…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. Bhim Singh , counsel for the complainant.
Sh. Jitender Kaushik , counsel for opposite parties Nos.1 & 2.
Sh. Deepak Kohli, counsel for opposite party No.3.
ORDER:
The facts in brief of the complaint are that the complainant had taken Mediclaim Policy from the respondent no. 1 since the year 2010 and the complainant was getting renewed his policy time to time and at present the complainant was having Policy No. 272400/48/2023/7830 valid from 03.12.2022 to 02.12.2023 and the Policy type is of Oriental Insurance Bank Saathi Policy Group Policy Schedule UIN: OICHLGP22026V012122 and the same was for the insured sum of Rs.5,00,000/-. The above said policy was for the complainant and his family members namely Smt. Lajjawati Wife, Vikas Rawat and Akash Rawat Sons and the complainant was paying regularly premium for renewal of his Mediclaim policy. The son of the complainant namely Vikas Rawat suffered problems of GI BLEED-RIGHT COLONIC APHTHOUS ULCERS INFECTIVE-MANAGED CONSERVATIVELY, ANTRAL + CORPUS GASTRITIS AND SMALL INTESTINAL BACTERIAL OVERGROWTH (INFECTIVE) and due to that problem son of the complainant got admitted on 18.05.2022 in M/s. Accord Superspeciality Hospital, (A unit of SCL Healthcare Pvt. Ltd. at Faridabad city Sector-86, Greater Faridabad-121 002 i.e. the respondent no. 3 and was discharged on 21.05.2022 from the said Hospital. Before admission the complainant gave the Policy of the respondent no. 1 bearing policy No. 272400/48/2022/8547 which was valid from 03.12.2021 to 02.12.2022 to the said Hospital and accordingly intimation was sent by said Hospital to the respondents nos. 1 & 2 and the respondent no. 2, being the TPA of respondent no. 1 (Part-D) Cashless Authorization sent Claim HH3B2300825 No. Letter dated 21.05.2022 for the sum of Rs.40,000/-. At the time of discharging of son of the complainant namely Vikas Rawat the final bill bearing No. IPCR-22-2/848 dated 23.05.2022 for Rs.1,05,000/- was raised by the respondent no. 3. Out of the above said amount, respondent no. 2 paid Rs.40,000/- (Rupees Forty thousand only) and balance amount of Rs.65,000/- was paid by the complainant to the said hospital as the respondent nos. 1 & 2 did not pay the balance amount of Rs.65,000/- ( Rs.5,000/- vide receipt No. ADGG/23/IP1826 dated 18.05.2022 by UPI Axis Bank and Rs.60,000/- vide receipt No. ASGG/23/IP2092 dated 22.05.2022 by UPI State Bank of India) to the said hospital illegally and unlawfully. The son of the complainant admitted in the said Hospital on 18.05.2022 and was discharged on 21.05.2022 vide discharge summary UHID No. 10008130 and IP No. 22/1428. Apart from the above balance amount the complainant also paid the amount for consultancy and medicines charges of Rs.14,947on different dates. Bill Numbers shown at S.No. 1, 4 & 6 were raised by Accord Superspeciality Hospital for consultancy and Bill Numbers shown at S. No. 2,3,5,7 & 8were raised by Raju Brothers Near Gupta Hotel Mohna Road, Ballabgarh, Faridabad for the medicines of the son of the complainant. In this manner the total sum of Rs.79,947/- (Rs.65,000 + Rs.14,947/- Rs.79,947/-) was paid by the complainant which was payable by the respondent nos. 1 & 2.. The complainant completed all the formalities of the respondents nos. 1& 2 and submitted all the requisite reports and even after submitting the same the complainant did not receive medical treatment charges of his said son for a sum of Rs.79,947/-. After that the complainant contacted many a times to the respondents nos. 1 & 2 but they did not pay any heed to the legitimate request of the complainant and avoided to pay the treatment charges/expenses illegally and unlawfully to the complainant. On the Cashless authorization letter the respondent no. 2 gave deduction reason as per clause 2.17 which was not applicable upon the treatment which had been given by the said Hospital to the son of the complainant. The complainant also sent the respondent no. 1 a letter dated 20.06.2022
mentioning therein to settle the balance claim amount which had been paid by the complainant and the complainant also sent the relevant document at Laxmi Nagar Delhi office of the respondent no. 2 but the complainant neither received the expenses of treatment which was paid by the complainant nor received any reply from the respondent nos. 1 & 2. The complainant sent legal notice dated 16.02.2023 to the opposite parties but all in vain. 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 medical treatment charges of the said son of the complainant for a sum of Rs.79,947/- to the complainant.
b) pay Rs.2,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs.25,000/- as legal expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the complainant had neither any locus standi nor cause of action to file the present complaint The complainant had not come before this Hon'ble Court with clean hands and had suppressed the true and correct facts from this Hon'ble commission, it was submitted that as per the version of the complaint, the son namely Vikas Rawat suffered problems of GI Bleed-Right Chronic Aphthous Ulcers with Corpus Gastritis Infective-Managed Conservatively, Antral + and Small Intestinal Bacterial overgrowth (Infective) and due to that problem he was got admitted on 18.05.2022 in Accord Superspeciality, Hospital and after treatment he was discharged on 21.05.2022 from the said hospital. The hospital sent cashless request which was authorized by the respondent no.2. At the time of discharge the hospital raised a bill of Rs. 1,05,000/-
and out of which an amount of Rs.40,000/- was paid only by the respondent no.2 and balance amount of Rs.65,000/- was paid by the complainant from his pocket. Apart from that an amount of Rs.14,947/- was also spent on medicine and submitted all the requisite reports and even after the complainant did not receive treatment charges of Rs.79,947/-. It was submitted that as per Duodenoscopy report the patient was suffering from Hiatus Hernia (Hill Grade-II) Linear Corpus and Antral Gastritis. It was submitted that at the time of discharge, the hospital raised the bill of Rs. 1,05,000/- an out of which the respondent no.2 paid Rs. 40,000/- as per the terms am conditions no.2.17 of the policy and remaining amount was not payable as per the terms and conditions no.2.17 of the policy. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3 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 answering respondent had been dragged into altogether false and frivolous litigation without any substances whatsoever against the Answering Respondent. As per the own version of the Complainant, as averred in the Complaint, he was having no grievances against the Answering Respondent. No incident of any negligence or deficient services had been mentioned or alleged by the complainant qua the answering respondent. The dispute if any was between the complainant and Respondent No.1 and 2 and the answering respondent has nothing to do with the same. Opposite party No.3 denied rest of the allegations leveled in the complaint.
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–Oriental Insurance Co. Ltd. with the prayer to: a) pay medical treatment charges of the said son of the complainant for a sum of Rs.79,947/- to the complainant. b) pay Rs.2,00,000/- as compensation for causing mental agony and harassment . c) pay Rs.25,000/- as legal expenses.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Tej Pal Rawat, Ex.C-2 – Insurance policy valid from 03.12.2022 to 02.12.2023, Ex.C-3 insurance policy valid from 03.12.2021 to 02.12.2022, Mark A – Cashless Authorization letter dated 21.05.2022, Mark-B – Certificate of Provisional Registration, Mark-C – Claim form – Part B, mark-D – In patient bill (summary), Mark-E – Discharge summary, Mark- F – Bill of supply cum receipt, Ex.C-4 & 5 –Advance receipts., Ex.C-6 – letter , Ex.C-6 – postal receipt, Ex.C-7 – legal notice, Ex.C-8 to 10– postal receipts,
On the other hand counsel for the opposite parties Nos.1 & 2 strongly agitated and opposed. As per the evidence of the opposite parties Nos.1 & 2 Ex.RW1/A – affidavit of Ramesh Kumar, Sr. Div. Manager, M/s. Oriental Insurance Company Ltd., Faridabad, Ex.R-1 – insurance policy valid from 03.12.2021 to 02.12.2022, Ex.R-2 – terms and conditions.
Shri Manoj Arora, counsel for opposite party No.3 has made a statement that written statement filed on behalf of opposite party No.3 be read as evidence on behalf of opposite party No.3 and close the same. Accordingly,
evidence on behalf of opposite party No.3 has been closed vide order dated 12.12.2023.
7. In this complaint, the complaint was filed for Shri Vikas Rawat who is covered with this policy with the prayer to Rs.79,947/-. No doubt, the complainant has the policy since 2010 and the complainant is paying the premium regularly since 2010. On the other hand, the repudiation was done by the opposite party as per the terms and conditions No. 2.17 of the policy. Counsel for the complainant argued at length and also stated at Bar that the complainant is paying the premium regularly and T & C of the company was never narrated to the complainant about the clause 2.17 and he has paid the money to the hospital from his own pocket and opposite party No.2 has deducted the amount from the billed amount.
8. After going through the evidence led by the complainant as well as the opposite parties, the Commission is of the opinion that as per discharge summary vide Mark E treatment and diagnose is “GE BLEED RIGHT COLONIC APHTHOUS ULCERS INFECTIVE-MANAGED CONSERVATIVELY BIOPSY REPORT AWAITED). In this case, the complainant is a regular customer of opposite party No.1 and the TPA repudiated the claim of the complainant on the ground of Clause 2.17 of the T & C of the company which are as under::
“2.17 Deductible is a cost sharing requirement under a health insurance policy that provides that the insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies, which will apply before any benefits are payable by the insurer. A deductible does not reduce the sum insured.”
The above Clause 2.17 of T &C was never narrated to the complainant and the bill was paid by the complainant himself. It is a settled law by Ld. Apex Court that once opposite parties took the premium since long opposite parties have to pay mediclaim of the complainant. The complainant is covered under the policy. In the interest of justice, the complaint is allowed.
9. Opposite parties Nos.1 & 2, jointly & severally, are directed to process the claim of the complainant and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing complaint till its realization The opposite parties Nos.1 & 2 are directed to pay Rs.5500/- as compensation on account of mental tension, agony and harassment alongwith Rs.5500/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 06.02.2024. (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.
