Delhi

East Delhi

CC/90/2018

RAKESH KR. - Complainant(s)

Versus

NATIONAL INS. - Opp.Party(s)

04 Jul 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110092

 

 

C.C. No. 90/2018

 

 

	Rakesh Kumar Aggarwal, R/o. 5/481-B, Opp. Gali No.1, Pandav Nagar, District East Delhi, Delhi-110032.	….Complainant
Versus
1.           2.	National Insurance Company Ltd. Through Manager, Direct Agent Branch: Scope Minar, Core-2, 11th Floor, North Tower, District Centre, Laxmi Nagar, New Delhi-110002.   Raksha TPA Pvt. Ltd., C/o Escorts Corporate Centre, 15/5, Mathura Road, Faridabad, Haryana-121003.	……OP1         ……OP2

 

 

Date of Institution: 09.03.2018

Judgment Reserved on: 04.07.2023

Judgment Passed on: 04.07.2023

                       

 

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms.Rashmi Bansal (Member)

 

 

 

Judgment By: Shri S.S. Malhotra (President)

 

 

 

JUDGMENT

 

1. By this judgment the Commission shall dispose off the complaint filed by the complainant against alleged deficiency in repudiating the mediclaim bill of the son of complainant insured.
2. Brief facts as stated by the Complainant in the amended complaint are that the complainant had been taking mediclaim policy from OP1 since 2014 and had policies from 22.11.2014 to 21.11.2015, 22.11.2015 to 21.11.2016 & 22.11.2016 to 21.11.2017 for himself, his wife and two children namely Sh. Shubham Aggarwal and Sh. Dhruv Aggarwal for sum assured of Rs. 3 lakh towards medical claim. Son of the complainant namely Sh. Shubham Aggarwal has been taking treatment from Max Super Speciality Hospital, Patparganj, Delhi but suddenly was to be admitted in Sir Ganga Ram Hospital, New Delhi as he was suffering from comprams of chronic nasal allergy and shortness of breath and choking sensation while sleeping since last six months and he was admitted for further investigation, evolution and management and for that hospitalization was required to decide upon further course of treatment. Mr. Shubham Aggarwal had to remain in hospital from 28.08.2017 to 04.09.2017 and during the said period in hospital a sum of Rs. 1,99,785/- was incurred on the treatment of his son. The hospital had sent a request for cashless treatment which was declined and after the discharge of his son from the hospital. The complainant lodged the claim and as per the directions of the OP, supplied all the relevant documents but the OP did not give any reply for a long time and finding no alternative, the complainant got issued legal notice dated 16.02.2018 upon the OPs but OP did not comply the notice and as such he has filed the present claim of Rs.1,99,785/- spent towards treatment of his son and Rs. 2 lakh as compensation with litigation cost of Rs.22,000/-.
3. The OP was served and has filed his reply taking preliminary objections that complaint is not maintainable for various reasons interalia i.e. that there is no deficiency in services on the part of OP, the complainant has not come to court with clean hands and patient was admitted in the hospital only for the diagnostic purpose i.e. hospitalization was for investigation and evolution and as such treatment could have been done by the hospital on OPD basis, therefore claim is not maintainable. On merit the complainant was having floater policy namely ‘Parivar Mediclaim Policy’ for Rs. 3 lakh and it was valid policy on the date when son of the complainant was admitted for hospitalization, the expenses incurred and the discharge of Sh. Shubham Aggarwal is not denied and the only defence taken by the OP is that since he was admitted for investigation and evolution purposes the same falls within the exclusion clause & therefore complaint of the complainant is liable to be dismissed & may kindly be dismissed.
4. Complainant has filed rejoinder thereby denying the contents of the written statement and re-affirming the contents of the complaint. The complainant has filed his own evidence and OP has filed affidavit of Sh. Pratap Singh, Assistant Manager. Complainant and the OP, both have filed their respective written arguments. The Commission has heard the arguments and perused the record.
5. The complainant had the policy for himself, his wife and two children for Rs. 3 lakh including of Sh. Shubham Aggarwal, who got admitted initially in Max Super Speciality Hospital, Patparganj and then at Sir Ganga Ram Hospital, cashless request for treatment was not accepted by the OP, complainant spent Rs.1,99,785/-, on the treatment of his son and remained in hospital from 28.08.2017 to 04.09.2017 are the facts which are not disputed. The only dispute raised by the OP is that since the son of the complainant was admitted for investigation and evolution purpose, this treatment could have been done as an OPD patient and this amount was not required to be spent as per the exclusion clause mentioned in the insurance policy and such admission of Sh. Shubham Aggarwal in the hospital was covered in the exclusion clause, therefore claim is not maintainable.  
6. The Commission has enquired from Ld. Counsel for OP as to on what basis the insurance company has come to the conclusion that such treatment or investigation or evolution purpose can be done as an OPD patient to which no reply has been placed on record, nor any document or opinion of the expert has been placed on record. Admittedly a patient has been taken to hospital, the patient was referred from Max Super Speciality Hospital, Patparganj to Sir Ganga Ram Hospital, the patient remained in hospital for 6-7 days on the opinion and recommendation of the treating doctor is a fact which was required to be countered by the OP, with equally qualified doctor’s opinion. The Commission is also of the opinion that the insurance official cannot be allowed to take the place of medical expert and once the medical expert states that admission is required, then either that fact has to be respected or in case that fact has to be contested by the insurance company, then equally good evidence has to be placed on record showing that the opinion of the doctor who advised admission was not well found. Such strong evidence was to be required to be brought on record by the OP which has not been filed on record. Therefore the opinion of the insurance official without any opinion of the expert is without any basis and cannot be strong enough against the medical opinion/advice of the expert i.e. treating doctor. Not only this, the Commission has not attributed any malafide on the hospital or doctor by stating, the hospital or the doctor, got the patient admitted for ulterior purpose of making money or that the patient had no ailment. There is no such averment in the written statement. Hence the Commission of the opinion that the conclusion arrived by the OP that the patient got admitted only for investigation his treatment could have been done without admitting in the hospital has not been proved.   
7. The Commission is accordingly of the opinion that rejection of not giving reply and not complying with the legal notice or even rejecting the claim by the OP amounts to deficiency in services.
8. Therefore it is ordered that as follows:

• OP would pay Rs.1,99,785/- with interest @ 6% p.a. to the complainant w.e.f. date of filing the complaint till actual payment.
• The OP would pay Rs.15,000/- as compensation alongwith Rs.10,000/- as litigation cost to the complainant.

9. This Order is to be complied within 30 days from the date of receiving the same & in case the OP would not pay the amount within 30 days, the rate of interest would be @9% from the date of filing the case upto the date of realization on the entire amount including of compensation/litigation amount.
3. opy of the Order be supplied/sent to the Parties free of cost as per rules.

File be consigned to Record Room.

Announced on 04.07.2023.