DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
ISBT KASHMERE GATE DELHI
CC No.31/2014
No. DF/Central/ Date :
Mr. AMARJEET SINGH SACHDEVA, S/o SHRI AJIT SINGH, R/o HOUSE NO.10/8-B, 1st FLOOR, KRISHNA NAGAR, DELHI - 110051
…..... COMPLAINANT
V/S
1. M/S. UNIQUE : C/o HOUSE No. 002, 3rd FLOOR, EAST PARK ROAD,
KAROL BAGH, NEW DELHI
2. UNITED INDIA INSURACNE CO. LTD., MDINDIA HEALTH CARE SERVICES (TPA) PVT., LTD., PLOT NO. 18/13, WEA GROUND FLOOR, GANGA PLAZA,
PUSA LANE, KAROL BAGH, NEW DELHI
... OPPOSITE PARTY
Coram: Mohd. Anwar Alam, President
Vikram Kumar Dabas, Member
Manju Bala Sharma, Member
ORDER Date: 20th Sept 2016
Manju Bala Sharma, Member
OP has denied all the allegations made by the complainant and stated that the complainant has fabricated the story of informing the executive of OP 1 when he realised his mistake of not intimating the Insurance Company in writing about his hospitalisation as required on the terms and conditions of the Insurance Policy.
OP 2 in its reply admitted the fact that the complainant took mediclaim policy from OP 2 and further stated that the complainant informed about his illness to OP 2 on 08/02/2012 i.e. after a delay of 13 days and denied the allegations made in the complaint.
Complainant filed its Rejoinder to the written statement of both the OPs and denied the allegations made by the OPs and reiterated the facts stated in the complaint. Affidavit of evidence has been filed by the complainant as well as the OP 1. After filing the written statement, OP 2 did not appeared and was proceeded with ex-parte on 02/11/2015.
Complainant has filed copy of the Bill of Rs. 1,30,000/- (One Lac Thirty Thousand) paid by him to AIIMS, bills of the medicines purchased by him discharge summary, case memo of the admission charges, copy of letter dated 16/03/2012 vide which complainant sent one cancelled cheque of his saving account, copy of e-mail dated 17/05/2012 received from Unique Life Care reply to the letter dated 17/05/2012 sent by the complainant to the OP on 23/05/2015 and letter dated 08/12/2012 sent to OP 2 with a copy of the same to the Head Office and Regional Office. OP 1 has filed copy of Policy issued by OP 2.
We have heard Learned Counsel for the complainant as well as OP 1 and gone through the relevant record as well as written arguments field by the OPs. Complainant has specifically stated in the complainant dated 24/01/2012 when he was admitted to AIIMS Hospital, after due diagnose then complainant was told that pace maker was to be planted in the body of the complainant, the complainant informed the executive of OP 1 that he is having cash less card and OP 1 asked the complainant to deposit the charges in cash and get the amount reimbursed from the Insurance Company and that after discharged from the Hospital the complainant on 08/02/2012 informed the Insurance Company about operation conducted and deposited all the entire claim documents with OP 1 and on 16/03/2012 the complainant has sent one cancelled cheque of his account to OP 1 which has been duly received by OP 1 on 16/03/2012 under his receipt. These facts have been reiterated by the complainant in its Rejoinder as well as affidavit filed by him. These facts have been denied by the OP 1, whereas OP 2 in his reply has admitted that the complainant informed about the operation conducted at AIIMS on 08/02/2012.
OP 1 has filed the Policy marked as Annexure I issued to it by United India Insurance Company which reads as under:-
‘’ xxx xxx xxx
(2) Claim Intimation : Intimation received by Unique and their offices will be treated as Intimation received by Md India-TPA but at the same time e mail of this intimation (soft Data) send by UNIQUE to MD India Ahmedabad office and Copy mark to nearest office of Md India for purpose of Investigation twice in day. (location will send by Md India to Unique).
(3) Claim file submission : All necessary claim files received by unique and their offices will be treated as files received by MD India –TPA and intimation of the said receipt shall be communicated to Md India abad office on daily basis.
‘’ xxx xxx xxx’’
The OP1 had failed to prove the fact that the complainant has not informed his executive about the cash less card and the executive of OP 1 asked him to deposit the amount and get the same reimbursed from the Insurance Company by complainant.
Annexure I filed by OP 1 clearly shows that intimation regarding the claim can be given to Unique and the same will be treated as intimation received by the TPA.
The fact that the complainant informed the executive of OP 1 about having his cashless card and the fact that executive of OP 1 asked him to deposit the charges in cash and get the re-imbursement from the Insurance Company cannot be disbelieved when in the Health Insurance Policy Annexure I issued by OP 2 it has been mentioned that intimation received by Unique will be treated as intimation received by the TPA and all claims filed received by Unique and their Office will be treated as files received by TPA.
It will not be out of place to mention here that OP 2 in its reply admitted that the complainant filed its claim on 08/02/2012. Thereafter, OP2 did not enter appearance and contest the claim of the complainant. OP 1 in its reply and affidavit of evidence has denied the fact that the complainant did not inform it about his being admitted to AIIMS Hospital on 24-01-2012 and also stated that it is not in his knowledge whether the complainant has intimated this fact to OP2 on 08-02-2012.
As per the policy Annexure I it is crystal clear that the intimation received by Unique and their office will be treated as intimation received by TPA there is nothing left to disbelieve the statement of the complainant that he informed about his admission in AIIMS Hospital and plantation of pace maker in complainant’s body with a belief that the intimation given to OP 1 is an the intimation to the Insurance Company (OP 2) also.
In view of the above, discussion we are of the opinion that the complainant has been able to prove that they are deficient in service on the part of OP 1 and OP 2. Holding both the OPs liable for the deficiency in service jointly and severally we direct the OPs to pay to the complainant a sum of Rs. 1,30,000/- (Onc Lac Thirty Thousand) paid by him to the AIIMS Hospital, Rs. 50,000/- (Fifty Thousand) as compensation and Rs. 10,000/- (Ten Thousand) as cost of litigation.
This order shall be complied with by the OPs within a period of 30 days from the date of receipt of this order failing which interest @ 12% shall be payable on the entire above mentioned amount from the date of this order till realisation. Copy of this order be sent to all the parties free of cost. File be consigned to Record Room.
Announced on this 20/09/2016.
MEMBER MEMBER PRESIDENT
