Haryana

Ambala

CC/383/2017

Anil Kalra - Complainant(s)

Versus

M/s Vidal Health T.P. A Pvt Ltd - Opp.Party(s)

P.K. Goel

13 Sep 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 383 of 2017.

                                                          Date of Institution         : 08.11.2017.

                                                          Date of decision   : 13.09.2018

 

Anil Kalra son of Sh.Gobind Lal Kalra, 50 years r/o 10-A, Ram Nagar, Ambala.

 

……. Complainant.

                                      Versus

 

1.M/s Vidal Health T.P.A. Pvt. Ltd. (Formerly TTK Healthcare TPA Pvt. Ltd.) through its Director, Anmol Palani-IInd Floor, 88, G.N.Chetty Road, T.Nagar, Chennai-600017.

2.M/s Tablets India Ltd.Jhaver Centre, IV Floor, R.A.Building, 19, Marshalls Road, Chennai-600008 (Ph.91-44-42050000) through its Director Sh.H.K.Jhaver.

3.The New India Assurance Company Limited office at Ambala Cantt.

 

                                                                             ….…. Opposite parties.

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER

 

Present:       Sh.P.K.Goel, counsel for complainant.

                   OP No.1 exparte.

                   Sh.Rajeev Sachdeva, counsel for OP No.2.

                   Sh.Dev Batra, counsel for OP No.3.

 

 

ORDER

                   The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 with the averments that he was employee of OP No.2 and it had provided a medi-claim insurance policy wherein medi-claim expenses were to be borne by employee firstly and lateron it were to be got reimbursed from insurance company of employer i.e. O.P.No.1 as franchisee through OP No.3.In May, 2017 the complainant was changed to Jallandhar region. In September, 2015, the complainant suffered heart attack on duty and had to undergo bye-pass surgery at Fortis Mohali where he remained admitted as a patient ID No.00540363 for a period 29.09.2015 to 08.10.2015 and he had spent Rs.2,56,639/- . The Op No.1 had asked to produce original receipts of the payment and when the same were not issued to him by the hospital then he had to take duplicate receipts for the payment made by him and supported by clarification letter. Several e-mails and telephonic calls had been made with numerous reminders but Op No.1 did not pay any heed. The delay in settling the claim is deficiency in service on the part of OPs as the claim lodged by the complainant is genuine one and there is no concealment whatsoever in the same.  In evidence, the complainant has tendered affidavit Annexure CA and documents Annexure C1 to Annexure C21.

2.                          On notice Op No.1 did not appear before this Forum, therefore, it was proceeded against exparte vide order dated 09.01.2018. OP Nos. 2 & 3 have filed their separate replies. OP No.2 in its reply has taken preliminary objections such as cause of action, maintainability, concealment of material facts and locus standi etc. The complainant was covered under group health insurance policy taken by Op No.2 from OP No.3 vide policy No.71310034150400000001 having validity from 24.04.2015 to 23.04.2016 and in this policy 465 employees were covered. The medi-claim policy was covered from the date of joining of employment and it covers the pre-existing disease of the employee.  Under the policy in question sum assured was for Rs.1 lac and the liability of the policy is between Op Nos. 1 & 3 and the Op No.2 is only to ensure that it takes out the medi-claim policy. Other  contentions have been controverted and prayer for dismissal of the complaint has been made.

3.                          Op No.3 in its reply has submitted that there is no deficiency in service on the part of Op No.3 and the present complaint has been filed in-connivance with OP Nos. 1 & 2. The complainant has never submitted its claim to the op No.3 and further it has neither withheld the same nor repudiated the claim.  The present complaint is not maintainable being filed on imaginary grounds and this Forum has no jurisdiction to entertain the same. The complainant has not submitted original bill/payment receipts of Rs.2,56,639/-, CAG Report & PTCA done previous discharge summary, therefore, no claim is made out for payment.  There were discrepancies in the statements given by hospital and the TPA was advised to send investigator to verify whether there have been any issues and whether any complaint had been lodged with the service provider. Other contentions have been controverted and prayer for dismissal of the complaint has been made. In evidence, the appearing OPs have tendered affidavits Annexure RX, Annexure R2/A, and documents Annexure R1 to Annexure R15, Annexure R2/1 to Annexure R2/3.

3.                We have heard learned counsel for the parties and gone through the case file very carefully.

4.                Admittedly, the complainant was employee under the OP No.2 i.e. Tablet India Ltd. and was insured under Group Health policy issued by Op No.3 for a sum insured of Rs. 1 lac. Complainant felt and got heart attack and was undergone byepass surgery at Fortis Hospital and remained under treatment from 29.09.2015 to 08.10.2015 as is evident from discharge summary Annexure C3. The complainant had spent Rs.2,56,639/- and as per bill Annexure C4 issued by the concerned hospital and complainant submitted the claim for reimbursement of the amount to OP No.1 and the same was forwarded to insurance for necessary consideration. The Op No.3 has declined the claim of the complainant on the ground that complainant failed to file the original bills. The complainant has showed the certificate issued by concerned hospital which is Annexure C14 in which the hospital clarified that the complainant remained admitted in their hospital from 29.09.2015 and discharged on 08.10.2015 and bills for Rs.2,56,639/- were issued but due to technical error in the system original receipts were not printed and the said receipts be treated as original.  

                             We have perused the file and the OP No.2 in its reply has admitted the policy in question and also admitted that the complainant is employee of Op No.2.

                             In the present case the Op No.3 had raised only one objection qua not submitting the original bills without verifying the bills submitted by the complainant to the insurance company and Op No.1 from the concerned hospital. The concerned hospital has certified the detail of bills (Annexure C5 to Annexure C13) issued by it through certificate  (Annexure C14) and clarified that due to technical fault the original bills could not be generated and the duplicate bills issued by the hospital be treated as original one but the Op No.3 has not accepted the clarification issued by the concerned hospital qua issuance of duplicate bills in the letter dated 17.05.2016 as well as 09.11.2016, therefore, this plea of Op No.3 is not tenable and is hereby rejected.

                             In the present case treatment taken by the complainant and spending of the amount of Rs.2,56,639/- is not disputed and the complainant had also taken the treatment during the subsistence of the policy in question. Perusal of the policy in question reveals that the sum assured was only Rs.1 lac, therefore, the complainant cannot claim beyond the insured amount from the insurance company and rest of the amount cannot be paid to the complainant.

                             Keeping in view the above facts and circumstances, it is clear that the OP No.3 has wrongly denied the claim of the complainant on technical ground whenever the concerned hospital has certified the bills vide Annexure C14 and the complainant is entitled the relief amount only to the tune of Rs.1 lac being sum insured. The present compliant is partly allowed with costs of Rs.5,000/- and the OP No.3 is directed to pay a sum of Rs.1 lac alongwith interest 9 % per annum from the date of filing of complaint till its realization after. The compliance of the order be made within a period of 30 days. Complaint against Op Nos.1 & 2 stand dismissed. Copies of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room.

ANNOUNCED ON:      13.09.2018

                                               

(PUSHPENDER KUMAR)                                  (D.N.ARORA)                        MEMBER                                                           PRESIDENT