District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.542/2021.

 Date of Institution: 19.10.2021.

Date of Order: 26.08.2022.

Jai Chand Chandila son of Shri Ram Pal, resident of village and P.O.Badoli, tehsil, Aadhar card No. 4366 534 6915, mobile No. 8076665711.

                                                                   …….Complainant……..

                                                Versus

1.                M/s. United India Insurance company ltd. SCO 06, Commercial complex, Green Channel road, Sector-16, Faridabad – 121002 through its Divisional Manager.

2.                M/s. Safeway Insurance TPA Private Limited, 815, Vishwa Sadan, District Centre, Janakpuri, New Delhi – 110 058 through its Directors/principal Officer.

                                                                   …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.

PRESENT:                   Sh.  Rakesh Baisla,  counsel for the complainant.

                             Sh.  L.S. Perswal, counsel for opposite party No.1.

                             Opposite party No.2 exparte vide order dated 11.01.2022.

ORDER:

                   The facts in brief of the complaint are that  the complainant obtained a Family Medicare Policy bearing No. 2221002820P105163255 valid form 22.08.2020 to 21.08.2021 and the insured amount was Rs.2,50,000/-.  The complainant became seriously ill and he remained hospitalized at Sir Ganga Ram Hospital, Rajender Nagar, New Delhi a she was suffering from right submandibular Sialadenitis with Sialolithiasis and hence he got admitted in the above said hospital on 19.10.2020 and remained there upto 2010.2020.  The complainant informed the opposite parties about his ailment immediately and even at that time the opposite parties approved the claim of the complainant, for estimated value.  During that period the complainant spent Rs.78,198/- on account of doctors’ fees, room charges etc. and the complainant paid the said amount to the above said hospital. Accordingly the complainant submitted his claim form with the opposite parties for the above said amount and also completed each and every formality with the opposite parties to the entire satisfaction of the opposite parties.  Even the original bills were duly submitted by the complainant with the opposite parties at that time. Inspite of completing each and every formality by the complainant, the opposite parties paid only rs.51m532/-, leaving the balance amount of Rs.26,666/-.  Besides this the complainant spent on account of Covid Test, Pharmacy bills, doctor consultant charges, ultrasound, medicines, taxi fair charges. etc. which comes to Rs.12,865/-.  As such the grand total amount comes to Rs.39,531/-.  The complainant asked several times to the opposite parties to make the payment of the above said amount but they always avoided it on one pretext or the other. The complainant sent legal notice  dated 14.09.2021 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)                release the payment of rs.39,531/- alongwith interest @ 18% p.a. from the date of its due till realization of whole amount.

b)                 pay Rs. 20,000/- as compensation for causing mental agony and harassment .

c)                 pay Rs. 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 complainant had actively concealed from this Hon’ble commission that the answering opposite party – insurance company through its TPA(opposite party No.2) had approved he claim of the complainant for Rs.51,532/- (Rs.41,418/- paid by opposite party No.2 to hospital and Rs.10,114/- taken as discount form hospital by opposite party No.2) which was found payable and the  maximum permissible amount under the policy in question, but the complainant was adamant to get the entire bill amount irrespective of the terms and conditions and scope of coverage under the policy in question.  The complainant failed to provide:-

i)                 request letter (with the name of patient/insured, police No. address, contact No. & sign and reason of delay in submission of documents by 48 days) for delay condonation to the National Insurance company on behalf of the insured/patient.

ii)                Original prescription of doctor against medicine dated 19.10.2020.

iii)               Original Covid report & USG film.

In this regard after receiving the claim form on 22.12.2020 for Rs.11,565/- vide letter dated 01.01.2021, reminder dated 13.01.2021, final reminder dated 25.01.2021 were sent by opposite party No.2 but the complainant did not bother to submit any document which was required by opposite party No.2 to process the claim Rs.11,565/-, therefore, the answering opposite party was left with no other option except to close the file by invoking clause No.5.5 of the insurance policy due to non submission of query reply by the complainant.  The complainant has claimed rs.39,531/- but as per claim form he had submitted claim of rs.11,565/- only that too by making a bill of Rs.1200/- twice, even to substantiate that claim he failed to submit the required documents despite repeated letters by the opposite parties as detailed in forgoing paras of this written statement.It was submitted that the complainant his wife and son were insured with the answering opposite party under family Medicare Policy No. 2014 vide insurance policy No. 2221002818P106372696 w.e.f. 22.08.2018 to 21.08.2019 & 2020-2021 for sum insured of Rs.2 Lac. & 2.5 lac under  floater insurance scheme for all the insured persons under the policy.  The said policy was renewed subsequently and complainant obtained enhancement of the sum insured. As per discharge summary the opposite party No2. Came to know that the complainant was admitted in Sir Ganga Ram hospital, New Delhi with diagnosis of right submandibular stralaenitis with stalolithisis” underwent surgical procedure “Right Sumbmandibular combined approach with Salivary duct Calculi Removal”.  Since the insured had covered under the mediclaim policy in which A, 2years waiting period was mentioned for calculus disease and as per  clause 5.1.4, in case of enhancement of sum insured the exclusion shall apply a fresh to the extent of sum insuredincreased  Therefore, while settling the claim of the complainant the claim was restricted on sum insured of rs.2,00,000/- for the policy  year 2018-19.  Therefore, the per day room entitlement of the petitioner was1% of the sum insured i.e. 2,000/- per day, being so all other payable expenses were proportionately deducted as mentionedin clause 1.2 of the policy.  The details of the approved and deduction was detailed below:

  Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                Registered notice issued to opposite party No.2 on 17.12.2021 not received back  either served or unnerved. Tracking details filed in which it had been mentioned that “Item delivery confirmed”.  Case called several time since morning but none appeared on behalf of opposite party No.2  therefore, opposite party No.2 was hereby proceeded against ex-parte vide order dated 11.01.2022.

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– United India Insurance company Limited  with the prayer to:a)  release the payment of Rs.39,531/- alongwith interest @ 18% p.a. form the date of its due till realization of whole amount. b)   pay Rs. 20,000/- as compensation for causing mental agony and harassment .c)           pay Rs. 11,000/-as litigation expenses.

                   To establish his case the complainant  has led in his evidenceEx.CW1/A – affidavit of Jai Chand Chandila,, Ex.C-1 – legal notice, Ex.C-2 & 3 – postal receipts, Ex.C-4 – insurancepolicy,, Ex.C-5 – bill, Ex.C-6 – discharge summary,, Ex.C-7 – Receipt, Ex.C-8 – not readable,, Ex.C-9 prescription, Ex.C-10 & 11 – tests, Ex.C-1 – prescription,, Ex.C-13 – not readable, Ex.C-14 OPD prescription of  Sir Ganga Ram Hospital , Ex.C-15 – OPD bill,, Ex.C-16 – Prescription of sir Ganga Ram Hospital,, Ex.C-17 & 18 – OPD bill of Sir Ganga Ram Hospital, Ex.c-19 – bill,, Ex.C-20 bill, ex.c-21 – Cashless authorization (Part-D).

On the other hand, counsel for the opposite party No.1 strongly

agitated and opposed.  As per the evidence of the opposite party  No.1Ex.RWA/1 – affidavit of Shri Dinesh Kumar, Administrative officer, United India Insurance company Limited., Ex.R-1to R3 – letters,regarding additional information required, Ex.R-4 – Repudiation letter, Ex.R-5 – Claim form,, ex.r-6 – insurance policy for the period 22.08.2018 to21.08.2019, Ex.R-7 – insurance policy for the period 22.8.20 to 21.08.2021.

7.                It is evident from ex.C-4, the complainant obtained a Family Medicare Policy bearing No. 2221002820P105163255 valid form 22.08.2020 to 21.08.2021 and the insured amount was Rs.2,50,000/-.  The complainant became seriously ill and he remained hospitalized at Sir Ganga Ram Hospital, Rajender Nagar, New Delhi as she was suffering from right submandibular Sialadenitis with Sialolithiasis and hence he got admitted in the above said hospital on 19.10.2020 and remained there upto 2010.2020.  The complainant informed the opposite parties about his ailment immediately and even at that time the opposite parties approved the claim of the complainant, for estimated value.  The complainant spent Rs.78,198/- on account of doctors’ fees, room charges etc. and the complainant paid the said amount to the above said hospital..  Inspite of completing each and every formality by the complainant, the opposite parties paid only Rs..51,532/-, leaving the balance amount of Rs.26,666/-.  Besides this the complainant spent on account of Covid Test, Pharmacy bills, doctor consultant charges, ultrasound, medicines, taxi fair charges. Etc. which comes to Rs.12,865/-.  As such the grand total amount comes to Rs.39,531/-.

                   On the other hand, opposite party repudiated the claim of the complainant vide letter dated 01.09.2021 (Ex.R-4)  on the ground that the claim was lodged by the complainant on 19.10.2020 but despiterepeated reminder by the TPA  refer  letters dated 01.01.2021, 13.01.2021 final reminder 25.01.2021.   The requirement has not been completed by you with till date.  Hence, the claim file is closed under clause No. 5.5. of the insurance policy due to non submission of query reply.”

8.                During the course of arguments, counsel for opposite party No.1 stated that they are ready to pay the  amount, subject to submission of the bills.

9.                After going through the evidence led by parties, the Commission is of the opinion  that  the complaint is allowed. Opposite party No. 1 is directed to process the claim of the complainant, subject to submission of the bills within 30 days from the date  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.   There are no order as to costs because the opposite party has sent several letters to  the complainant for supply the required documents. Copy of this order be given to the parties  concerned free of costs and file be consigned to record room.

Announced on:26.08.2022                                   (AmitArora)

                                                                                  President

                    District Consumer Disputes

          Redressal  Commission, Faridabad.

                                                (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                   Redressal Commission, Faridabad.