as the same are required to be settled within 30 days from the date of submission of their claim forms, but the OPs No.1 and 2 put it on deaf ears and neither bothered to settle the claim of the complainant nor, they provide any intimation to the complainant about the status of his claims though the period of more than 1 year has already been lapsed from the date of submission of first claim nor any suitable reply has been given by the OPs despite repeated requests and reminder of complainant. Ultimately, on 27.12.2018, the complainant thereafter managed to succeed to approach to the OPs No.1 and 2 through their customer care, who disclosed the complainant that the OP No.2 has already recommended to OP No.1 for the repudiation of all the claims of the complainant and also send one copy of the said recommendation letter, but strangely enough the said letter was not bearing any date of repudiation of his claims. It is only then i.e. on 27.12.2018 the complainant came to know that his claims have been recommended for repudiation by the OPs and then on 15.01.2019, the complainant immediately approached to the local divisional office of the OP No.3 for getting the copies of the said recommendation letters of repudiation and on his demand, the complainant was supplied three unsigned letters bearing dated 24.03.2018, 26.07.2018 and 30.11.2018 alongwith unsigned copies of repudiation letter of OP No.1 and from the perusal of said repudiation letters, the complainant came to know about the status of his claims for the first time only on 15.01.2019. Perusal of the said repudiation letters also shows that the OPs have illegally, malafidely and arbitrarily repudiated the claims of the complainant without any rhyme and reasons with wrong allegations that the complainant is a chronic alcoholic and he has suffered pancreatitis due to chronic alcohol and has wrongly repudiated the claim of the complainant. Whereas the true facts are that neither the complainant is a chronic alcoholic nor the problem of complainant has occurred due to consumption of alcohol nor there is any history of any problem from alcohol nor there is any history of any problem from alcohol to the complainant from the date of policy i.e. since 1996, rather to the knowledge of the OPs, the problem of pancreatitis has occurred to the complainant only due to the reason of Cholelithiasis in GB (stones in gallbladder) and was not a result of consumption of alcohol. Even as per diagnose of the doctors of D. M. C. Hospital, Ludhiana held on 03.09.2018. It is quite apparently clear from the history of discharge card of the complainant that the complainant suffered the problem of Acute Necrotizing Pancreatitis With Status Diversion Loop Ileostomy due to gallstone not due to alcohol as alleged by the OPs while repudiating the claim of the complainant. Moreover, as per report of the doctors of D. M. C. Hospital, Ludhiana, the operation conducted on the person of complainant was also due to the gallstone.
6. There is a gross negligence on the part of the OPs for repudiating the claims of the complainant and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the medical treatment bill of Rs.11,75,250/- to the complainant with interest @ 24% per annum from the date of payment till the date of refund plus a compensation of Rs.4,00,000/- and litigation expenses of Rs.50,000/- and for economic loss suffered by the complainant of Rs.50,000/-.
7. Notice of the complaint was given to the OPs No.1 and 2, who despite service did not bother to appear and ultimately, OPs No.1 and 2 were proceeded against exparte, whereas OP No.3 is a Performa OP and thus, he was not summoned in this complaint.
8. In order to prove his case, the complainant brought on the file number of documents i.e. his own affidavit Ex.CA and certain other documents Ex.C-1 to Ex.C-33.
9. We have heard the learned counsel for the complainant and also gone through the case file very minutely.
10. In order to establish his case, the complainant has brought on the file numerous documents, where-from we can make assure that the complainant is a permanent employee of OP No.3/Life Insurance Corporation of India and admittedly, the Life Insurance Corporation of India got a group medical insurance master policy for different zone and the policy in question was obtained by the OP No.3 i.e. Northern Zone having policy No.12070034180400000003 and copy of the said letter is available on the file Ex.C-2 and complainant being the permanent employee of OP No.3 become beneficiary and as such, he is also insured under the aforesaid policy and further, in order to prove that the complainant remained admitted 3 or 4 times in D. M. C. Hospital, Ludhiana, there are numerous documents placed on the file including bills, whereby the complainant make the payment of the expenses incurred respectively, on each occasion and further the complainant also placed on the file certain documents showing that the complainant submitted a claim, but neither the cashless facility was provided to the complainant nor a reimbursement of the incurred medical claim bill was passed by the OP for the best known reason, rather the same was repudiated without any solid substances and ground. The repudiation letters are available on the file Ex.C-25 to Ex.C-27. The main allegation raised in the said repudiation letter is only that the alleged disease was occurred to the complainant due to alcohol, but simply making allegation in the repudiation letter is not sufficient until the same is not supported by any medical evidence, admittedly, in this case, the OP did not come present to contest this complaint and in order to give strength to the averments made in the repudiation letter, the OP has to appear and bring on the file certain medical evidence, where-from this Forum can ascertain that the alleged disease was occurred to the complainant due to consumption of alcohol, but in the absence of any documentary evidence, it is very difficult to accept the version, whatsoever taken by the OP in the repudiation letter. Moreover, the evidence of the complainant remained un-rebutted and un-challenged, which cannot be discarded because the same is supported by the complainant by way of affidavit. So, with these observations, we came to conclusion that the complainant is entitled for the relief claimed.
11. In the light of above detailed discussion, complaint of the complainant is partly accepted and OPs No.1 and 2 are directed to pay/reimburse the medical expenses incurred during the admission in the hospital on different occasions, to the tune of Rs.11,75,250/- to the complainant with interest @ 12% per annum from the date of filing complaint i.e. 21.01.2019, till its realization and further, OPs No.1 and 2 are directed to pay compensation of Rs.50,000/- for causing mental tension and harassment to the complainant and further OPs No.1 and 2 are also directed to pay litigation expenses of Rs.10,000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
05.08.2019 Member President
