District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 646/2021.
Date of Institution: 14.12.2021.
Date of Order:15.03.2023.
Smt. Kamlesh Kaushik wife of Shri Rajbir, resident of House No. 1799, Sector-8, Faridabad.
…….Complainant……..
Versus
1. M/s. United India Insurance Company Ltd., D-8, C.S.A. Marg Vikas Marg, Laxmi Nagar, New Delhi, East Delhi – 110 092 through its Managing Director/Principal Officer.
2. M/s. United India Insurance Company Ltd., SCO -106, Commercial Complex, Sector-16, Faridabad, Haryana through its Branch Manager.
3. Health Insurance TPA of India Ltd., at A-110, 2nd floor, Majestic Omnia Building, Sector-4, Noida – 201301 (U.P) through its Branch Manager.
…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. Ashok Kumar, counsel for the complainant.
Sh. Sachinder Bhatia, counsel for opposite parties Nos. 1 to 3.
ORDER:
The facts in brief of the complaint are that the complainant was insured with the opposite parties since 15.10.2018 under family medical policy since 2014 and had been covered by the policy No. 2215002919P109076028 valid upto 14.10.2019 and the complainant was still insured with the opposite party insurance company. Due to pain in lower abdomen the complainant got admitted in QRG Health City Hospital, Plot No.1, Sector -16, Faridabad where she remained admitted and got discharged on 07.03.2019, She under went surgery there and the hospital charged an amount of Rs.1,00,758/- and at that time the TPA only paid Rs.68,988/- thus an amount of Rs.31,770/- got deposited by the complainant through her husband Mr. Rajbir who was also insured under the same policy. After complainant got discharged the claim was submitted for payment of the balance amount of Rs.31,770/- as well as claim for the expenses incurred on the purchase of medicines amounting to Rs.12,552/- prescribed by the concerned doctors during the follow up treatments. The opposite parties had paid only an amount of Rs.8802/- through NEFT which got credited in the account of .Rajbir (principal insured), the husband of the complainant on 15.4.2019 and the balance amount of Rs.36,320/- was still due against the said claims and opposite party company was liable to pay the same to the complainant but opposite party had completely failed to make the payment of the said due amount. The complainant had complied all the requirements but the opposite parties yet had not paid any amount towards the balance claimed amount of Rs.36,320/-. The complainant sent legal notice dated 27.01.2020 to the opposite party 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) reimburse the entire balance amount of claim of Rs.36,320/- ID mentioned above alongwith interest as well as the further expenses incurred by complainant on her follow-up treatments from the date of due till actual realization.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 31,000 /-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 complainant had not come present before this Hon’ble Commission with clean hands and suppressed the true and material facts in the above matter as the complainant obtained the medical claim insurance policy issued from answering opposite party valid from 15.10.2018 to 14.10.2019. The admission of patient on 04.03.2019 regarding the suffering of pain in Lower Abdomen and on the advice of the doctors and hospital managed and conducted the Ovarian Cystectmy and Ashesiolysis under package was done and discharged on 07.03.2019 in QRG Health City Faridabad and given the course of Ovarian Cystectmy and Ashesiolysis under Package done by the hospital and charged the amount as per Package and mentioned in the final bill and further as per insurance policy under Family Medicare Policy 2014 and GIPSA package schedule wherein the package amount covered under the hospital as settled between the insurance company regard to treatment conducted by the hospital and for this the insurance company was entitled to pay an amount of Rs.68,988/- to the hospital as per package and settled with the hospital under GIPSA package between the Third Part Administrator/insurance company with the hospital and the complainant also signed the GIPSA PPN network declaration form, and further TPA settled the amount as per tariff applicable as per package and also paid and settled the balance amount of Rs.31,770/- as per terms and conditions as the details were as:
Claimed amount Rs.31,770/-
Settled amount 14,660/-
(as the balance amount of Rs.17080/- deducted due to reason of, Rs.16380/- had been deducted against the package of ovarian cystectomy as the TPA already paid under PPN package of TAH + BSO +adhesiolysis (Removal of uterus, fallopian tube and ovary). Hence, no amount was due against the insurance company and TPA as the amount already paid as per the insurance policy. Further, with regards to additional claimed amount of Rs.12,502/- towards follow up treatment charges wherein the TPA and settled an amount of Rs.8002/- and the balance amount of Rs.4500/- deducted due to reason of not provided the doctor prescription of dated 18.02.2019 and 18.3.2019 as Rs.3000/- and bills of Rs.1500/- also not provided, therefore the TPA not paid the said amount, 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 Company Ltd.with the prayer to: a) reimburse the entire balance amount of claim of Rs.36,320/- ID mentioned above alongwith interest as well as the further expenses incurred by complainant on her follow-up treatments from the date of due till actual realization. b)pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 31,000 /-as litigation expenses
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Kamlesh Kaushik, Ex.C1 – insurance policy valid from 15.10.2018 to 14.10.;2019,, Ex.C2 – query letter dated 20.02.2020, ex.C3 - letter dated 2.3.3020, Ex.C4 – Final Bill of supply summary, Ex.C5 & C6– Advance Deposit receipt, Ex.C7 – postal receipt,, Ex.C-8 – Dawa Patar, Ex.C-9 – invoice cum receipt,, Ex.C-10 –& 11 Tax invoice,, Ex.C12 – invoice cum receipt,, Ex.C-13 – Test., Ex.C-14 – Invoice cum receipt,, Ex.C-15 – prescription,, Ex.C-16 – test,, Ex.C-17 – test, Ex.C-18 to 21– Tax invoice, Ex.C-22 – Invoice cum receipt,, Ex.C-23 – Tax invoice,, , Ex.C-24 – OPD consultation summary,, Ex.C-25 to 29– invoice cum receipt, Ex.C-30 – Discharge summary,, ex.C-31 – OPD consultation summary, Ex.C-33 – legal notice, Ex.C-34to 36 – postal receipts.
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 Dinesh Kumar, Admin. Officer, M/s. United India Insurance Co. Ltd., Branch Office at SCO-106, Sector-16, Faridabad, Ex.R-1 – GIPSA PPN Network Declaration by Patient/patient’s attender,, Ex.R-2 – Final Bill of supply summary, Ex.R-3 – insurance policy,, Ex.R-4 - email.
6. During the course of arguments, counsel for the complainant has admitted this fact that opposite parties have already paid some of the claim to the complainant. On the other hand, counsel for opposite parties argued at length and stated that opposite parties have already paid Rs.14,660/- in the account of the complainant. But the opposite parties have failed to establish that they have paid the amount to the complainant.
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties, jointly & severally, are directed that if the opposite parties have already paid the amount to the complainant, give the receipt to the complainant in which account opposite patties have deposited the amount. If the opposite parties did not pay the balance amount to the complainant then ordered to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the balance amount alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.1100/- as compensation for causing mental agony & harassment alognwith Rs.1100/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 15.03.2023 (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.
