Delhi

New Delhi

CC/252/2011

Lokesh Gupta - Complainant(s)

Versus

M/S. The Oriental Insurance Company Ltd. - Opp.Party(s)

20 May 2022

ORDER

 

 

CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

                      Case No.CC. 252/2011                        

In the matter of:

LOKESH GUPTA,

WZ-523A, GALI No.17

SADH NAGAR, PALAM COLONY,

DELHI-110045                                                   ……..COMPLAINANT

 

Versus

 

THE ORIENTAL INSURANCE COMPANY Ltd.

613-620, ANSAL CHAMBERS-II

BHIKAJI KAMA PLACE

NEW DELHI

Also at:

1.THE ORIENTAL INSURANCE COMPANY Ltd.

BOMBAY LIFE BUILDING

N-36, CONNAUGHT CIREUS,

NEW DELHI-11001

2.THE RAKSHA T.P.A. Pvt. Ltd.

15/5 MATHURA ROAD, FARIDABAD,

HARYANA-121003.                 ………………………………OPPOSIRE PARTIES

                           

Quorum:

Ms. Poonam Chaudhry, President

        Shri Bariq Ahmad , Member

        Ms. Adarsh Nain, Member

                                                Dated of Institution : 07.03.2011                                                                      Date of Order        : 20.5.2022

 

O R D E R

BARIQ AHMAD, MEMBER

COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT 1986

1. The complainant has filed the present complaint against the OPs under section 12 of Consumer Protection Act, 1986. The gist of the complaint is that the  complainant and his wife  of complainant Smt. Sushma Gupta were mediclaim policy holder of the OP Co., through policy No. 215100/48/2010/1718, valid from 12.09.2009 to 11.09..25010. Mrs. Sushma Gupta was admitted to Ekansh Nursing Home for the treatment of Acute Viral Hepatitis (Hepatitis-E) and discharged from the said Nursing Home on 31.03.2010. The complainant filed the present complaint being aggrieved by the rejection of his claim by OP Insurance Co. vide their e-mail letter Annexure-D, on the ground “the Hospital is not as per norms of policy (according to clause no. 2.1)” and claim file closed/no claim. He further stated that on 19.03.2010 the complainant sent the intimation letter about the hospitalization of his wife to the O.P. No.2 (Raksh TPA Pvt. Ltd.) through speed post receipt no. SP ED7003172511N. thereafter submitted a claim of Rs.80,652/- along with all documents to T.P.A./ OP No.2 through speed post, all the documents as well IPD (impatient Department) documents/papers were sent to TPA through Speed post dated 05.04.2010, despite his repeated request and visits for consider his claim, nothing was done by the OP Co., hence this complaint.
2. Complaint has been contested by OP no.1. In its written statement, OP stated that the complaint was not maintainable as there was a violation of condition No.1 of the insurance policy since the complainant choose to take treatment from hospital which is not registered for 15 beds in accordance with the terms of contract and prayed for the dismissal of the complaint. The OP has not disputed the medical insurance policy for the complainant , his wife and his daughter for a sum of Rs3,00,000/-.
3.  It is further contained by the OP No.1 that a claim was reported by the complainant on 19.3.2010 to OP No.2/ TPA intimated the OP-2 that the complainant‘s wife Smt. Sushma Gupta was admitted to Ekansh nursing home 18.3.2010 for treatment. The complainant also sent claim form along with some papers. On scrutinized/ processed the claim the Raksha TPA/ OP no 2 recommended to OP no.1 that the claim of the complainant is not maintainable on account of “hospital is not as per norms of policy, claim stands not payable acute viral hepatitis. A claim of the complainant repudiated wide a letter dated 27.4.2010. The OP further contended that the complainant had submitted a certificate of registration of Ekansh nursing home dated 31.07.2009 clearly shows that the registered only for 10 beds and not for 15 beds which was a precondition of the contract.
4. Both the parties have filed their evidences by way of affidavit. In order to prove his case, the complainant filed his evidence by affidavit. The complainant placed on record, copy of Individual claim policy schedule Mark-Annexure-A. Copy of intimation letter dated 19.3.20 along with SPED Mark-Annexure-B, copy of submission of treatment record dated 05.04.2010 with postal receipt send to OP-2 Mark- Annuxure-C, Copy of registration certificate of Ekansh Nursing Home Mark-Annuxure-D, copy of repudiation letter dated 27.04.2010 as Mark Annexure-E. In other hand OP has filed evidence by affidavit of Sh. Umesh Mehta posted as Sr. divisional manager OIC on the line of WS/ reply.
5. We have heard the learned counsel for parties and perused the record. It is not in dispute that the complainant has taken a Medical Insurance policy No.215100/48/2010/01718 valid from 12.09.2009 to 11.09.2010 for sum insured of Rs3,00,000/- and premium was paid of Rs.12992/- on 12.9.2009 for himself, his wife and his daughter nor is it in dispute that the wife of the complainant was admitted in the hospital during subsistence of the policy. The policy was, therefore, valid on the date of the hospitalization. It is the case of complainant that the complainant filed the claim with OP Insurance Co. as his wife/one of the member of health policy was hospitalized in Ekansh Nursing Home for the treatment of fever with Thrombocytopenia and on 18.3.2010 and discharged on 31.3.2010. for acute viral hepatitis, hospital issued a final bill number BN90209 dated 31.3.201 for total RS. 67320/- Thereafter submitted a claim of Rs.80652/- along with all documents to T.P.A./ OP No.2.  but nothing was done by the OP Co. and the claim was  repudiated on 27.4.2010 on the ground on the ground of hospital is not as per norms of policy on arbitrarily & flimsy ground
6. OP filed WS stated that the complaint is not maintainable as there was violations of condition No.2.1 of the insurance contract since the complainant choose to take treatment from the hospital which is not registered for 15 beds in accordance with terms of contract.
7. We have perused the condition 2.1 of the insurance contract and terms & conditions of the insurance policy in respect of the medical health policy. The policy wording of condition No.2.1 (i) of the said policy while covering treatment, state; Hospital/Nursing Home means any institution in India established for indoor care and treatment of sickness and injuries and which either; a) has been registered either as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner OR  b) should comply with the minimum criteria as under: I) it should have at least 15 in-patients beds ii) fully equipped operation theatre of its own wherever surgical operations are carries out: iii) fully qualified Nursing staff under its employment round the clock: iv) fully qualified Doctors should be in charge round the clock. On perusal of registration certificate of Hospital Mark-Annxure-D. it seems that hospital/Nursing home from where the wife of the complainant take treatment falls under clause (a) of the term of the policy (registered with the Directorate of Health Services, Govt. Of NCT of Delhi). In the absence of such an exclusion, the OP/insurance company will have to indemnify the insured hospitalization bill. The OP insurance company failed to placed on record the D-panel list/letter of Ekansh Nursing Home, 122-123, Shahbad Daulat Pur, Dehi-110042, which shows that the treatment taken by the complainant during this period was not covered under the policy, hence in our view the repudiation was unjustified.
8. In view of above discussion, we are of the considered view that the claim for the period from 18.3.2010 to 31.3.2010 a sum of Rs.80,652/-, as per details of expenses dated 05.4.2010 filed by the complainant, the repudiation of the claim by OP-1 is unjustified, Hence, we allowed the present complaint with following directions to OP-1:-

1. Pay to the complainant sum of Rs.80,652/- (Rupees Eighty Thousand Six Hindered FiftyTwo only) along with 7% interest from the date of filing of claim i.e. 05.04.2010 till realization.
2.  Pay to the complainant a sum of Rs.10,000/-(Rupees Ten Thousand Only)  towards compensation which will also include the cost of litigation.

If OP-1 is fail to pay the said amount within stipulated time it shall be liable to pay interest on the total awarded amount @ 9% PA, from the date of this order.

Order accordingly. Office is directed to send one true copy of      this order to the parties/speed post in accordance with the rules. This final order be sent to server (www.confonet.nic.in). Thereafter, file be consigned to record room.

Announced on this   20^th day of May 2022.

 

 

 

(POONAM CHADHARY)

President

 

 

       

 (BARIQ AHMAD)                                            (ADARSH NAIN)       

        Member                                                            Member