Delhi

New Delhi

CC/880/2013

Narender Manchanda - Complainant(s)

Versus

M/S. United India Insurance Company Ltd. - Opp.Party(s)

24 Apr 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

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

I.P.ESTATE, NEW DELHI-110002

 

 

Case No.CC-880/2013

 

 

IN THE MATTER OF:

Narendra Manchanda

R/o 1244/3, Chhota Bazar,

Kashmere Gate, Delhi – 110006.                                   

 

...Complainant

 

Versus

 

 

 

1. United India Insurance Company Ltd.

Divisional Office – 8, 503-504, Kailash Bldg.,

    5^th Floor, Kastubra Gandhi Marg,

New Delhi – 110001.

(Through its General Manager/Branch Manager)

 

Also at :

14, Whites Road,

Chennai – 600014.

(Through its CMD)

 

 

2. M/s E-Meditek (TPA) Services Ltd.

Plot No. 577, Udyog Vihar, Phase-5,

Gurgaon, Haryana – 111016.

(Through its General Manager/Branch Manager)

                                             

…Opposite Parties

 

 

 

Quorum:

 

 

Ms. Poonam Chaudhry, President

Mr. Shekhar Chandra, Member

 

                                                         

Date of Institution:27.09.2013

 Date of Order     : 24.04.2023

 

 

ORDER

 

SHEKHAR CHANDRA, MEMBER

 

The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986  against OP  alleging deficiency of services.

1. Briefly stated facts of the case are that the Complainant had taken a cashless Senior Top Up Medicare Policy no. 040800/48/10/36/00000771 from the OP no.1 for himself and his mother Mrs. Kaushalya for the period from 08/06/2010 to 07/06/2011 for a sum insured of Rs.3,00,000/. The Complainant had paid the premium for the above policy through a cheque and the same was duly encashed by the OP no.1 from their bank. OP no. 2 is the TPA of the OP no.1.
2. The complainant submits that Mrs. Kaushalya, the mother of the Complainant was admitted at Medanta Medicity Hospital for her Diabetes Mellitus, Hypertension, Acute Coronary Artery Syndrome treatment on 13/01/2011 and remained in the hospital till 16/02/2011 and thereafter the Complainant applied for cashless facility for the Complainant against the above referred policy for Rs. 3,00,000/- for the treatment of his mother but instead of providing him a hassle free service, the OP no. 2 asked the Complainant to submit medical history of his mother duly certified by Treating Doctor.
3. It is submitted by the complainant that since the Complainant was too busy in taking care of his mother during her treatment at the said Hospital and post care after her discharge from the hospital, hence could not find enough time to fulfill the uncalled for and ill motivated demands and requirements of the OP no. 2 and that too when it was never disclosed by the OP no. 1 at the time of issuing the above said policy that further documents would be required at the time of actual treatment, if any, or shall be needed to be produced by the insured and his family. The cashless facility was declined to the Complainant as he failed to produce the documents as demanded. The Complainant lodged the post treatment claim with the OP no.2 and, therefore, he was allotted claim no. UI/SPUP/12011/15835387.
4. After much dillydallying, vide letter dated 05/07/2011, the opposite parties declined the claim of the Complainant conveying as under:

"We still have not received the complete documents/information called for which are essential for us to further process the claim inspite of three query letters.

In view of the above, we are left with no option but to mark your claim as "no claim"

 

5. It is further submitted that the Complainant submitted the required documents to the OP no. 2 on 29/07/2011 at their office at Gurgaon and a valid receipt was duly given by the OP no. 2 to the Complainant towards the same but nothing was done despite several oral assurances by the OP no. 2 till the date of filing of this Complaint, due to which the Complainant has lost all hopes of his claim amount due from the OP out of indemnity contract by way of insurance.
6. It is stated by the complainant that both the OPs were legally bound to provide a cashless facility to the Complainant as agreed without going into the details of pre-existing illness etc. since cashless policies are issued by the insurer only after thoroughly verifying all the medical facts and or history of the insured and even otherwise this was the second and or third renewal of the Medicare policy by the same insurer i.e. the OP no. 1. It is further submitted that such a foul play by both the OP smacks of utter monopolistic arrogance which is both unwarranted as well as unsolicited as per the norms of any civilized society.
7. The complainant states that under the above compelling circumstances, the Complainant was left with no alternative but to pay all the bills in cash to the Hospital for the treatment provided to his mother by the Hospital, which in fact both the OPs were legally and contractually bound to pay but for the malafide intentions displayed by both the Opposite Parties, the amount was paid only by the Complainant to the Hospital which the OP were actually liable to pay,
8. It is further stated that the OPs were liable to pay a sum of Rs. 3,00, 000/- against the claim no. 15835387 to the Complainant for which the Complainant has sent all the required documents to enable the OP no. 2 to process the claim of the Complainant but the OP no. 2 instead of settling the instant claim, have turned a blind eye and have treated the claim as "NO CLAIM" for malafide reasons best known to them.
9. As regard the cause of action, it is submitted by the complainant that the cause of action for filing this present Complaint first arose when the ailing mother of the Complainant was discharged from the Medanta Medicity Hospital, Gurgaon, Haryana on 16/02/2011 and the amount of Rs. 3,00,000/- was not paid by the OP. The cause of action further arose on 05/07/2011 when the OP no. 2 marked the claim of the Complainant as 'no claim' and it further arose when the Complainant submitted all the documents sought by the OP no. 2 on 29/07/2011 at their office. Further the cause of action arose on various dates till October, 2011 when the Complainant personally visited the office of the OP no. 2 on various occasions but every time he was assured by the OP no. 2 that his claim was being processed on submission of further documents by the Complainant and it was only in the month of October, 2011, that the OP no. 2 orally refused to entertain the valid claim of the Complainant on false, fabricated and frivolous grounds and the cause of action is still subsisting and continuing one as nothing whatsoever has been done by the OP till date in order to satisfy the valid claim of the Complainant.
10. Thus, the complainant has filed the present complaint case with the prayers that an order/direction be issued to the OPs to pay a sum of Rs. 3,00,000/-  jointly or severally to the Complainant alongwith interest accrued thereon @ 24% from the date of payment made by the Complainant and future interest till its realization. It is also prayed for a order/direction to the OPs to pay a sum of Rs. 1,00,000/-  jointly or severally as compensation for mental harassment, physical agony, mental trauma and financial loss incurred and or sustained by the Complainant with cost of litigation incurred by the complaint.
11. In response to the notice of the present complaint case, the opposite parties have filed the reply stating that the present claim is against the law as well facts on the record, and the complainant has also not approached this Commission with clean hands, without disclosing the facts on the records, hence the same is liable to be dismissed with cost. It is stated that the complainant is holding a fresh Super Top up medicare policy Bearing no. 040800/48/10/36/00000771 issued by Opposite  No. 1 for the period of 08/06/2010 to 07/05/2011.
12. It is further alleged that the complainant is trying to cover up his own wrong of not supplying the documents despite of reminders/ letters dated March 15th 2011, and May 20th 2011. Despite reminders, the complainant did not provide documents which were required for Investigation and assessment of the present claim. Thereafter OP has no option but to close the claim as NO CLAIM. TPA has closed the claim file as NO CLAIM vide letter dated July 5th 2011 and same was intimated to the complainant. The OP was required documents, history of diabetes mellitus, hypertension, acute LVF, coronary artery disease consultation paper duly certified by treating Doctor (as per the consultation paper provided, patient is already a case of diabetes mellitus) and the copies of all past year policies (only super top up policies), but the complainant failed to provide documents which were required by the OPs essentially for evaluation and assessment of the claim. Owing to lackadaisical attitude of insured, the OP had no option but to close the file. Rather, on scrutiny of the available documents, it is found that CLAIM FOUND NOT ADMISSIBLE UNDER CLAUSE B 4.1 (PRE- EXISTING DISEASE) and hence the present complaint is liable to be dismissed.
13. It is submitted that the health insurance is a contract like other contract and subject to terms and condition of the said contract, and the complainant in any case is bound by the terms and condition of the policy as the same was signed by him. The OPs have every right to investigate the claim and essential documents were required but complainant has never provided the same and claim has been closed as NO CLAIM vide letter dated 05.07.2011.
14. It is submitted that on the recommendations of the Third Party Administrator who is a professional agency and engaged for a fee or remuneration by the insurance companies for the provision of health services under an agreement and under the provision of IRDA Regulations (Third Party Administrator-Health Services) 2001, the Company decides the admissibility of claim. That even otherwise in the insurance policies of such nature as relates to the present case, the company relies upon professional recommendation and decisions of TPA which requires to be followed by the company under the provision as stated. TPA was required essential documents for scrutiny of claim but it was not provided.
15. The opposite parites submit that the OP/company is not liable to pay claim as prayed in the complaint because of the unsupported and lackadaisical attitude of the complainant.
16. In the rejoinder the allegations made in the reply have strongly been denied by the complainant. As regard the allegation of the OP regarding non-furnishing of the documents, it is submitted by the complainant that the allegation of the OPs is contrary to their own communication dated 15^th March, 2011 wherein they have acknowledged the receipt of claim with the documents of the complainant.
17. We have perused the record and heard the parties. We are of the opinion that there is deficincy in the service of the opposite parties. The complainant had discharged its duty and submitted the required documents but inspite of reminder, the Ops have failed to discharged its obligation/duty. We accordingly accept the claim of the complainant and direct the opposite parties jointly and severally to pay a sum of Rs. 3,00,000/- to the complainant with interest @ 9% per annum from the date of accrual till realisation, within eight weeks from the date of receipt of this order. The Complainant shall also be entitled to compensation which is quantified to Rs. 50,000/- with Rs. 25,000/- as litigation expeses.  In case the opposite parties fail to pay the claim amount within the time stipulated above, the complainant shall be entitled to interst at the enhanced rate of 15% per annum.   

A copy of order be sent to all the parties free of cost. The order be also uploaded in the website of the Commission (www.confonet.nic.in).

File be consigned to the record room along with a copy of the order.

 

[Poonam Chaudhry]

President

 

 

[Shekhar Chandra]

Member