District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.394/2021
Date of Institution: 11.08.2021.
Date of Order: 15.11.2023.
Soniya aged about 37 years wife of late Sh. Bhola resident of House NO.2C/JK-370, NH-2, NIT, Faridabad-121001. Aadhaar No. 5422 5478 6888.
…….Complainant……..
Versus
1. M/s. United India Insurance Co. Ltd., Div. Office at 5-R/5, (Above Aastha Eye Center), Neelam Chowk, NIT, Faridabad through its Divisional Manaer/principal Officer,
2. M/s. Vipul Medicorp TPA Pvt. Ltd., B-16, Ansal Chambrs-1, Bhikaji Kama Place, new Delhi – 110 0066 through its C.E.O./Authorized Signatory.
…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. Ravinder Yadav, counsel for the complainant.
Sh.N.K.Tanwar, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that husband of the complainant namely Sh. Bhola (now deceased) was regular mediclaim policy holders of the opposite parties since long for himself and for his family members (Sonia-wife, Neha-daughter, Rahul-son & Saurabh-son) under “Family Medicare Policy 2014”. The details of which were as under:
Policy No. Valid from To
2228002814P111479064 20.03.2015 19.03.2016
2228002815P115558061 20.03.2016 19.03.2017
2228002817P101371219 19.04.2017 18.04.2018
2228002818p102298501 17.05.2018 16.05.2019
All above for Rs.3,00,000/-
2228002819P102182774 17.05.2019 16.05.2020
For Rs.4,00,000/-
2228002820P101277876 17.05.2020 16.05.2021
For rs.4,00,000/-
The husband of the complainant namely Sh. Bhola suffered from Lower Limb Pain and Swelling back since 4-5 days, itchy and discolourstion of both lower limb, Nil Oral intacke, 2/3 episodes of vomiting and approached Medicheck Hospital, 1-C-76 & 53, NIT, Faridabad on 12.08.2020 in ICU vide IPD No. 2020/1067 and where several tests were done and the doctors gave treatment to the patient but the condition of the patient could not be improved and hence the complainant got the patient – Bhola discharged from said Hospital as LAMA on 14.08.2020. However, the treatment bill of Rs.85,487/- after discount total payment amount was Rs.77,763/- was provided by the opposite parties. Thereafter, the patient admitted in Sarvodaya Hospital & Research center, Sector-8, YMCA Road, Faridabad on 15.08.2021 vide IP No. IP216249 and the doctors of said hospital informed the opposite parties about admission of the patient and requested for providing cashless facilities, but the opposite parties denied for the same. The patient – Bhola remained admitted in Sarvodaya Hospital, Faridabad on 15.08.2020 and he was discharged on 24.08.2020 with follow up advice. The said hospital raised the bill for Rs.3,35,247/- but the opposite parties refused to make the said payment and hence, the complainant had to arrange the amount from her known, private financer and made a sum of Rs.2,19,999/- to the said hospital and then got the patient discharged. The patient was taking the medicines prescribed by the doctors of Sarvodaya Hospital and Research Center, but on 02.09.2020, the condition of the patient again became critical and the complainant immediately got the patient admitted in Prachi Hospital, SSI plot NO.2, NIT-3, Opp. Chimni Bai Dharamshala, Faridabad and kept him on ventilator but no improvement was found and hence the complainant got him discharged as LAMA on 04.09.2020 and raised the bill for Rs.50,000/-, but the complainant with all efforts arranged only Rs.40,000/- and same paid to the said Prachi Hospital, Faridabad. The husband of the complainant namely Bhola died on 04.02.2020. The complainant submitted the required documents as demanded by the opposite parties from the complainant and also resolved all the queries. 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 claimed amount of Rs.2,59,999/- alongwith interest @ 18% per annum from the date of bill till actual realization to the complainant.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the complainant had not filed for reimbursement the final bill with the required and requisite documents and reports mentioned in the complaint either with the answering opposite party or with TPA at any point of time. The complainant was not entitled for the claim asked in the complaint against the answering opposite party, as the complainant herself had not submitted the treatment bill for reimbursement within 6 months time limitation as there was a time limit for submission of final claim for reimbursement for medical expenses as defined by the Govt. of India, Ministry of Health and Family Welfare Department. The opposite party issued Family Medicare Policy bearing No. 2228002820P101277876 covering the risk from 17.05.2020 to 16.05.2021 in the name of Bhola and others. The said policy was issued subject to terms and conditions mentioned in the policy itself. On 12.08.2020, the complainant’s husband namely Bhola got admitted with the ailment of Lower Limb pain and swelling back, Lower Limb since 405 days Itchy and discoloration of both lower limb at medichek Hospital, NIT Faridabad and he was discharged against Lama ON 14.08.2020 AT ABOUT 16:50P.M. During the treatment, cashless facility was requested by the concerned hospital and the same was processed as per policy terms and conditions. The hospital had raised a bill of Rs.85,487/-, discount of Rs.7,814/- was given and net bill was Rs.77,673/-. The said net/final bill as well as the treatment record of the patient Bhola was checked and Rs.68,373/-, out of amount of Rs.77,673/- was approved by the opposite party and Rs.9300/- was disallowed towards the articles which were not covered under the mediclaim policy. Accordingly the amount of Rs.68,373/- was paid by the opposite party. The patient namely Bhola was got admitted with Sarvodaya Hospital, Sector-8, Faridabad on 15.08.2020 at about 6:43 a.m. with the complaints of lower limb pain and swelling in both lower limb since 3-4 days associated with thin and discoloration of both lower limb, reduced urine frequency, multiple episodes of vomiting , breathing difficulty on exertion. The request for cashless facility was made and which was processed as per the policy terms and conditions. The opposite party initially approved cashless facility for Rs.30000/- on 18.01.2020 and Rs.70,000/- on 22.08.2020. The detailed supporting treatment record was not provided by the hospital and for that, the said hospital informed by the TPA M/s. Vipul Medcorp Insurance, vide letter dated 24.08.2020 the preauthorization of cashless facility for treatment in the hospital was issued subject to terms and conditions exclusion and limitation of health coverage plan of beneficiary and the preauthorization of cashless was declined with the reason that “put the case in reimbursement with all supporting documents to decide admissibility”. The TPA of opposite party received a final bill of Rs.3,35,347/- on 24.08.2020 upon which the TPA had requested the hospital to provide justification from the treating doctor or prolonged hospitalization alongwith all investigations reports and treatment chart date wise, but the said hospital failed to provide the required information and documents/record to the TPA of opposite party, but no reply was ever received from the hospital, hence the cashless facility was cancelled and advised to put the case in reimbursement. The final bill and requisite reports treatment file for the period 15.08.2020 to 24.08.20 were not submitted for reimbursement by the complainant. Opposite parties 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–- M/s. United India Insurance Company Ltd.. with the prayer to: a) a) pay the claimed amount of Rs.2,59,999/- alongwith interest @ 18% per annum from the date of bill till actual realization to the complainant. b) pay Rs.1,00,000/- 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 evidence, Ex.CW1/A – affidavit of Soniya, Ex.C-1 – letter dated 04.05.2017, Ex.C-2 – insurance policy for the period 20.03.2015 to 16, Ex.C-3 – insurance policy for the period 20.03.2016 to 19.03.2017, Ex.c-4 – insurance policy dated 19.4.2017 to 18.04.2018, Ex.C-5 – insurance policy valid from 17.5.2018 to 16.5.2019, Ex.C-6 – insurance policy valid from 17.08.2019 to 16.05.2020, Ex.C-7 – Receipt,, Ex.C-8 – discharge summary,, Ex.C-9 – final bill dated 14.08.2020, Ex.C-10 – discharge summary, Ex.C-11 – insurance bill of supply dated 24.08.2020, Ex,C-12 – bill, Ex.C-13 & 14 – receipts Ex.C-16 – LAMA summary, Ex.C-17 -& 18 bills, Ex.C-19 – death certificate, Ex.C-20 – legal notice, Ex.C-21 & 22 – postal receipts.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A - affidavit of Shri I.D.Sharma, United India Insurane Company Limited, Divisional Office, 5-R/5, First floor, Aastha Eye Centre), Neelam Chowk, NIT, Faridabad, Ex.R-1 – isnruance policy valid from 17.05.2020 to 16.05.2021, Ex.R- 2- customer information sheet, Ex.R-3 – Certificate in respect of compliance of section 64 VB of Insurance Act,1938, Ex.R-4 – Cashless facility denial letter dated 24.08.2020, Ex.R-5 – email dated 14.09.2021.
6. It is evident from letter dated 24.08.2020 vide Ex.R-4 in which it has been mentioned that” put the case in reimbursement with all supporting documents to decide admissibility. However, please note that denial of cashless facility does not mean denial of treatment to patient. However, it means that the patient will have to pay the charges at the hospital. He/she can send us the bills and all related documents in original and lodge a reimbursement claim with us. The claim will be processed and settled by us subject to the terms and conditions of the policy.”
Keeping in view of the above letter, the Commission is of the opinion that the complainant is directed to lodge claim within 15 days with the insurance company and then the insurance company will settle the claim within 30 days from the date of receipt of claim from the complainant. However, if the claim of the complainant is repudiated then he is at liberty to file the fresh complaint before this Commission. So the present complaint is disposed off being pre-mature. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 15.11.2023 (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.