District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 292/2020.
Date of Institution:08.09.2020
Date of Order: 05.05.2023.
1. Daya Chand, aged about 46 years, S/o Shri Om Parkash
2. Ms. Nandani, aged about 14 years, daughter of Sh. Daya Chand through her father as natural guardian Sh. Daya Chand both R/o Masani Mohalla, Near Govt. School, Fatehpur Billoch, Tehsil Ballabgarh, Distt. Faridabad (Haryana).
…….Complainants……..
Versus
1. M/s. United India Insurance Company Ltd., 5R/4, Gobind Bhawan, NIT, Near B.K.Chowk, Faridabad – 121001.
2. Health Insurance TPA of India Ltd., TPA Code No. 20012,
Corporate office and CPC, 2nd floor, Majestic Omnia Building, A-110, Sector-4, Noida, U.P., Service to be effected through M/s. United India Insurance Company Ltd., 5R/4, Gobind Bhawan, NIT, Near B.K.Chowk, Faridabad – 121001.
…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. C.S.Sharma , counsel for the complainant.
Sh. D.K.Gosain, counsel for opposite party No.1.
Opposite party No.2 exparte vide order dated 5.8.2022.
ORDER:
The facts in brief of the complaint are that the complainant No.1 Sh. Daya Chand s/o Shri Om Parkash opted mediclaim health family policy form the United India Insurance Company Ltd. w.e.f. 18.04.2019 to 17.04.2020 vide policy No. 2210002819P101060871 and paid a sum of Rs.10,520/- as pemium to the insurance company for the family members his wife Smt. Rekha, daughters Ms. Anjali and Ms. Nandani i.e. complainant No.2 and son Kamal and the above said policy further renewed w.e.f. 18.04.2020 to 17.04.2021 by paying the premium to the insurance company for the family members mentioned above. The daughter of the complainant No.2 namely Ms. Nandani (minor) aged about 14 years, who was insured under the mediclaim policy by the opposite parties under family plan, suffered illness due to vomiting after meals, headache and body-ache and pain in all over body since one week ago from 12.08.2019 and the daughter of the complainant Ms. Nandani i.e. the complainant No.2 was taken for treatment to Sarvodaya Hospital & Research Centre, Sector-8, Faridabad on 12.08.2019 and after on check up by the doctors of the hospital the complainant No.1 was advised to get admit the patient Ms. Nandani i.e. the complainant No.2 for further treatment and thus the complainant No.2 was got admitted on 12.08.2019 in Sarvodaya Hospital & Research Centre, Sector-8, Faridabad and the doctor provided the treatment and diagnosed the disease severe anemia with leucopenia, hypovitaminosis and gastritis due to recurrent vomiting and daughter of the complainant i.e the complainant No.2 remained admitted upto 17.08.2019 and the
opposite parties were duly informed by the complainant No.1 and by the Sarvodaya Hospital & Research Centre, Sector-8, Faridabad. The information regarding the admission and treatment of the daughter of the complainant No.1 Ms. Nandani i.e. the complainant No.2 was given to the opposite parties firstly on telephone on 12.08.2019 and the opposite parties had confirmed the intimation with the pre-authorization approval letter dated 13.08.2019 but the official of the opposite parties had not visited in the hospital and had not paid any heed to the information delivered to them by the complainant No.1 and the opposite parties rendered deficient short service in pursuance of their unfair trade practice. The complainant NO.1 requested the opposite parties to pay the bill amount of Rs.62,056/- to Sarvodaya Hospital & Research Centre, Sector-8, Faridabad for the treatment of the complainant No.2 but the opposite parties deferred the legitimate request of the complainant No.1 and refused to pay the bill amount of Rs.62,056/- to Sarvodaya Hospital & Research Centre, Sector-8, Faridabad on behalf of the daughter of the complainant i.e the complainant No.2 and the complainant No.1 was forced by the opposite parties to pay the bill amount in cash to the Sarvodaya Hospital & Research Centre, Sector-8, Faridabad and whereas later on the opposite parties assured the complainant No.1 to pay/release the bill amount of Rs.62,056/- on submission of the claim form in respect of treatment of complainant No.2. The complainant No.1 had submitted all the documents alongwith claim form in respect of the treatment of the complainant No.2 to the opposite parties Nos.1 & 2 but the opposite parties Nos.1 & 2 in collusion with each other and in pursuance of their unfair trade practice refused to pay the bill amount of Rs.62,056/- on the false allegation that the patient i.e the complainant No.2 had complaint of heavy bleeding since one year and admitted for blood transfusion, patient were chronic
and the policy was opted on 18.04.2019, so the disease of the patient were re-existing and the claim of the complainants repudiated under the alleged clause 4.1 & 5.13 (2) vide repudiation letter dated 28.03.2020. The complainant No.1constantly requested the opposite parties to pay the bill amount of Rs.62,056/- but the opposite parties finally refused to pay the bill amount on 07.08.2020. The complainant sent legal notice dated 10.08.2020 to the opposite parties through registered post 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 Rs.62,056/- alongwith interest @ 24% p.a. from the date of due i.e.17.08.2019 till the date of realization the amount.
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) any other relief which the Hon’ble District Commission found fit and proper may also be awarded to the complainants with cost of the complaint.
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 opposite party had issued mediclaim insurance policy No. 2210002819P101060871 valid from 18.04.2019 to 17.04.2020, subject to the terms and conditions and exclusion clauses and the limited liability of said insurance policy. There was no deficiency in service on the part of answering opposite parties as the claim of the complainants with regards to hospitalization of Ms. Nandini daughter of the complainant, the same was got processed and investigated
by opposite party No.2 on the basis of the documents provided to opposite party No.2 and after investigation, it was found that disease of the complainant No.2 was pre-existing and the claim of the complainant was repudiated under clause 4.1 and 5.13(2) vide repudiation letter dated 28.03.2020 sent to the complainant giving reasons regarding repudiation of the claim. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3 Notice issued to opposite party No.2 on dated 15.07.2022 not received back either served or unserved. Tracking details filed in which it had been mentioned that “Item Delivery Confirmed” Therefore, opposite party No.2 was hereby proceeded against ex-parte vide order dated 05.08.2022.
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 with the prayer to: a) pay Rs.62,056/- alongwith interest @ 24% p.a. from the date of due i.e.17.08.2019 till the date of realization the amount. b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . c) any other relief which the Hon’ble District Commission found fit and proper may also be awarded to the complainants with cost of the complaint.
To establish his case the complainant has led in his evidence,
Ex.CW1/A – affidavit of Daya Chand, Ex.C-1(colly) – insurance policy for the period 18.04.2019 to 17.04.2019,, Ex.C-2 – identity card, Ex.C-3 – Pre-authorization approval letter, dated 13.08.2019, Ex.C-4 – pe-authorization query letter, Ex.C-5 – pre-authorization denial letter, Ex.C-6 (colly) – patient retained IPD record, Ex.C-7 – Discharge summary, Ex.C-8(colly) – Bill of supply (Final Bill), Ex.C-9 – legal notice, Ex.C-10 to 12 – postal receipts,
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 Dinesh Kumar, Administrative Officer, M/s. United India Insurance Company Limited, Ex.R-1 – insurance policy valid from 18.04.2019 to 17.04.2020, Ex.R-2 – repudiation letter dated 28.03.2020, Ex.R3 - pre-authorization denial letter, dated 17.08.2019, Ex.R-4 – pre-authorization query letter dated 16.08.2019.
7. In this case, the complaint was filed by the complainant with the prayer to pay Rs.62,056/- alongwith interest @ 24% p.a. from the date of due i.e.17.08.2019 till the date of realization the amount.
8. It is evident from Ex.C-1 (colly) that the complainant No.1 Sh. Daya Chand S/o Shri Om Parkash obtained mediclaim health family policy form the United India Insurance Company Ltd. w.e.f. 18.04.2019 to 17.04.2020 vide policy No. 2210002819P101060871 and paid a sum of Rs.10,520/- as premium to the insurance company for the family members his wife Smt. Rekha, daughters Ms. Anjali and Ms. Nandani i.e. complainant No.2 and son Kamal and the above said policy further renewed w.e.f. 18.04.2020 to 17.04.2021 by paying the premium to
the insurance company for the family members mentioned above. The daughter of the complainant No.2 namely Ms. Nandani (minor) aged about 14 years, who wasinsured under the mediclaim policy by the opposite parties under family plan, suffered illness due to vomiting after meals, headache and body-ache and pain in all over body since one week ago from 12.08.2019 and the daughter of the complainant Ms. Nandani i.e. the complainant No.2 was taken for treatment to Sarvodaya Hospital & Research Centre, Sector-8, Faridabad on 12.08.2019 and after on check up by the doctors of the hospital the complainant No.1 was advised to get admit the patient Ms. Nandani i.e. the complainant No.2 for further treatment and thus the complainant No.2 was got admitted on 12.08.2019 in Sarvodaya Hospital & Research Centre, Sector-8, Faridabad and the doctor provided the treatment and diagnosed the disease severe anemia with leucopenia, hypovitaminosis and gastritis due to recurrent vomiting and daughter of the complainant i.e the complainant No.2 remained admitted upto 17.08.2019 and the opposite parties were duly informed by the complainant No.1 and by the Sarvodaya Hospital & Research Centre, Sector-8, Faridabad.
9. It is evident from Pre-Authorization approval letter dated 13.08.2019 vide Ex.C-3which was issued by opposite party No.2 to the hospital. Opposite party No.2 vide preauthorization query letter dated 16.08.2019 sought information from the hospital mentioned in the said letter to process the assessment of preauthorization request vide ExR-3 Preauthorization denial letter dated 17.08.2019 vide EX.R-4 intimated to the hospital that the claim has been denied as per the instruction of opposite party No.1 on detailed scrutiny of the documents submitted to opposite party No.2, they observed that Chroncity of the ailment
cannot be ruled out at present juncture. Hence, preauthorization facility cannot be extended in this case, Please come for possible reimbursement. Further it was intimated to the hospital “Kindly do not charge more than GIPSA agreed rates as GIPSA rate are applicable for both cashless and reimbursement claims.” Opposite party has repudiated the claim of the complainant vide Ex.R2 on the ground that “(i) As per submitted documents it is evident that patient was hospitalized as a diagnosed case of severe anemia with leucopenia, hypovitaminosis, gastritis & managed medically & discharged with follow up advice. On Verification of claim patient has complaint of heavy bleeding since 1 year & admitted for blood transfusion. Complaints are chronic. Policy inception dated is 18.4.2019. So this disease stands pre-existing also this case has been misrepresented. Hence claim is recommended for repudiated under clause 4.1 & 5.13(2).
10. During the course of arguments, counsel for the complainant has placed on record photocopy of ICICI Lombard Health Care Card bearing policy No. 4128i/iH/88110572/00/000 valid from 06.03.2014 to 05.03.2015 Opposite party repudiated the claim of the complainant under clause 4.1 and 5.13(2) vide repudiation letter dated 28.03.2020. It does not cover before 48 months. After filing of this policy it was the duty of the opposite party to verify the policy whether it is continued or only for the period upto 2015. There is policy No.2210002819P101060871 valid from 18.04.2019 to 17.04.2020 which is placed on file vide Ex.C-1(colly).
The counsel for the complainant has placed on record authority in case titled Vipin Grover & Anr. Vs. New India Assurance Co. Ltd. Passed by Hon’ble National Consumer Disputes Redessal Commission, New Delhi II(2018) CPJ 374(NC).
11. After going through the evidence as well as citation placed by the complainant, the Commission is of the opinion that the complaint is allowed. Opposite parties are 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 alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- 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: 05.05.2023 (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.
