BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.224-14

Date of Institution:21-04-2014

Date of Decision:04-03-2015 

Saurav Sharma son of Sh.Ashok Kumar Sharma, resident of House No.14392, Bazar  Loharan Wala, Chowk  Lachhmansar, Opposite  Dimpy Bakery, Amritsar.

Complainant

Versus

1. National Insurance Company Limited, through its Chairman/ Legal Representative, having its Corporate Regional Office at Royal Insurance Building, 2^nd Floor, 14, Jamshed Ji Tata Road, Church Gate, Mumbai-400020.
2. National Insurance Company Limited, through its Branch Manager/ Legal Representative, having its Branch Office at SH 25, D-Block, Ranjit Avenue, Amritsar.
3. Karvat Healthcare Service Pvt.Ltd. through its Branch Manager/ Legal Representative, having office at 102, 1^st Floor, Sumer Kendra, P B Marg, Near Mahindra Tower, Worli, Mumbai-400018.
4. Dedicated Healthcare Services TPA (India) Pvt.Limited, through its Branch Manager/ Legal Representative, having office at Cambata Building (Eeos Theatre Building) East Wing, 2^nd Floor, 42, Maharshi Karve Road, Mumbai-400020.

           Opposite Parties

Complaint under section 12 and 13 of the Consumer Protection Act.

Present: For the Complainant: Sh.R.S.Bhullar, Advocate.

              For the Opposite Parties No. 1 & 2: Ms.Neena Kapoor, Advocate

             For the Opposite Party No.3: Sh.K.K.Thakar, Advocate.

             For the Opposite Party No.4: Exparte.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member     

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Saurav Sharma under the provisions of the Consumer Protection Act alleging therein that he purchased medical insurance policy for himself as well as for his wife namely Poonam Sharma and for his son Sarthak Deep Sharma bearing policy No.251100/46/12/85000001901/0111476 for the period from 11.3.2013 to 10.3.2014 for sum insured of Rs.1 lac and policy premium was Rs.2209/-. In the month of June 2013, the wife of complainant suffered an immense pain in the lower  abdomen as well as in chest and  the complainant admitted in Dhaliwal Hospital, Amritsar and remained their from 15.6.2013 to 17.6.2013 and the complainant paid Rs.6462/- for the medical treatment of his wife to said hospital. After few  days, the wife of complainant again suffered pain in the lower abdomen for which she was again admitted in Dhaliwal Hospital, Amritsar from 22.6.2013 to 24.6.2013 and paid Rs.12153/- for medical expenses to Dhaliwal Hospital, Amritsar, but wife of the complainant was not recovering in Dhaliwal Hospital, Amritsar and condition became worst and miserable day by day and due to non satisfaction from the Dhaliwal Hospital, Amritsar in the medical treatment of the complainant’s wife, she was shifted to Apollo Hospital on 24.6.2013 for her better medical treatment and remained hospitalized in Apollo Hospital from 24.6.2013 to 3.7.2013 and got recovered. During her hospitalization, the complainant spent an amount of Rs.35858/- in that hospital. In this way, the complainant spent an total amount of Rs.54473/-  as per all hospital and medical bills for the treatment of his wife.  The complainant informed the Opposite Parties  regarding the hospitalization of his wife in the aforesaid hospitals  and submitted all the medical bills to Opposite Parties  No.1 and 2 through Opposite Party No.3 for the settlement of his claim, but the Opposite Parties  did not pay any heed to the request of the complainant.  However, even after closing the case of the complainant due to non supply of documents, the Opposite Party No.4 credited the partial claim amount of the complainant to the tune of Rs.7889/- in March, 2014 i.e. after three months from the date of closure of claim. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to make the payment of Rs.46584/- as expenses incurred by the complainant during the hospitalization of his wife as per medical bills. Compensation and litigation expenses were also demanded.
2. On notice, opposite parties No. 1 and 2 appeared and filed written version in which it was submitted that  the insured has not complied with the conditions and did not supply some of the requisite documents required to provide the claim facility and major claim has been settled and given to the claimant when demanded.  It is submitted that TPA demanded the insured  to submit the documents after discharge from the hospital to consider the reimbursement on merit, however the same has never been supplied in  time to evaluate the claim despite letters and reminders. However, the cashless claim of the complainant worth Rs. 17000/- has been settled by Opposite Party No. 4  to the hospital and other claim related to cashless claim is rejected with a reason that investigation report is not attached. Further the claim No.DHS13Z083201 is settled for Rs. 7889/- with certain deductions towards registration charges, room rent charges and RMO charges. The claim No.DHS13Z083222 is closed for want of query reply. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C2 to Ex.C57 and closed the evidence on behalf of the complainant.
4. Opposite Parties No.1 and 2 tendered into evidence affidavit of Sh.H.S.Chawla, Divisonal Manager Ex.OP1,2/1 alongwith documents Ex.OP1,2/2 to Ex.OP1,2/4  and closed the evidence on behalf of the Opposite Party. Similarly, Opposite Party No.3 tendered affidavit of Sh.Ashok K.Karvat Ex.Op3/1 and documents Ex.OP3/2 to Ex.OP3/9 and closed the evidence of Opposite Party No.3.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got medical insurance policy for himself as well as for his wife namely Poonam Sharma and for his son Sarthak Deep Sharma bearing policy No.251100/46/12/85000001901/0111476 for the period from 11.3.2013 to 10.3.2014 for sum insured of Rs.1 lac and policy premium was Rs.2209/-. In the month of June 2013, the wife of complainant suffered an immense pain in the lower  abdomen as well as in chest. As such, she was admitted in Dhaliwal Hospital, Amritsar on 15.6.2013  and was discharged on  17.6.2013 and the complainant spent about Rs.6462/- on the treatment of his wife. Again  the wife of complainant suffered pain in the lower abdomen for which she was again admitted in Dhaliwal Hospital, Amritsar from 22.6.2013 to 24.6.2013 and spent Rs.12153/- on her medical treatment for medical expenses to Dhaliwal Hospital, Amritsar, but wife of the complainant did not recover and as such, she was admitted in Apollo Hospital on 24.6.2013 and was discharged on 3.7.2013 and the complainant spent an amount of Rs.35858/- on her medical treatment. In all, the complainant spent an total amount of Rs.54473/-. The claim was lodged with Opposite Parties No.1 and 2, but the Opposite Parties No.1 and 2 did not settle the claim of the complainant. Ultimately, the complainant has to file the present complaint. Ld.counsel for the complainant  submitted that all this amounts to deficiency of service on the part of the opposite parties.
7. Whereas the case of the Opposite Parties No.1 and 2 is that TPA of Opposite Parties No.1 and 2 i.e. Opposite Party No. 4 demanded the insured  to submit the documents after discharge from the hospital to consider the reimbursement on merit, but the complainant did not supply the documents to TPA. In this regard, the Opposite Parties No.1 and 2 produced on record letters written by Opposite Party No.3 to complainant which are Ex.OP3/2 to Ex.OP3/9 and the letters directly written by Opposite Party No. 4 to complainant Ex.OP1,2/3 and Ex.OP1,2/4. The complainant supplied these documents very late and ultimately, the Opposite Parties No.1 and 2 settled the claim of the complainant and made payment of the claim amount to the complainant.   Ld.counsel for the Opposite Parties No.1 and 2 submitted that there is no deficiency of service on the part of the opposite parties No.1 and 2.
8. From the entire above discussion, we have come to the conclusion that the wife of the complainant who was duly insured with Opposite Parties No.1 and 2 remained admitted in Dhaliwal Hospital, Amritsar from 15.6.2013 to 17.6.2013 and from 22.6.2013 to 24.6.2013 in Dhaliwal Hospital, Amritsar and in Apollo Hospital, Amritsar 24.6.2013 to 3.7.2013 and spent about Rs. 54473/- on the medical treatment of the wife of the complainant. No doubt, the Opposite Parties No.1 and 2 ultimately, settled the claim of the complainant and made the payment of the claim amount to the complainant. The complainant himself got recorded his statement that he has received the payment of his claim amount from Opposite Parties No.1 and 2. However, the Opposite Parties No.1 and 2 have made the payment after filing of the present complaint thereby, the complainant was harassed mentally as well as economically and he has to file the present complaint. Ld.counsel for the complainant submitted that he is entitled to compensation as well as costs of litigation from the Opposite Parties for delaying the payment of claim amount. Whereas, ld.counsel for the Opposite Parties No.1 and 2 submitted that it is the complainant who was not cooperating with the Opposite Parties. Opposite Party No. 4-TPA wrote so many letters to the complainant to supply the documents which are mentioned in the letter written by Opposite Party No. 4, to supply the documents which are mentioned in the letters written by Opposite Party No. 4 through Opposite Party No.3. Said letters are Ex.OP1,2/3 to Ex.OP1,2/9 from 20.8.2013 to 12.2.2014 and whenever the complainant supplied the documents to TPA (Opposite Party No.4), his claim was settled and payment of the claim amount was made to the complainant. We have gone through the letters written by TPA i.e. OP4 to the complainant demanding certain documents which are mentioned in these letters. Said letters are Ex.OP1,2/2 dated 20.8.2013, Ex.OP1,2/3 dated 27.9.2013, Ex.OP1,2/4 dated 25.10.2013, Ex.OP1,2/5 dated 25.10.2012, Ex.OP1,2/6 dated 2.12.2013, Ex.OP1,2/7 dated 18.12.2013, Ex.OP1,2/8 dated 12.1.2014 and Ex.OP1,2/9 dated 12.2.2014 and when the complainant supplied the documents to Opposite Party No. 4-TPA of Opposite Parties No.1 and 2, the Opposite Parties No.1 and 2 settled the claim of the complainant and made payment of the claim amount to the complainant and this fact has been admitted by the complainant himself through his statement in this Forum dated 20.2.2015. So, it stands fully proved on record that it is the complainant who did not supply the documents to the Opposite Parties particularly to Opposite Party No. 4-TPA, that is why the Opposite Parties No.1 and 2 could not settle the claim of the complainant earlier. So, it can not be said that the entire delay in deciding the claim of the complainant is attributable to the Opposite Parties only. However, the Opposite Parties No.1 and 2 made the payment of the claim amount to the complainant after the filing of the present complaint and the complainant was forced to file the present complaint. Resultantly, we hold that the complainant is entitled to the costs of litigation.
9. Consequently, this complaint is dispose of with the directions to Opposite Parties No.1 and 2 to pay the costs of litigation to the complainant to the tune of Rs. 2000/-. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 04-03-2015.                                          (Bhupinder Singh)                                                   

                                                                       President

hrg                                                 (Kulwant Kaur Bajwa)    (Anoop Sharma)

              Member                               Member