District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 523/2021.
Date of Institution:06.10.2021.
Date of Order:10.05.2023.
1. Indu Bhatia D/o Chand Kumar Bhatia, R/o H.NO. 2264, Housing Board Colony, Sector-28, Faridabad.
2. Chand Kumar Bhatia, R/o H.No. 2264, Housing Board Colony, Sector-28, Faridabad.
…….Complainants……..
Versus
1. The New India Assurance Co. Ltd., Office at: NH-5/R-2, Near B.K.Chowk, NIT, Faridabad, Haryana – 121001.
2. Oncoplus Hospital, B-73, Bhishm Pitamah Marg, Block-B, Defense Colony, New Delhi – 110 024.
…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. Vaseem Khan , counsel for the complainant.
Sh.D.K.Gosain , counsel for opposite party No.1.
Sh. Jayaditya Gupta, counsel for opposite party No.2.
ORDER:
The facts in brief of the complaint are that the complainant NO.1 purchased a mediclaim policy from opposite party for herself as well as her parents bearing policy No. 31270034209500000 valid from 24.06.2020 to 23.06.2021 for the insured sum of Rs.3,00,000/-. The said policy was being renewed since 1998 therefore a claim bonus of Rs.1,50,000/- was also included in the policy, so the total sum insured was 4,50,000/- for last 13 years, On 27.04.2021 the complainant NO.2 (Father of complainant No.1) fell ill and was complaining of fever, so he got conducted various tests and diagnosed of Covid positive. The condition of the complainant No.2 did not improved by taking medications at home under medical advice, due to which the complainant No.2 was then advised for immediate hospitalization. In the month of May 2021 the second wave of Covid -19 was at peak no beds were available in the hospitals at Faridabad so after a long search the complainant No.2 was admitted in Oncoplus Hospital, defence Colony, New Delhi on 05.05.2021 and the bed was allotted to the complainant No.2 on package basis, per day charges. The complainants had accepted the package offered by the said hospital as there was no bed available in any other hospital and only bed available was on these terms. Due to poor medical condition of the complainant No .2 the family of the complainant NO.2 had to agaree to the same. Complainant No..2 was tested and treated for Covid by Dr. Dixit Kumar Tahakur, in Oncocoplus Hospital and was thereby discharged on 14.05.2021 after his condition improved.
At the time of admission of the complainant No.2 in Oncoplus Hospital Defence Colony, New Delhi a sum of Rs.2,00,000/- was deposited as advance payment on 05.05.2021 via Credit card and thereafter again upon being asked by the hospital a sum of Rs.1,00,000/- was paid by the complainants as
advance payment on 07.05.2021 and another sum of Rs.2,00,000/- was paid by the complainants on 11.5.2021. Thereafter at the time of discharge of complainant NO.2 from Oncoplus Hospital, Defence Colony, New Delhi a final bill of Rs.6,30,000/- was generated by the hospital on 14.05.2021. After adjusting the advance already paid, balance sum of Rs.1,30,000/- was paid in final settlement by the complainant at the time of discharge of complainant No.2 from hospital. As the complainant felt ill during the subsistence of the above mentioned policy and an intimation regarding the complainant NO.2 being Covid Positive and admitted in Oncoplus Hospital, Defence Colony, New Delhi was given to the opposite party. Snce Oncoplus Hospital, Defence Colony, New Delhi was not included in the list of hospitals in which cashless facility was provided by the opposite party, so complainant could not get cashless facility at the said hospital, and complainant No.1 later on applied for the reimbursement claim for a total sum of Rs.4,50,000/- against policy NO. 31270034209500000363 via email dated 29.06.2021 on advise of the insurance agent of opposite party in respect of hospitalization of complainant NO.2 in Oncoplus Hospital, defense Colony, New Delhi and all the necessary documents including the claim form and hospital bills were scanned and attached in said email dated 29.06.2021. However, the opposite party or its TPA neither acknowledge the receipt of email nor provided any claim number to the complainant NO.1. Thereafter again vide two emails dated 03.07.2021 the soft copy of all the necessary documents were sent by the complainant No.1 upon being asked by the agent of the opposite party company, but still the opposite party neither acknowledged the receipt of email nor provided any claim number to the complainant No.1. When no response was received by the complainant No.1 from opposite party company for more than 10 days then the complainant NO.1 visited the TPA office of opposite party at Noida on 12.07.2021 and the complainant
NO.1 was shocked to see that the emails sent by the complainant NO.1 were still unread in the inbox of their email account.
Thereafter again when no response was received from the TPA or opposite party company then again complainant No.1 made a telephonic inquiry from customer care on 21.07.2021 about the status of claim No. 211200132537 upon which complainant No.1 was informed that she needs to submit the bifurcation of bill issued by hospital upon which the complainant NO.1 informed the opposite party company that no such bifurcation bill had been issued by the hospital to complainants to call as well as via email dated 21.07.2021. An amount of Rs.33,573/- was transferred into the bank account of the complainant on 24.09.2021 by the opposite party company in lieu of the above mentioned reimbursement claim of Rs.6,50,258/-, whereas the actual amount which should have been paid by7 the opposite party was Rs.4,50,000/- which was the total sum insured for the policy No. 31270034209500000363 without assigning any reason for deducting such huge amount of the claim. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay the balance claim amount of Rs.4,16,427/- alongwith interest @ 18% p.a. from the date of receipt of the claim documents by opposite party ie. 29.06.2021 till realization.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 50,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted
that on receipt of mediclaim in respect of complainant NO.2 it was got processed and investigated by Health Insurance TPA of India and the claim of the complainants was settled for Rs.33,573/- whereas the admissible amount was Rs.20,259/- only and as such an amount of Rs.13,315/- had been excess paid. The hospital had charged Rs.70,000/- per day as package charges, the breakup of the same had not been provided by the complainant to Health Insurance TPA of India Limited. Hence the charges for 9 days i.e Rs.6,30,000/- had been deducted by Health Insurance TPA of India Limited. In view of Delhi Govt. Package notified by the government for Covid-19 patients and capping was fixed for the hospitals. Therefore in case higher amount had been charged by the concerned hospital against the package notified by the government then in that case the claim of the complainants if if any lies with the said hospital only and the complainants can seek legal remedy against Oncoplus Hospital, Defence Colony, New Delhi. The complainant sent the email to the customer care service and also contacted them on telephone and the complainant was asked to provide the bifurcation of the package bill of the hospital, which was never provided either to the opposite party or to TPA. It was also submitted that as per the policy terms and conditions, room rent charges was payable 1% of the sum insured and similarly the other charges were also payable as per the rent charges of 1% payable of the sum insured payable and in case the patient opt for the room, the rent of which was higher than the payable as per the terms and condition of the policy, the complainant had to bear that and also the other charges proportionately. Unless and until bifurcation of package charges was provided to the opposite party then it was practically not possible to settle the claim of the complainant. In any case the opposite party was not liable to reimburse the claim as per package. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party–The New India Assurance Co. Ltd. with the prayer to: a) pay the balance claim amount of Rs.4,16,427/- alongwith interest @ 18% p.a. from the date of receipt of the claim documents by opposite party ie. 29.06.2021 till realization. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 50,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, CW1/A – affidavit of Indu Bhatia, Ex.C1(colly) policy schedule, Ex.C-2 – Final Bill, Ex.C-3 to 5 – Receipts, Ex.C6 (Colly) – Discharge summary,, Ex.C-7 - letter dated 28.6.2021,Ex.C-8 – cancelled cheque, Ex.C9(colly) – claim form, Ex.C-10 – claim, Ex.C-11 – letter dated 28.08.2021,Ex.C-12 – message from New India Assurance Co., Ex.C-13 to 22 – emails, Ex.C-23 – adhaar card,
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shashi Parkash, Sr. Divisional Manager, New India Assurance Company Limited, NH-5-R/2, NIT, Faridabad, Ex.R-1 – policy schedule, Ex.R-2 – query letter.
6. During the course of arguments, counsel for oppsoite party No.2 has submiited the break up of the bill vide Annx. X. The details are as under:
3. Benefits Covered under the policy:
3.2 Proportionate Deduction
Proportionate Deduction is applicable on the Associate Medical Expenses, if the insured person opts for a higher room than his eligible category. It shall be effected in the same proportion as the elegible rate per day bears to the actual rate per day of room rent. However, it is not applicable on
- Cost of pharmacy and consumables.
- Cost of implants and medical devies
- Cost of diagnostics.
During the course of arguments, counsel for opposite party No.2 has also filed an order passed by Shri Vikram Dev Dutt, Pr. Secretary (Health & FW) on 20.06.2020 in which it has been mentioned that:
“2. The rates for private hospitals beds would be all inclusive as a package. This will include, but not limited to: bed, food and other amenities, monitoring, nursing care, doctors’ visits/consults, investigations including imaging, tratment as per the national protocol for COVID care and standard care for co-morbidities, oxygen, blood transfusion etc.”
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant, after deduction the paid money, within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.2200/- as compensation
for causing mental agony & harassment alongwith Rs.2200/- 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: 10.05.2023 (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.
