District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.478/2021.

 Date of Institution:21.09.2021.

Date of Order: 13.06.2022.

Gajender Kumar Dixit, aged 43 years, son of Shri Mansha Ram R/o House No. 2599, Sector-2, Ballabgarh, District Faridabad, Haryana, Aadhaar No. 4784 26753006, Mobile NO. 9810915645.

                                                                   …….Complainant……..

                                                Versus

1.                The United India Insurance Co. Ltd., Divisional Office – 28, 5R/5, Above Aastha Eye Centre, NIT, Faridabad- 121001.(Through its Branch Manager).

2.                M/s. Vipul Med Corp Insurance TPA Pvt. Services plot NO. 515, Udyog Vihar, Phase-5, Gurgaon, Haryana – 122016.

                                                                   …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.

PRESENT:                   Sh. Sanjay Dixit ,  counsel for the complainant.

                             Sh. Ravinder Chandila, counsel for opposite parties.

ORDER:  

                   The facts in brief of the complaint are that  the complainant was continuously taking medical insurance policy for the last 8years and had also taken the policy from M/s. United India Insurance Co. Ltd., for the year 2021-2021 bearing policy No. 2228002820P101770638  valid from 30.05.2020 to 29.05.2021.  Due to ongoing Corona Virus Disease, the complainant felt Acute Respiratory problem on 02.05.2021.  he become just like unconscious.  The family members of the complainant took him to the nearest hospital in emergency i.e Urocare Apolo Hospital, Sector-2, Faridabad, where the doctors checked him and admitted him.  The test report of RT PCR of the complainant was found positive and the hospital started treatment. The complainant remained admitted in the hospital form 02.05.2021 to 10.5.2021 and was discharged with advice of taking of medicines for 7 days.  For the treatment/tests etc. from 02.05.2021 to 10.5.2021, the hospital charged Rs.2,06,268/- from the complainant which he paid after arranging from his relatives.  During the treatment, as prescribed by the doctors of the hospital, some medicines were purchased from the nearest chemist shops of the local market for which Rs.19,053/- were incurred by the complainant from his own pocket.  Thus for the above mentioned treatment, the complainant spent Rs.2,25,321/- in total.  After the recovery from the disease, the complainant submitted his medical claim for Rs.2,25,321/- to the opposite party No.2 alongwith all the discharge summary/documents/bills etc. on 18.05.2021.  Opposite party No.2 vide its letter dated 17.07.2021 informed regarding passing of the claim of the complainant for Rs.1,06,155/- only which it had transferred to the bank account of the complainant and an amount of Rs.1,19,166/- was still pending against the opposite parties.  The complainant was surprised to see the claim settled amount in the letter.  He immediately contacted the opposite party No.2 and Branch office of opposite party No.1 which replied that this was the final amount which they can settle and refused to reconsider the claim of the complainant.   Due to ongoing lockdown, practice of the complainant had also suffered and thus he was in dire need of money.  On the other hand the opposite parties Nos.1 & 2 have mischievously settled the claim of the complainant less than 48% only. 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 the remaining amount of Rs.1,19,166/-.

 b)                pay Rs.50,000/- as compensation for causing mental agony and harassment .

c)                 pay Rs.11,000/- -as litigation 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 insurance company had never undertaken to provide medical services to the insured out of the scope of the terms and conditions of the Government of Haryana Department of Health and Family Welfare Endst. NO. 3Pm(covid)/2020/9047-9097 order dated 25.06.2020 pertaining to the insured Gajender Dixit Kumar & his family members of settlement of a claim.  In view of the factual status as well as the applicable law in force in this regards to the subject claim, the opposite parties hereby was not intended to either to give oral or written consent so as to enter into pre-litigative present proceedings need dropping even at this stage. The patient Gajender Kumar was hospitalized at Apolo Multi & Super Hospital Ballabgarh Faridabad from 02.05.2021 to 10.05.2021, he was admitted in emergency with complaints of fever 7 days, cough x 2 days, breathlessness x 1 day and was diagnosed as a case of fever with breathlessness, HRCT chest cause covid pneumonitis, and body etc.  pain and he was discharged the said hospital raised the bill for Rs.2,25,321/- on examination of the claim allowed of Rs.58,800/- disbursed to the insured account proportionate deduction done Rs.60,366/- as per State Govt. rates for Covid-19 treatment.

a)       the charge were Rs.1,30,000/- per day for ICU isolation and Rs.8,000/- per day for isolation bed charge.

b)      the charge were high end investigation E.G. HRCT chest, D-dimer, inter leukin 6, LFT & KFT. Approved for Rs.14,400/-.  Rest charges were not admissible as part of package.

c)       The charge for registration charge of Rs.4,000/- not payable.

Under the Government of Haryana department of Health and family welfare Endst. No. 3Pm (covid)/2020/9047-9097 order dated 25.06.2020.  The patient was currently covered under a family health policy No. 2228002820P101770638 commence from 30.05.2020 to 29.05.2021 which was a year coverage.   However, the insured was previously covered under individual health policy . The insured had applied cashless facility for Rs.225321/- which was approved by them for Rs.1,06,155/- vide policy NO.2228002820P101770638 commence from 30.05.2020 to 29.05.2021 under their cashless file number/claim No. 22RB01UiHo241.  They had disallowed an amount of Rs.60,366/- as the patient’s sum insured limit for disease proportionate deduction done Rs.60,366/- as per State Govt. rates for Covid-19 treatment.  The complainant got herself insured under the Government of Haryana department of Health and family Welfare endst. No.3Pm (covid)/2020/9047-9097 order dated 25.06.2020 but failed to understand that in the treatment of the ailment was not covered as per “the Government of Haryana department of Endst. NO.3Pm(covid)/2020/9047-9097 order dated 25.06.2020 of the insurance policy which runs as for clause no(1) of the Govt. under Endst. No.3Pm(covid)/2020/9047-9097 order dated 25.06.2020.  The prescribed rates should be all inclusive as a package.  The rates would include, but be not limited to charge such as all lab investigations, radiological diagnostics, monitoring charges.  Drugs, consumables including PPI masks gloves/etc. doctor’s visit/consultation, nursing care Physiotherapy, procedural charges (such as intubation, intra-arterial/neck line, catheterization of all types, chest tube splintage, cardioversion, Haemodialysis or besides dialysis echocardiography etc. transfusion of blood &* its components including blood grouping & cross Match. Deploying of equipment (such as alpha bed, infusion pump, multi-para monitors, intermittent pneumatic compression (IPC) devices, nebulisers etc. diet. Etc. as per the National Guidelines for management of Covid-19.  However this would not include the experimental therapies (e.g. Ramdesivir.etc).  hence the view of above complainant not calculate deduction of balance amount as per Govt. guide line.  In obtaining circumstances of the cases, the complainant had no locus standi and cause of action to sustain the present complaint since the alleged ailment was not payable as per the Government of Haryana department of Health and Endst. No. 3Pm (covid)/2020/9047-9097 order dated 25.06.2020 of the insurance policy. Opposite parties Nos.1 & 2 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 parties – United India Insuance Co.Ltd.& Anr. with the prayer to : a)the charge were Rs.1,30,000/- per day for ICU isolation and Rs.8,000/- per day for isolation bed charge. b)the charge were high end investigation E.G. HRCT chest, D-dimer, inter leukin 6, LFT & KFT. Approved for Rs.14,400/-.  Rest charges were not admissible as part of package. c)   The charge for registration charge of Rs.4,000/- not payable.

                   To establish his case the complainant has led in his evidenceEx.CW1/A – affidavit of Gajender Kumar Dixit,, Ex.C1 –insurance policy, Ex.C2 – OPD card, Ex.C-3 – discharge summary, Ex.C-4 – claim form, Ex.C-5 – Claim Settlement letter.

          On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties, Ex.EX.RW1/A – affidavit of Shri I.D.Sharma, Senior Divisional Manage, M/s. united India Insurance Company Ltd. NIT, Faridabad.

6.                The counsel for the complainant has argued that the complainant  was continuously taking medical insurance policy for the last 8 years  and the complainant has also taken the policy from M/s. United India Insurance Co. Ltd., for the year 2021-2021 bearing policy No. 2228002820P101770638  valid from 30.05.2020 to 29.05.2021.  Due to ongoing Corona Virus Disease, the complainant felt Acute Respiratory problem on 02.05.2021.  He become just like unconscious.  The family members of the complainant took him to the nearest hospital in emergency i.e Urocare Apolo Hospital, Sector-2, Faridabad, where the doctors checked him and admitted him.  The test report of RT PCR of the complainant was found positive and the hospital started treatment. The complainant remained admitted in the hospital form 02.05.2021 to 10.5.2021 and was discharged with advice of taking of medicines for 7 days.  For the treatment/tests etc. from 02.05.2021 to 10.5.2021, the hospital charged Rs.2,06,268/- from the complainant which he paid after arranging from his relatives.  During the treatment, as prescribed by the doctors of the hospital, some medicines were purchased from the nearest chemist shops of the local market for which Rs.19,053/- were incurred by the complainant from his own pocket.  Thus for the above mentioned treatment, the complainant spent Rs.2,25,321/- in total.  After the recovery from the disease, the complainant submitted his medical claim for Rs.2,25,321/- to the opposite party No.2 alongwith all the discharge summary/documents/bills etc. on 18.05.2021.  Opposite party No.2 vide its letter dated 17.07.2021 informed regarding passing of the claim of the complainant for Rs.1,06,155/- only which it had transferred to the

bank account of the complainant vide Ex.C-5.  An amount of Rs.1,19,166/- was still pending against the opposite parties.

                   On the other hand, counsel for the opposite party  argued that the complainant was hospitalized at Apolo Multi & Super Hospital Ballabgarh Faridabad from 02.05.2021 to 10.05.2021, he was admitted in emergency with complaints of fever 7 days, cough x 2 days, breathlessness x 1 day and was diagnosed as a case of fever with breathlessness, HRCT chest cause covid pneumonitis, and body etc.  pain and he was discharged the said hospital raised the bill for Rs.2,25,321/- on examination of the claim allowed of Rs.58,800/- disbursed to the insured account proportionate deduction done Rs.60,366/- as per State Govt. rates for Covid-19 treatment. The Government of Haryana department of Health and family welfare Endst. No. 3Pm (covid)/2020/9047-9097 order dated 25.06.2020.  The patient was currently covered under a family health policy No. 2228002820P101770638 commence from 30.05.2020 to 29.05.2021 which was a year coverage.   However, the insured was previously covered under individual health policy . The insured had applied cashless facility for Rs.225321/- which was approved by them for Rs.1,06,155/- vide policy NO.2228002820P101770638 commence from 30.05.2020 to 29.05.2021 under their cashless file number/claim No. 22RB01UiHo241.  They had disallowed an amount of Rs.60,366/- as the patient’s sum insured limit for disease proportionate deduction done Rs.60,366/- as per State Govt. rates for Covid-19 treatment.

7.                After going through the evidence led by parties, the Commission is of the opinion  that  the complaint is allowed. Opposite parties are directed to process the  balance claim of the complainant  as per policy within 30 days  of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint  till its realization.  The opposite

parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties  concerned free of costs and file be consigned to record room.

Announced on:  13.06.2022                                 (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.