District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.95/2019.
Date of Institution: 21.02.2019.
Date of Order: 23.01.2023.
Pankaj Singh son of Shri Tej Bahadur Singh Parmanent resident of E-1496, 22 feet Road, Dabua Colony, NIT, Faridabad.
At present resident of House No. G-2434, SF, Sainik Colony, Sector-49, NIT, Faridabad.
…….Complainant……..
Versus
1. M/s. United India Insurance Company, D.O.-21, Sector-16, Faridabad through its Senior Divisional Manager/Branch Manager/Principal Officer.
2. Health Insurance TPA of India Limited, Office at Majestic Omnia Building, Second floor A-110, Sector-04. Noida (UP) through its Senior Divisional Manager/Branch Manager/Principal Officer.
…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. Vinay Singh, counsel for the complainant.
Sh. Sachinder Bhatia, counsel for opposite party No.1.
Opposite party No.2 exparte vide order dated 25.02.2021.
ORDER:
The facts in brief of the complaint are that the complainant was the
consumer of the opposite party vide health insurance policy bearing No. 2221002817P104757649 for an insured sum of Rs.9,00,000/-. The complainant was admitted in Medanta the Medicity, Sector-38, Rajeev Chowk, Gurgaon from 29.06.2018 to 12.07.2018 for further treatment and invoice raised by the said hospital was Rs.2,85,878.07 and it includes medical charges medicine etc. During the hospitalization of the complainant the opposite party through its TPA namely health insurance TPA of India Limited had only approved Rs.63,262/- and still failed to pay Rs.2,22,616.07 to the complainant and had been withheld without any cause and reason best known to the opposite party. The entire invoices issued by the said hospital were handed over to the opposite party during the aforementioned hospital and the complainant also submitted the claim form to the opposite party vide claim form No. 2939/04 dated 25.07.2018. Inspite of receiving the said document, including approval letter dated 07.07.20189, copies of bill etc. the opposite party were avoiding the request of the complainant from one false pretext to another false pretext. Inspite of receiving the documents from the complainant the opposite party failed to reply the same till date in proper manner. The complainant sent legal notice dated 10.01.2019 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) pay an amount of Rs.2,22,616.07 of the medical expenses alongwith the interest @ 24%p.a.
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 31,000 /-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 not come before this Hon’ble Forum with clean hands and concealed the true, vital and material facts before this Hon’ble Forum were that the complainant was having the problem of Acute Necrotizing Pancreatitis since 2012 as clearly mentioned in the discharge summary and continuously taking treatment for the present disease in the hospital by taking the treatment of same problem and at that time the policy of the complainant issued from the opposite party having sum insured of the complainant as Rs.1,75,000/-. It was further submitted that during the present hospitalization from 29.06.2018 to 12.07.2019 the concerned TPA i.e. Third Party Administrator authorized an amount of Rs.63,262/- being the balance sum insured applicable for the period 2013-14 and already stated in Pre-Authorization Approval letter that the sum insured exhausted as applicable of sum insured Rs.1,75,000/- for the year 2013-14, therefore in view of the above opposite party passed an amount of Rs.63,262/- in favour of the complainant and directly paid the said amount to the hospital. Further in view of the above complainant was not entitled for the balance amount of Rs.2,22,616/- as stated in the present complaint, hence in view of the above complainant was not entitled to receive any amount from the opposite party. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Registered notice was sent to opposite party No.2 on 21.01.2021 not received back either served or unserved. Case called several times since morning but none had appeared on behalf of opposite party No.2. Learned counsel for the
complainant filed the tracking report in which the item delivered confirmed on 28.01.2021. Therefore, opposite party No.2 was hereby proceeded against ex-parte vide order dated 25.02.2021.
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 & Ors. with the prayer to: a) pay an amount of Rs.2,22,616.07 of the medical expenses alongwith the interest @ 24%p.a. b) pay Rs. 2,00,000/- 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 Pankaj Singh, Annexure P-1 – Hospitalization & Domiciliary Hospitalization Benefit Policy, Annexure P-2 – Bill of supply,, Annexure P-3 – Pre-Authorization Approval letter,, Annexure P-4 – legal notice,, Annexure P-5 – postal receipt, Annexure P-6 – Discharge Summary, Annexure P-7 – Bill of supply, Annexure P-8 – complaint. Annexure P-9 – written statement of opposite party No.1, Annexure P-10 - affidavit of Pankaj Singh, Annexure P-11 – Affidavit of Shri J.P.yadav, Sr. Div. Manager of opposite party No.1, Annexure P-12 – order dated 29.09.2014 passed by DCDRF, Faridabad , Annexure P-13 – insurance policy valid from 30.06.2013 to 29.06.2014, Annexure P-14 – Family Medicare Policy valid from 30.06.2014 to 29.06.2015, Annexure P-15 - Family Medicate Policy valid from 30.06.2015 to 29.06.2016, Annexure P-16 – Family Medicare Policy valid from 30.06.2016 to 29.06.2017, Annexure P-17 – Family
Medicare Policy valid from 30.06.2017 to 29.06.2018, Annexure P-18 – Family Medicare Policy valid from 30.06.2018 to 29.06.2019,.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A – affidavit of Smt. Kailash Taneja, Assistant Manager, United India Insurance Co. Ltd. At Divisional Officer-21, SCO-106, 2nd floor, Commercial Complex, Sector-16, Faridabad,, Annexure O/1 - Pre-Authorization Approval letter, Annexure O/2 – Bill of supply, Annexure O/3- Discharge summary of Medanta, Annexure O/4 – Discharge summary of Fortis Escorts,, Annexure O/5 – Inpatient bill, Annexure O/6 – Pre-Authorization Approval letter, Annexure O/7 – Family Medicare Policy valid from 30.06.2017 to 29.06.2018,
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the details given below:
Total Bill amount : Rs.2,85,878.07
Approved : Rs. 63,262.00
Balance amount : Rs.2,22,616.07
50% of the enhanced policy i.e : Rs. 87,500.00
Rs.1,75,000/-
Payable amount : (Rs.63,262/- plus rs,87,500/- = 1,50,762/-)
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: 23.01.2023 (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.
