District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.156/2021.
Date of Institution: 18.03.2021.
Date of Order: 12.09.2022.
1. Satish Vohra S/o Fakir Chand, R/o 2C-67, NIT, Faridabad.
2. Pankaj Vohra S/o Satish Vohra R/o 2C-67, NIT, Faridabad.
…….Complainants……..
Versus
M/s. United India Insurance Company Limited, Divisional Office-10, Office at 5R/4, Gobind Bhawan, 2nd floor, NIT, Faridabad through its Divisional Manager.
…Opposite party……
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. Sandeep Gupta, counsel for the complainant.
Sh. D.K.Gosain, counsel for opposite party
ORDER:
The facts in brief of the complaint are that the complainant Shri Satish Vohra had originally purchased family medicare policy No. 222000/48/11/06/00002372 valid for the period 01.11.2011 to 31.10.2012 for complainant No.1, his wife and his children. The said policy was being renewed every year without any break by complainant NO.1 by paying the requisite premium as demanded by opposite party and lastly complainant No.1 got renewed the family medicare policy of opposite party for the period 01.11.2020 to 31.10.2021 vide policy No.22210002820P108420685. The son of the complainant NO.1 namely Pankaj Vohra (complainant No.2) fell sick on 23.11.2020 and was admitted in Shivmani Hospital, NIT, Faridabad. The complainant No.2 was eventually discharged on 24.11.2020 and complainant No.1 had to pay treatment charges of Rs.26,973/- to Shivmani Hospital. Medicare policy obtained by complainant No.1 was a cashless policy but inspite of that opposite party repudiated the claim of complainant No.2 arbitrarily and without any basis and it was intimated by the hospital to complainants and since complainant No.2 was employed and was not a student, so opposite party had repudiated the claim of the complainant, as in the policy document complainant N.2 had been shown to be a student. Complainant NO.1 had originally purchased the medicare policy in 2011 and at that time age of complainant No.2 was only 13 years and he was a school going student and since then the policy was being renewed at the end of opposite party and no fresh proposal form had ever been filed by complainant No.1 after purchasing the original policy in the year 2011. Opposite party company had never raised any query from complainant No.1 at the time of renewing the said policy so mistake if any could not be attributed to complainant No.1 and was rather attributed to officers of opposite party. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) refund the amount of Rs.26,973/- alongwith interest @ 18% p.a. from the date of payment made by the complainant to the opposite party till the refund in made to the complainant.
b) pay Rs. 10,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 10,000 /-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 the complainants had neither any cause of action nor locus standi to file the present complaint. The opposite party issued policy No.2210002820P108420685 valid from 01.11.2020 to 31.10.2021 to Satish Vohra thereby insuring Satish Vohra, his wife and his son and daughter, who were students subject to the terms and conditions and exclusion clauses as well as limited liability under the said insurance policy, which were never disputed by the insured. There had been no deficiency in service on the part of the opposite party as the claim of the complainant No.2 was processed by Medsave Health TPA Limited on receipt of documents for cashless preauthorization request form Shivmani Hospital for his hospitalization on 23.11.2020 as a case of Covid Pneumonia and as per query reply received from the hospital Medsave Health TPA Limited understood that the patient was employed so not covered as per policy conditions therefore, cashless was denied vide letter dated 24.11.2020 sent to Shiv Mani Hospital by MedSAve Health TPA Limited. 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– United India Insurance Co. Ltd.with the prayer to: a) refund the amount of Rs.26,973/- alongwith interest @ 18% p.a. from the date of payment made by the complainant to the opposite party till the refund in made to the complainant. b) pay Rs. 10,000/- as compensation for causing mental agony and harassment . c) pay Rs. 10,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A- affidavit of Satish Vohra,, Ex.C-1 - Request for cashless hospitalization for health insurance policy Part-C, Ex.C2 – insurance policy for the period 01.11.2011 to 31.10.2012, Ex.C-3 – Family Medicare Policy valid from 01.11.2012 to 31.10.2013, Ex.C-4 – Family Medicare Policy valid from 01.11.2013 to 31.10.2014, Ex,C-5 – Family Medicare Policy valid from 01.11.2014 to 31.10.2015, Ex.C-6 – Family Medicare Policy 2014 valid from 01.11.2015 to 31.10.2016, Ex.C7 – family Medicare Policy 2014 valid from 01.11.2016 to 31.10.2017, Ex.C-8 – Family Medicare Policy 2014 valid from 01.11.2017 to 31.10.2018, Ex.C-9 – Family Medicare Policy 2014 valid from 01.11.2018 to 31.10.2019, Ex.C-10 – Family Medicare Policy 2014 valid form 01.11.2019 to 31.10.2020, Ex.C-11 (colly P20 to 23) Family Medicate Policy 2014 valid from 01.11.2020 to 31.10.2020, Ex.C-12 – IPD Bill, Exs.C13 – Advance Receipt, Ex.C-14 – Discharge summary, Ex.C-15 – legal notice,, Ex.C-16 – postal receipt, Ex.C-17 (colly) – Lab/X-ray report, Ex.C-18 – GST Invoice,, Ex.C-19 - HRCT Chest report,, Ex.C-20- Advanced NCR Diagnostics.
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 Shri Dinesh Kumar, Administrative Officer, M/s. United India Insurance Company Limited, D.O.10, SCO-106, 2nd floor, sEctor-16, Faridabad.,, Ex.R1 – Family Medicare Policy 2014 valid for the period 01.11.2020 to 31.10.2021,, Ex.R-2 – letter dated 24.11.2020 regarding denial of cashless facility for the treatment of Mr. Pankaj Vohra.
6. In this case the complainant Shri Satish Vohra had originally purchased family medicare policy No. 222000/48/11/06/00002372 valid for the period 01.11.2011 to 31.10.2012 for complainant No.1, his wife and his children. The said policy was being renewed every year without any break by complainant No.1 by paying the requisite premium as demanded by opposite party and lastly complainant No.1 got renewed the family medicare policy of opposite party for the period 01.11.2020 to 31.10.2021 vide policy No.22210002820P108420685. The son of the complainant NO.1 namely Pankaj Vohra (complainant No.2) fell sick on 23.11.2020 and was admitted in Shivmani Hospital, NIT, Faridabad. The complainant No.2 was eventually discharged on 24.11.2020 and complainant No.1 had to pay treatment charges of Rs.26,973/- to Shivmani Hospital. It is evident from repudiation letter dated 24.11.2020 vide Ex.R2 on the ground that “ “the liability of the insurance company under this policy is not determinable at the present from the details provided to us regarding the history of the insurance and disease. Cashless denied because patient is employed and so not covered as per policy conditions.”
7. After going through the evidence led by the parties, the Commission is of the opinion that Complainant No.1 had originally purchased the medicare policy in 2011 and at that time age of complainant No.2 was only 13 years and he was a school going student and since then the policy was being renewed at the end of opposite party and no fresh proposal form had ever been filed by complainant No.1 after purchasing the original policy in the year 2011. Opposite party company had never raised any query from complainant No.1 at the time of renewing the said policy .
8. Keeping in view of the above, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant 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. The opposite party is 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: 12.09.2022 (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.
