District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.439/2019.
Date of Institution: 10.09.2019.
Date of Order: 16.09.2022.
Anish Garg aged 39 years S/o Shri Shiv Kumar Garg r/o H.NO. 658, Sector-16A, Faridabad.
…….Complainant……..
Versus
1. M/s. United India Insurance Co. Ltd., DO-21, SCO-106, HUDA Market, Sector-16, Faridabad.
2. The Senior Divisional Manager M/s. United India Insurance Co. Ltd., DO-21, SCO-106, HUDA Market, Sector-16, Faridabad.
3. Syndicate Bank, SCF-65, HUDA Market, Sector-16A, Faridabad.
4. Branch Manager, Syndicate Bank, SCF-65, HUDA Market, Sector-16A, Faridabad.
5. M/s. MedSave Health Insurance TPA Ltd., F-701A, Ldo Sarai, Mehrauli, New Delhi – 110 030.
…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. G.L.Rawat, counsel for the complainant.
Sh. Sachinder Bhatia, counsel for opposite parties Nos.1 & 2.
Sh. Anup Kumar, Counsel for opposite parties Nos.3 & 4.
Opposite party No.5 ex-parte vide order dated 18.11.2019.
ORDER:
The facts in brief of the complaint are that the complainant was having his saving bank account No. 92552010004110, with M/s. Syndicate Bank, Sector-16A, Faridabad, the opposite party No.3 herein, whereas the opposite party No.4 was the Branch Manager of opposite party No.3. On the asking of the opposite party No.4 on behalf of opposite party No.3, the complainant took medicalim insurance policy from the opposite party No1 through the opposite party No.2 by making the payment of Rs.6400/- towards Mediclaim Insurance premium for the period 25.07.2018 to 24.07.2019. Opposite parties Nos.3 & 4 were having tie up with opposite parties Nos.1 & 2 for getting all the customers/account holders of the opposite parties Nos.3 & 4 insured. Accordingly an amount of Rs.6400/- was deducted from the account of the complainant by opposite parties Nos.3 & 4 in order to make the payment of insurance premium to the opposite parties Nos.1 & 2. Accordingly , opposite parties Nos.1 & 2 issued insurance policy NO. 2221002818P105397028 covering the insurance risk from 25.07.2018 to 24.07.2019 for the sum insured of Rs.4,00,000/- in the name of the complainant Anish Garg, covering the family members of the complainant namely Deepali
Garg (wife of the complainant), Arshia Garg (daughter of the complainant) and Ansh Garg (son of the complainant) alongwith the complainant. It was worth mentioning here that prior to the above mentioned insurance policy, the complainant was also having the earlier insurance policy from opposite parties Nos.1 & 2 through the opposite parties Nos.3 & 4 bearing insurance policy No. 2221002817P106083935 covering the insurance risk from 25.07.2017 to 24.07.2018 for a total sum insured of Rs.3,00,000/-. Prior thereto, the complainant was having uninterrupted medical claim insurance policies right from 23.07.2010 onwards with M/s. National Insurance Limited. Thereafter the complainant shifted to United India Insurance Company Limited through Syndicate Bank, being the customer/client/account holder of Syndicate Bank which promoted Synd Arogya (Group Health Insurance Scheme) for the account holder of syndicate bank. On 13.03.2019, the complainant had pain in jaw and as such visited Gupta Nursing Home, sEctor-16A, Faridabad, whereby Dr. Suresh Gupta referred the complainant QRG Hospital, Faridabad asking about diabetes and hypertension. The complainant got admitted in QRG Health City, Hospital, Sector-16, Faridabad for his treatment and required check up, whereby the complainant submitted his insurance policy to the hospital authorities to avail cashless facility. Accordingly, the hospital authorities of QRG Health City Hospital, sent mail to the opposite party No.5, the 3rd party Administrator of the opposite parties Nos.1 & 2 seeking permission for cashless treatment of the complainant. To the utter surprise of the complainant, the opposite party No.5 rejected the cashless facility taking a frivolous and baseless plea invoking clause 4.1 of the insurance policy i.e. pre existing disease, whereas the complainant was not having any such pre-existing disease as alleged by the opposite party NO.5 in email dated 14.3.2019. The complainant was discharged from QRG Health City Hospital, sEctor-16A, Faridabad on 15.03.2019 vide Discharge summary No. 100053292. It was submitted that the treating doctor team put stent Tetrilimus 3.5 x 40 mm. The hospital Authorities put hospitalization/inpatient bill worth Rs.1,76,291/- in cash against receipt Nos. QHA/19/328900 dated 13.03.2019 for Rs.10,000/- & QHA-19/333414 dated 15.03.2019 for Rs. 1,66,291/-. After the discharge form the hospital, the complainant submitted letter dated 30.03.2019 to opposite party No.5, the TPA of opposite parties Nos.1 & 2 claiming reimbursement of the mediclaim. The original required papers were also submitted to the opposite party No5., appearing at serial No.1 to 11. Thereafter the opposite party No.5 sent a letter dated 0105.2019 to the complainant raising query pertaining to the mediclaim insurance policy and to provide invoice and sticker of stent used, Opposite party No.5 upon receipt of the demanded documents, sent email dated 31.05.2019 whereby the opposite party No5. Treated the insurance policy in question a fresh policy ignoring the fact that the complainant was being insured right from the year 2010, which would become crystal clear from the averments mentioned in para No.2 of the complaint. 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) make the payment of Rs.1,76,291/- alongwith interest @ 12% p.a. from the date of seeking cashless medical facility till its actual payment to the complainant.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 25,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the complainant had not come present before this Hon’ble Forum with clean hands and suppressed the true and material facts in the above matter as the complainant obtianed the medical claim insurance policy issued form answering opposite party by making the payment of Rs.6400/- towards premium and the insurance policy was valid from 25.07.2018 to 24.07.2019. The above said policy issued by the answering opposite party in the name of the complainant and in this regard the complainant paid the premium as demanded by the opposite party and the insured the policy for a period of Rs.4,00,000/- The complainant admitted in the hospital i.e. QRG Health City Hospital, Sector-16, Faridabad for the treatment and further discharged on 15.03.2019 and paid an amount of rs.1,76,291/- to the hospital. In view of the above, the TPA i.e Med Safe Health Insurance TPA Ltd., rejected the cashless facility under Clause No.4.1 of the insurance policy i.e pre existing diseases and in this regard, further the complainant applied for reimbursement with the opposite party and after coming through all the relevant documents the TPA issued the query letter dated 24.5.2019 to the complainant to provide the certificate from United India Insurance Company for continuous coverage, but inspite of sending the letters dated 01.06.2019, 24.05.2019, 08.06.2019 & 23.05.2019 complainant failed to submit the certificate for continuous coverage of the policy, resulting which finally the concerned TPA closed the entire file of the complainant due to the reason of non compliance to query as pertained in their reminders sent to the complainant by the concerned TPA Department to the answering opposite party vide letter dated 29.06.2019. Therefore, in view of the above facts and reasons the claim of the complainant closed due to the reasons of not providing the continuous certificate and the illness of the complainant to be declared as pre existing disease as the policy of the complainant treated as the first policy, therefore it comes under the Clause No.4.1 of the insurance policy i.e pre existing illness and its complication were not payable. Opposite parties Nos. 1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite parties Nos.3 & 4 put in appearance through counsel and filed written statement wherein Opposite parties Nos.3 & 4 refuted claim of the complainant and submitted that bare perusal of documents as filed by the complainant nowhere reveals that the answering opposite parties owes any liability to pay the said amount as claimed by the complainant. It was nowhere mentioned in the documents as filed by the complainant that the answering opposite party shall pay the amount to the complainant upon hospitalization or upon any other medical contingency . The complainant had made communication dated 30.03.2019 with Medsave health Insurance TPA Ltd. For the reimbursement of his claim which clearly reveals that the liability (if any) was of the opposite party No.1 and not of the answering opposite parties. The policy had been issued by opposite party No1, receipt shad also been issued by opposite party No.1 and all the communication with regard to the present claim had also been made with opposite party No.1 & 2 and 5 which makes it crystal clear that the answering opposite parties had no role in the present claim. Letter dated 14.03.2019 reveals that Med Save health Insurance (TPA) Ltd, rejected the claim owing to pre-existing illness and its complications were not payable in policy. It was submitted that the said communication made between Med Save Health Insurance (TPA) Ltd. i.e opposite party No.5 and complaint clearly reveals that the contract was only between the complainant and the opposite party No.1 in which the answering opposite parties had no say either t pass the claim or reject it, moreover the answering opposite parties had not issued any policy or receipt and therefore the answering opposite parties could not be made liable and therefore, the present complaint be dismissed against opposite parties. Opposite parties Nos.3 & 4denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. Registered notice was sent to opposite party No.5 on 11.10.2019 received back served or unserved. Case called several times since morning. But none appeared on behalf of opposite party No.5. Therefore, opposite party No.5 was proceeded against ex-parte vide order dated 18.11.2019.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
7. In this case the complaint was filed by the complainant against opposite parties– United India Insurance co. Ltd. with the prayer to: a) make the payment of Rs.1,76,291/- alongwith interest @ 12% p.a. from the date of seeking cashless medical facility till its actual payment to the complainant. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 25,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Anish Garg,, Ex.C-1 – insurance policy Ex.C-1 - insurance policy valid from 23.07.2010 to 22.07.2011, Ex.C-2 – insurance policy valid from 23.07.2011 to 22.07.2012, Ex.C-3 – insurance policy valid from 23.07.2012 to 22.07.2013, Ex.C-4 – insurance policy valid from 23.07.2013 to 22.07.2014, Ex.C-5 - Insurance policy valid form 28.07.2014 to 27.07.2015, Ex.C-6 – insurance policy valid from 28.07.2015 to 27.07.2016, Ex.C-7 – insurance policy valid from 28.07.2016 to 26.07.2017,, Ex.C-8 – insurance policy valid form 25.07.2017 to 24.07.2018, Ex,C-9 – insurance policy valid from 25.07.2018 to 24.07.2019, Ex.C-10 – prescription dad 13.03.2019,, Ex.C-11 - email dated 14.3.2019 regarding denial, Ex.C-12 (colly) – Discharge summary,, Ex.C-13 – Final Bill,, Ex.C-14 & 15 Advance Deposit Receipt, Ex.C-17 – Claim Form – Ex.C-17, Ex.C-19 – Courier receipt, Ex.C-19 – Query letter, Ex.C-20 – Sticker stent, Ex.C-21 – Hunter, Ex.C-22 – email dated 31.05.2019.
On the other hand counsel for the opposite parties Nos.1 & 2 strongly
agitated and opposed. As per the evidence of the opposite parties Nos.1 & 2 Ex.RW1/A – affidavit of Subhash Narwal, Assistant Manager, Divisional Manager, United India Insurance Co. Ltd. Office at Divisional Office at SCO-106, Sector-16, Commercial Complex, Faridabad , Ex.R-1 - Request for Cashless Hospitalization for Medical Insurance policy,, Ex.R-2 - query letter, Ex.R-3 – email dated 14.3.2019 Ex.R-4 – letter date 01.05.2019, Ex.R-5 – letter dated 24.05.2019, Ex.R-6 – query letter dated 23.05.2019, Ex.R-7 & 8 – Reminders, Ex.R-9 – letter dated 29.06.2019 , Ex.R-10 – email dated 31.05.2019 regarding obtaining the continuity certificate from your current policy issuing office., Ex.R-11 – insurance policy valid form 25.07.2018 to 24.07.2019, Ex.R-12 insurance policy valid from 25.07.2017 to 24.07.2018.
As per evidence of opposite parties Nos.3 & 4 – affidavit of Shri Gaurav Avasthi Employee No. 607593 Branch Manager/Authorized person-cum-power of Attorney Holder-Cum-Principal Officer of Syndicate Bank branch SCF 65, HUDA Market, sector-16A, District Faridabad,, Annexure R-1 – power of attorney, Annexure R-2 – Syndarogya proposal form.
8. In this case, the complainant had pain in jaw and as such visited Gupta Nursing Home, Sector-16A, Faridabad, whereby Dr. Suresh Gupta referred the complainant QRG Hospital, Faridabad asking about diabetes and hypertension. The complainant got admitted in QRG Health City, Hospital, Sector-16, Faridabad for his treatment and required check up, whereby the complainant submitted his insurance policy to the hospital authorities to avail cashless facility. Accordingly, the hospital authorities of QRG Health City Hospital, sent mail to the opposite party No.5, the 3rd party Administrator of the opposite parties Nos.1 & 2 seeking permission for cashless treatment of the complainant. The opposite party No.5 rejected the cashless facility invoking clause 4.1 of the insurance policy i.e. pre existing disease, whereas the complainant was not having any such pre-existing disease as alleged by the opposite party NO.5 in email dated 14.3.2019.
9. After going through the evidence led by the parties, the Commission is of the opinion that the cashless facility of treatment of the complainant in respect thereto it was submitted that the concerned TPA i.e Med Save Health Insurance TPA Ltd. rejected the cashless facility of the complainant on the ground that the complainant issued the policy from answering opposite party in the period of 25.07.2017 to 24.07.2018 and 25.07.2018 to 24.07.2019 and failed to give the certificate of continuous coverage and as per the treatment record the patient was having pre existing disease and not cover under the provision of the Exclusion Clause 4.1 of the insurance policy that relates to pre existing disease. In the interest of justice, the complaint is allowed. Opposite parties are directed to process the claim of the complainant, subject to certificate of continuous coverage 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. Opposie party No.1 is also directed to corrspondence with opposite parties Nos.2 & 3 to approve the case of the complainant. Complainant is also directed to follow up the correspondence with opposite parties. Opposite parties are also directed to correspondence with each other for issuing the continuity certificate. 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: 16.09.2022 (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.
