Chandigarh

DF-II

CC/233/2013

Mahi Ram Siag - Complainant(s)

Versus

M/s Oriental Insurance Company Ltd. - Opp.Party(s)

Mr. B.S.Sudan, Adv.

28 Dec 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	233 of 2013
Date  of  Institution	:	27.05.2013
Date   of   Decision	:	28.12.2015

 

 

 

 

 

Mahi Ram Siag s/o Sh.Shiv Raj Siag, resident of Siag Fruit Farm Abohar C/o Chamber No.91, New Court Complex Abohar.

 

             …..Complainant

Versus

 

1]  M/s Oriental Insurance Company Ltd., A-25/27, Asaf Ali Road, New Delhi 110002

 

Regional office:- Surindra Building, S.C.O. 109-110-111, Sector 17-D, Chandigarh.

 

2]  MEDIASSIST – Third Party Administrator – SCO 61, 2^nd Floor, Phase-7, SAS Nagar 160062.

 

3]  Punjab National Bank, Regional Office: SCO No.133-135, Sector 17-C, Chandigarh.

 

    Branch Office: Circular Road, Abohar.

 

4]  OMNI Hospital, SCO No.343-44-45, Sector 34-A, Chandigarh.

 

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      :     Sh.B.S.Sudan, Advocate

 

For Opposite Party(s)   :     Sh.Satpal Dhamija, Adv. for OP-1.

OPs No.2, 3 & 4 exparte.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant availed Mediclaim Insurance Policy bearing  No.233203/48/2011/398 (Ann.C-1) from Opposite Party No.1 through Opposite Parties No.2 & 3, which was valid from 23.11.2010 to 22.11.2011 (Ann.C-1).  It is averred that under the said Mediclaim policy, the complainant was entitled for cashless services at the enlisted hospitals and reimbursement of pre/post hospitalization.  It is stated that on 11.4.2011 for Transmetatarsal amputation 3^rd toe GA/SA celluties, Osteomyelitis, the complainant was admitted in Opposite Party No.4 Hospital and submitted request for cashless hospitalization on 12.4.2011, which was not extended on the pretext to get the reimbursement from Opposite Party No.1. That the complainant got the indoor surgical amputation of 3^rd toe of Right foot on 12.4.2011 to avoid any further complications and incurred expenses to the tune of Rs.65,350/- (Ann.C-2 Colly.). Thereafter, the complainant lodged his claim with Opposite Party Insurance Company for reimbursement. It is asserted that the complainant as per letter dated 11.11.2011 (Ann.C-3) received from Opposite Party No.2 (TPA) seeking some information from the complainant, duly provided the same to Opposite Party on 25.11.2011. It is pleaded that despite completing all the formalities, the status of the medical reimbursement claim till date is pending and the fate of the same has not been intimated to the complainant.  Alleging the said act of the OPs as gross deficiency in service and their indulgence into unfair trade practice, hence this complaint has been filed.

 

2]       The Opposite Party No.1 Insurance Company has filed the reply and admitted the issuance of insurance; treatment taken by the complainant during policy period and submission of claim for reimbursement of medical expenses. It is submitted that the complainant got indoor treatment for surgical amputation of 3^rd toe of Right foot on 12.4.2011 at Opposite Party No.4 Hospital in order to avoid further complication but submitted the bills only on 19.10.2011 i.e. after a gap of more than six months, which is a clear cut violations of the terms & conditions of the policy.  It is submitted that the claim lodged by the complainant was forwarded to Opposite Party No.2, who vide letter dated 11.11.2011 required some information from the complainant, which the complainant alleged to have furnished on 25.11.2011, but the same has not been received by Opposite Party No.2. It is further submitted that in the absence of required information, the claim of the complainant could not be decided as the same is vital for settlement of the claim of the complainant. It is pleaded that the present complaint is liable to be dismissed being pre-mature compliant as the claim lodged by the complainant could not have been decided by the competent authority for want of required documents. Further submitted that the bills produced by the complainant are beyond the period of hospitalization and the prescription and consultations cannot be taken into consideration at all.  It is also pleaded that since no decision has been conveyed by Opposite Party No.2 to Opposite Party No.1 regarding the status of claim of the complainant, in the absence of required information, thus the present compliant is not maintainable. Rest of the allegations have been denied with a prayer to dismiss the complaint.

 

         Opposite Party No.2 & 4 did not turn up despite service of notice, hence they were proceeded exparte vide order dated 17.7.2013 and 11.9.2013 respectively. 

         Further, the Opposite Party No.3 initially put in appearance through Sh.Mahesh Sharma, Sr.Manager, Authorised Representative and filed reply, but later on absented, hence it was proceeded exparte vide order dated 24.9.2013.  Thereafter, Sh.H.S.Bhatia, Advocate appeared for Opposite Party No.3, but he too did not turn up on 21.12.2015, when the case was fixed for arguments, hence we proceed to dispose of this Complaint on merits under Rule 4(8) of the Chandigarh Consumer Protection Rules, 1987 read with Section 13 (2) of the Consumer Protection Act, 1986 (as amended upto date) even in the absence of Opposite Party No.3.

          

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the parties and have also perused the record as well as written arguments.

 

5]       In the present complaint, there is no dispute to the issuance of the Mediclaim policy No.233203/48/2011/398 (Ann.C-1) provided by the Opposite Party No.1 through Opposite Parties No.2 & 3 valid for the period 23.11.2010 to 22.11.2011 entitling the complainant/insured for cashless services at the enlisted hospitals and reimbursement of pre/post hospitalization.  It is also not a matter of dispute that the complainant during the subsistence of the above said coverage, underwent Transmetatarsal amputation 3^rd toe of right foot, GA/SA celluties, Osteomyelitis, at Opposite Party No.4 Hospital.

 

6]       The ld.Counsel for the complainant submitted that the complainant applied for the cashless treatment facility by submitting documents on 12.4.2011, which was declined and was advised to get the treatment by paying the charges and thereafter, claim for its reimbursement afterwards. It is further submitted that the complainant underwent the treatment on 12.4.2011 and was discharged on 13.4.2011 and incurred an expenses of Rs.65,350/- for the said treatment.  The claim was lodged with the Opposite Party Insurance Company for its reimbursement and the complainant received a letter dated 11.11.2011 (Ann.C-3) from Opposite Party No.2 (TPA) seeking some information from the complainant, which was duly provided to the Opposite Party on 25.11.2011. It is claimed that despite completing all the formalities, the status of the medical reimbursement claim till date is pending and the fate of the same has not been intimated to the complainant.  The said act of the OPs has been claimed as gross deficiency in service and also shows their indulgence into unfair trade practice.

 

7]       The ld.Counsel for Opposite Party No.1 submitted that there is no dispute that the complainant got indoor treatment for surgical amputation of 3^rd toe of Right foot on 12.4.2011 at Opposite Party No.4 Hospital in order to avoid further complication and submitted the bills on 19.10.2011 i.e. after a gap of more than six months and claimed that this is a clear cut violations of the terms & conditions of the policy.  Further claimed that the claim lodged by the complainant was forwarded to Opposite Party No.2, who vide letter dated 11.11.2011 required some information from the complainant, which the complainant alleged to have furnished on 25.11.2011, but the same has not been received by Opposite Party No.2.  The ld.Counsel for Opposite Party No.1 claimed that the information sought vide Ann.C-3 (letter dated 11.11.2011) by the Opposite Party No.2 was vital for the settlement of the claim of the complainant, which he failed to produce; claimed that the present complaint is liable to be dismissed on this ground only, it being pre-mature compliant, as the claim lodged by the complainant could not have been decided by the competent authority for want of required documents. Further submitted that the complainant has placed bills of exaggerated amount in respect of his claim without prescription and consultation papers and the complainant also failed to clarify the above fact.  Hence, the claim of the complainant, could not be settled due to negligence of the complainant.

 

8]       The complainant vide present compliant raised dispute stating that the OP Insurance Company has not settled his claim lodged for the reimbursement of the expenses incurred by him for his above said treatment, which the OPs were liable to pay, being covered under the policy in question.

 

9]       The matter to be considered is whether the complainant is entitled for reimbursement of the expenses incurred by him for his treatment.

 

10]      During the course of arguments, the ld.Counsel for complainant referred to an application filed by Opposite Party No.1 dated 23.1.2015 for amendment/modification of the written statement, which was dismissed vide order dated 10.4.2015.    

              

11]      It is pertinent to mention over here that during the pendency of the complaint, the complainant had moved an application dated 26.11.2013 requiring the Opposite Parties to produce the complete record of the claim bearing No.CCN 2086814 under policy No.233203/48/2011/398 in the name of Mahi Ram Siag (complainant) along with entire communication, including electronic communication. The said application dated 26.11.2013 was allowed vide order dated 1.7.2014 with directions to Opposite Party No.1 to bring in original case file of the claim bearing No.CCN 2086814 under Policy  No.233203/48/2011/398 in the name of Mahi Ram Siag, alongwith entire communication with the complainant and OPs No.2 to 4.

 

12]      It is gathered that instead of abiding by the instructions given by this Forum vide order dated 1.7.2014, referred above, the Opposite Party No.1 as a counter blast moved an application for modification/amendment of written statement along with copy of amended written statement duly supported with sworn affidavit.  The record further reveals that the said application of Opposite Party No.1 was dismissed, hence the written statement filed earlier by Opposite Party No.1, is to be taken into consideration for the decision of the present complaint and not the amended one.

 

13]      It is also gathered from the record that the number of opportunities were given to the Opposite Party No.1 to produce the original claim file/record of the complainant, but till the date of arguments, it failed to comply with the directions/order dated 1.7.2014.  Thus, an adverse inference is to be taken against the Opposite Party No.1 for the same. 

 

14]      It will be worth to look into the letter dated 11.11.2011 (Ann.C-3) issued by Opposite Party No.2 seeking information and requiring the documents from the complainant.  As a matter of convenience, the relevant extract of the said letter is reproduced as under:-

     

     “Kindly provide letter from treating doctor stating the duration of diabetes.

     Kindly provide 1st consultation paper when Diabetes was diagnosed.  Along with investigation reports supporting the diagnosis.

     Kindly give the reason for Delay in submission of claim documents.

     Kindly provide prescription for Medicine Bills submitted dated 17/4/2011, 19/4/2011, 28/4/2011, 6/5/11, 12/5/11, 15/5/11, 17/5/11, 19/5/11, 24/5/11, 2/6/11, 4/6/11, 6/6/11 & 9/6/11.

     Kindly provide consultation papers for submitted receipts dated 19/4/11, 26/4/11, 2/5/11, 4/5/11, 6/5/11, 7/5/11, 9/5/11, 11/5/11, 12/5/11, 14/5/11, 16/5/11, 23/5/11, 26/5/11, 27/5/11, 28/5/11, 1/6/11 & 6/7/11.”

 

15]      In our opinion, the information sought by Opposite Party No.2 asking about the duration of Diabetes suffered by the complainant, his first consultation papers when Diabetes was diagnosed; it is sufficient to say that query of Opposite Party No.2 is well answered in the medical certificate, which is filled by the treating doctor itself that the diabetes of the complainant was diagnosed  20 days back and the said certificate was also appended with the claim form submitted by the complainant i.e. Ann.C-2.  More so, the complainant also appended an authorization letter whereby the Opposite Party No.2 was authorised to seek any information/records in order to verify the fact of treatment availed by the complainant in Opposite Party No.4 Hospital.  So, in our opinion, the Opposite Party No.2 should have verified the record thoroughly for the decision of reimbursement of the claim in question.   

 

16]      The further query in regard to the bills has also been answered by the complainant by submitting all the bills mentioned in the letter dated 11.11.2011 duly countered signed by the treating surgeon in order to authenticate the medicines mentioned therein which were the prescribed one.  The averment of complainant in regard to the submission of counter signed bills to the Opposite Party cannot be doubted.  So, it could be rightly presumed that the complainant left no stone unturned to satisfy the queries of Opposite Party No.2.  Despite all, the Opposite Parties No.1 & 2 gone to slumber and the complainant was left to wait endlessly.  The conduct of Opposite Parties No.1 & 2 in not deciding the fate of the claim of the complainant and make it pending for uncertain period, is nonetheless a gross deficiency in service on its part, which certainly caused a great harassment to the complainant, not only mentally but financially too.  More so, the OPs did not feel it proper even to file reply to the legal notice issued by the complainant dated 9.7.2012 (Ann.C-4) sent through registered post vide Ann.C-5, which further added to the harassment of the complainant.

 

17]      In view of the above observations, we are of the concerted view that the Opposite Parties No.1 & 2 are found deficient in rendering proper service to the complainant. Hence, the present complaint of the Complainant is allowed against the Opposite Parties No.1 & 2 and is dismissed qua Opposite Parties NO.3 & 4 being proforma party only. The Opposite Parties No.1 & 2 are directed jointly & severally as under:-

 

1. To reimburse an amount of Rs.65,350/- incurred by the complaint on the treatment;
2. To pay an amount of compensation to the tune of Rs.25,000/- for causing him harassment and mental agony on account of deficient services and shows their indulgence in unfair trade practice for keeping the Mediclaim case of the complainant pending since 2011 without deciding its fate;

 

3.  To pay litigation expenses amounting to Rs.7,000/-.

 

         The above said order shall be complied within 45 days of its receipt by the Opposite Parties No.1 & 2 jointly & severally; thereafter, they shall be jointly & severally liable for an interest @18% per annum on the amount as mentioned in sub-para (i) & (ii) from the date of filing of this complaint, besides paying litigation expenses of Rs.7000/-, as aforesaid. 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

28.12.2015                                                

                                                                                      Sd/-  

 (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

                                                                                                                     

                                                                       

                                                                                Sd/-

(PRITI MALHOTRA)

                                                                MEMBER

Om 

 

 

 

DISTRICT FORUM – II

CONSUMER COMPLAINT NO.233 OF 2013

PRESENT:   None   Dated the 28th day of  December, 2015

O R D E R                        Vide our detailed order of even date, recorded separately, the complaint has been allowed against Opposite Parties.                    After compliance, file be consigned to record room.

 

(Jaswinder Singh Sidhu)	(Rajan Dewan)	(Priti Malhotra)
Member	President	Member