District Consumer Disputes Redressal Forum, Faridabad.
Consumer Complaint No.295/2018.
Date of Institution: 18.6.2018.
Date of Order:21.11.2022.
Devraj Baweja S/o Shri C.R. Baweja R/o House No. 449, Sector-15A, Near BSNL, Telephone Exchange, Faridabad.
…….Complainant……..
Versus
1. M/s. TATA AIG Insurance Company Ltd., Regd. office: Peninsula Business Park, Tower A, 15th Floor, GanpatraoKadamMarg, Lower Parel, Mumbai – 400 013 through its Divisional Director/M.D.
2. E Meditech Insurance TPA Limited, TATA AIG Claim, Plot NO. 577, UdyogVihar, Phse-V, Gurugram (Hr) through its Divisional Manager.
3. Royale (Multispecialty Hospital), A-3, Central Green, NIT-5, Faridabad.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: AmitArora……………..President
Mukesh Sharma………Member.
Indira Bhadana………..Member
PRESENT: M.s. Anita Sehrawat counsel for the complainant.
Sh. O.P.Gaur,counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 29.08.2019.
Opposite party No.3 ex-parte vide order dated 28.11.2019.
ORDER:
The facts in brief of the complaint are that the complainant was the holder of mediclaim policy provided by the opposite parties Nos. 1 & 2, covering all types of risks. Opposite party No.1 issued the mediclaim policy bearing No. 0235296839 (Policy Type: Wellsurance Executive) in the name of the complainant w.e.f. 24.12.2017 to 23.12.2018. Unfortunately, the complainant was suffering from serious disease i.e. cough with sputum, breathing difficulty, fever with chills, chest heaviness thereafter on 01.03.2018 the complainant had got admitted in the hospital of opposite party No.3 as per the guideline, rules and norms of the insurance policy which was issued by opposite parties Nos.1 & 2 and the said hospital falls under this insurance policy. Some negotiations were done between opposite party No.3 and the complainant and shown the said policy and the same was accepted by opposite party No.3 through internet process and hence the treatment of the complainant would be conducted by opposite party No.3 as cashless. When the complainant got admitted in the hospital of opposite party No.3 under the insurance policy then opposite party No.3 had got signed the some printed papers from the complainant and retained the copy of insurance policy in his possession and the opposite party No.3 told the complainant that opposite party No.3 will inform the opposite parties Nos.1 & 2 for claim of the complainant regarding the admission and done the some estimate of the treatment of the complainant. Thereafter some tests/xxx rays of the complainant were conducted by opposite party No.3 and treated by Dr. Sunil Dhingra of opposite party No.3 under the supervision and control of opposite party No.3. Thereafter opposite party No.3 demanded cash amount of Rs.20,000/- from the complainant and as per the request of opposite party No.3 after considering the commitment of the opposite party No.3, the complainant had paid an amount of Rs.20,000/- to opposite party No.3 vide receipt No. 2076 dated 03.01.2018 and paid an amount of Rs.20,000/- vide receipt No. 2183 dated 05.01.2018 and also paid an amount of Rs.11,220/- vide receipt No. 2397 dated 08.01.2018 to opposite party No.3 and opposite party No.3 told to the complainant that opposite party No.1 had sent the proposal of treatment of the complainant to opposite parties Nos.1 & 2 and at the time of discharging, the same had been adjusted in the final bill. Opposite party No.3 had treated the complainant remained admitted since 03.01.2018 to 08.01.2018 and the opposite party No.3 had raised a bill Sr. No. 510 dated 08.01.2018 of Rs.51,220/- and at the time of discharge of the son of the complainant, opposite party No.2 demanded the bill amount from the complainant and told to the complainant that they will send the necessary treatment record/case summary to opposite parties Nos.1 & 2 then the opposite parties Nos.1 & 2 will release said claim. On the assurance and instructions of opposite party No.3, the complainant had paid the amount of Rs.51,220/- to opposite party No.3 and got discharged by opposite party No.3 to the complainant. Thereafter the complainant went to the office of opposite parties Nos.1 & 2 alongwith all the treatment records bills, receipts and form and asked the opposite parties Nos.1 & 2 to release the claim but the opposite parties Nos.1 & 2 refused to release claim to the complainant as opposite parties Nos.1 & 2 had only received treatment documents in respect of claim of the complainant and had not received the survey report from opposite party No.3 as the treating doctor of opposite party No.3 clearly stated that this claim was not admissible. On the survey report of treating doctor of the opposite party No.3, opposite parties 1 & 2 repudiated the claim of the complainant.The complainant sent legal notice dated26.03.2018 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 cost of the said claimed of Rs.51,220/- as insurance claim amount alongwith interest @ 18% p.a. from the date of accident till actual realization of the amount in full.
b) payRs.2,00,000/- as compensation for causing mental agony and harassment .
c) payRs. 11,000 /-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 insured had availed the Wellsurance Executive policy bearing No. 0235296839 for the period of 24.12.2017 to 23.12.2018 for covering the family for the sum insured therein. The insurance company submitted that the insurance was based of Utmost Good Faith. Both the parties were bound by the terms and conditions of contract of insurance. The liability of the insurer would be within the four corners of the contract of insurance alone as held by the Supreme Court in a series of decisions as in Sony Cherian, HarchandChandanLal, VikramGreentech, Deokar Exports, SatwantKaurSandhu cases. Viewed thus, both factually and legally the claim had been settled in accordance with policy terms and the insurer cannot be held liable and compelled to pay the sum which was not payable under the contract of insurance, therefore, deemed fit to be repudiated by the insurer. As a matter of the insurance contract (if exists and enforceable) and as per the judicial precedents, insurance claim was not a source of enrichment to an insured person. It was submitted that the complainant had suppressed and concealed his pre-existing disease, which constitute misrepresentation and suppression of the material facts & information in obtaining the health insurance policy from the insurance company. It was submitted that the insurance contract was based on the principle of utmost good-faith. It was further submitted that the complainant lodged the mediclaim with opposite party No.2 on 15.01.2018 in respect of hospitalization of the patient – Dev Raj Baweja, claiming hospitalization in Royale Multi Specialties Hospital, 5B/5, Central
Green, NIT, Faridabad – 121001 for the period 03.01.2018 to 08.01.2018 and claiming reimbursement as per inpatient bill for a sum of Rs.51,220/-. As per the discharge summary for the period 03.01.2018 to 08.01.2018, the patient was allegedly hospitalized with the complaint of cough with sputum, breathing difficulty, fever with chill and chest heaviness. However, finally diagnosed with “Lower Respiratory tract infection with Pyrexia and Sepsis (A potentially life-threatening condition caused by the body’s response to an infection. The body normally releases chemicals into the bloodstream to fight an infection. Sepsis occurs when the body’s response to these chemicals was out of balance, triggering changes that can damage multiple organ systems). Opposite party NO.2 being the Third Party Administrator for and on behalf of opposite party No.1 vide its letter dated 30.01.2018 called upon the complainant to supply and tender the following documents:-
i) First consultation paper.
ii) Indoor case papers.
iii) Lab reports, lab bills, doctor’s fee receipt, chemist bills prior to hospitalization.
iv) Lab reports, lab bills, doctor’s fee receipt, chemist bills after hospitalization.
v) X-rays report, Citi Scan, MRI, USG Films/plates. If underwent such tests.
vi) Bank details with cancelled cheque.
vii) Recent coloured photographs.
viii) Copy of PAN card.
It was also submitted that the complainant arranged certain selective documents. As a result, opposite party No.2 again called upon the complainant to furnish, supply and tender the listed documents vide its reminder letter dated 17.02.2018. A this, the complainant arranged various documents and furnished to opposite party No.2. It was submitted that the insurance company had thoroughly and carefully investigated into the subject claim and observed that the insured was alleged hospitalized for the period 03.01.2018 to 08.01.2018. It was submitted that the insured had not presented any representation to the insurance company in reply to above letters, hence the claim of the complainant was repudiated and policy was cancelled vide letter dated 27.02.2018. Opposite party No.1denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Registered notice sent to opposite party No.2 on 23.07.2018 not received back. Case called several times since morning. But none appeared on behalf of opposite party No.2. More than one month had elapsed. Therefore, opposite party No.2 was proceeded against ex-parte vide order dated 29.09.2019.
4. Notice issued to opposite party No.3 received back duly served but despite service he was not present. Therefore, opposite party No.3 was proceeded against ex-parte vide order dated 28.11.2019.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file as well as written arguments filed by the parties have been perused.
7. In this case the complaint was filed by the complainant against opposite parties – Tata AIG General Insurance Co. Ltd.with the prayer toa) pay cost of the said claimed of Rs.51,220/- as insurance claim amount alongwith interest @ 18% p.a. from the date of accident till actual realization of the amount in full. b) payRs. 2,00,000/- as compensation for causing mental agony and harassment . c) payRs. 11,000 /-as litigation expenses.
To establish his case, the complainant has led in his evidence Ex.C1 – legal notice, Ex.P2 – postal receipt, Ex.C-3 – insurance policy, Ex.C4 – Wellsurance policy schedule , Ex.C-5 – Receipt, Ex.C-6 – Discharge summary, Ex.C-7 – Inpatient bill, Ex.C-8 – Lab detail, Ex.C-9 – Receipt, Ex.C-10 to C-11 – X-ray, Ex.C-12 – List of used Medicine.
On the other hand counsel for the opposite party strongly agitated and opposed .As per the evidence of the opposite party No.1 Ex.O/1 - - insurance policy, Ex.O/2 – Discharge summary, Ex.O/3 – Inpatient bill, Ex.O/4 – List of used medicine,, Ex.O/5 – Lab detail, Ex.O/6 – Tests,, Ex.O/7 – Discrepancy letter dated 30.01.2018,, Ex.O/8 – Final Investigation Report, Ex.O/9 – Discrepancy letter dated 17.02.2018, Ex.O/10 (colly) – Indoor treatment record, Ex.O/11 – Registration certificate, Ex.O/12 - repudiation letter dated 08.03.2018.
8. Counsel for the complainant argued that the complainant has a Wellsurancepolicy bearing No.0235296839 valid from 24.12.2017 to 23.12.2018 issued by the opposite party. The complainant was suffering from serious disease i.e cough with sputum breathing difficulty, fever with chills and chest heaviness, therefore, remained hospitalized. Opposite party NO.3-Royale Multispecialty Hospital have got signed some printed papers from the complainant and told that such papers would be arranged to the insurance company. But the hospital asked the complainant to deposit the bill amount of Rs.51,220/-. The claim of the complainant has been declined by the insurance company vide letter dated 08.03.2018.
9. The counsel for the opposite party No.1 has submitted written arguments in which he has stated that the complainant lodged the mediclaim with opposite party No.2 – M/s. E Meditek Insurance TPA Ltd., on 15.01.2018 in respect of hospitalization of the patient – Dev Raj Baweja, claiming hospitalization in Royale Multi Specialties Hospital, 5B/5, Central Green, NIT, Faridabad for the period 03.01.2018 to 08.01.2018 vide Ex.O/2 and claiming reimbursement as per inpatient bill for a sum of Rs.51,220/-. As per the discharge summary for the period 03.01.2018 to 08.01.2018, the patient was hospitalized with the complaint of cough with sputum, breathing difficulty, fever with chill and chest heaviness.However, finally diagnosed with “Lower Respiratory tract infection with Pyrexia and Sepsis”. Opposite party No.2 vide its letter dated 30.01.2018 vide Ex.O/7 called upon the complainant to supply the following documents
i) First consultation paper.
ii) Indoor case papers.
iii) Lab reports, lab bills, doctor’s fee receipt, chemist bills prior to hospitalization.
iv) Lab reports, lab bills, doctor’s fee receipt, chemist bills after hospitalization.
v) X-rays report, CTScan, MRI, USG Films/plates. If underwent such tests.
vi) Bank details with cancelled cheque.
vii) Recent coloured photographs.
viii) Copy of PAN card.
Opposite party again sent a discrepancy letter dated 17.02.2018 vide Ex.O/9 to the complainant to submit the required documents as mentioned above. But the complainant has not presented any representation to the insurance company, in respect of the letter dated 17.02.2018. Hence, the claim of the complainant was repudiated vide letter dated 27.02.2018 vide Ex.O/12.
10. After going through the evidence led by the parties, the commission is of the opinion that it seemsthat the complainant has not submitted the relevants documents to opposite parties as per letter dated 17.02.2018. In the interest of justice, the complaint is allowed. The complainant is directed to submit the requisite documents as asked for by the opposite parties within 15 days of receiving this order. The opposite parties Nos. 1 & 2 are directed to process the claim within 30 days of receiving the documents from the complainant as per the terms and conditions of the policy and pay the due amount to the complainant alongwith interest @ 6% p.a from the date of filing of complaint till its realization. The opposite parties Nos.1 & 2 are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment and Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on: 21.11.2022 (AmitArora)
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.
