Delhi

North East

CC/41/2020

Sanjay Kumar Jain - Complainant(s)

Versus

National Insurance Co. Ltd. - Opp.Party(s)

08 Feb 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

Complaint Case No. 41/20

 

 

 

 

In the matter of:

 

		Sh. Sanjay Kumar Jain, R/o 1/5113, Gali No. 5, Balbir Nagar Extn., Shahdara Dist., Delhi 110032		Complainant
		Versus
	1.           2.               3.	National Insurance Company Limited, Direct Agent Branch Office Scope Minar, Core 2, 11th Floor, North Tower, District Laxmi Nagar, New Delhi 110092   Raksha Health Insurance TPA Pvt. Ltd., Through its Chairperson, Mrs. Ritu Nanda Registered office at: Plot No. 202, 1st Floor, Phase III, Okhla Industrial Area III New Delhi 110020   Pushpanjali Medical Centre A-14-15, Pushpanjali, Vikas Marg Extn., New Delhi 110092		Opposite Parties
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		23.09.2020 30.11.2023 08.02.2024

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Ms. Adarsh Nain, Member

 

The Complainant has filed the present complaint under Consumer Protection Act, 2019 against  Opposite Parties  which are National Insurance Company Limited i.e. Opposite Party No. 1,  Raksha Health Insurance TPA Private Limited i.e. Opposite Party No. 2, Pushpanjali Medical Centre i.e. Opposite Party No. 3.

Case of the Complainant

1. The case of the Complainant as per the complaint is that the Complainant had taken a medical insurance policy vide policy number 361701 50 18100 5047 for with sum insured of Rs.  4,00,000/- for himself and his family from the Opposite Party No. 1.  Opposite Party  No. 2, being a third party  administrator provides services to Opposite Party No. 1. The Complainant states that on 16.09.2019, Complainant’s wife was admitted in Opposite Party No. 2 hospital with complaint of Low grade fever, loss of appetite, joints pain etc. She remained there for five days from 16.09.2019 -21.09.2019 and treated by       Dr. Mukesh Ajmera for the ailments suffered and was discharged on 21.09.2019. It is alleged that at the time of discharge, Rs. 76,024/- were claimed form Opposite Party No. 1 but the said claim was repudiated at the advice of TPA. It is also stated that the Insurance company cleared only the interim claim of Rs.17,000/- during the course of admission in hospital. It is further stated that Complainant’s wife remained under treatment and supervision of the same doctor even after the discharge. The Complainant also submitted the claim form manually with Opposite Party No. 1 and Opposite Party No. 2 along with all the required documents along with post and pre hospitalization expenses. It is alleged that Opposite Party No. 1 company sent a letter dated 09.03.2020 to the Complainant repudiating the Complainant’s claim under policy exclusion clause 4.13, mentioning that ;

“patient was admitted with low grade fever and in treatment chart, no specific treatment was done as the admission was done for evaluation purpose which is not payable under the terms and conditions of the policy.

2.  The Complainant submits that notices were served to both Opposite Party No. 1 and Opposite Party No. 2 and also received reply from Opposite Party No. 2 citing the same reasons for repudiation. The Complainant further submits that the conduct of Opposite Party No. 1 and Opposite Party No. 2 amounts to deficiency in services and unfair trade practices warranting present complaint. The Complainant has prayed for claim amount of Rs. 76,024/-, Rs. 9,980/- towards pre and post hospitalization expenses, Rs. 25,000/- as compensation and 40,000/- as litigation expenses with interest 18 % p.a. from the date 07.10.2019 till disposal of case.  

Case of the Opposite Party No. 1

3. The Opposite Party No. 1 contested the case and filed their written statement. Opposite Party No. 1, while admitting the subject policy, takes preliminary objections that that the company’s liability is subject to terms and conditions of the policy. On merits, it is submitted that the claim of the Complainant was rejected as the Complainant has not fulfilled those terms and conditions. As per terms and conditions of the policy reasonable and customary clause 4.13 which means “Hospitalization for the purpose of diagnosis and evaluation, irrelevant investigations charges : Expenses incurred at hospital primarily for diagnostic, X-ray or laboratory examinations or others diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a  hospital.
4. It is contended that the Complainant has no cause of action as his claim was rejected on the ground of Clause 4.13, hence, the claim is not payable as per the terms and conditions of the policy. It is further contended that the TPA had sent the matter to the senior doctor for review and the claim was recommended as not payable. It is also submitted that they have approved the claim amount of Rs. 17,000/- on the basis of pre authorisation medical record. The Opposite Party No. 1 has also contended that Dr. Mukesh Ajmera wrote the letter dated 23.09.2019 on the basis of private consultancy/opinion and Opposite Party No. 1 has repudiated the claim on the basis of discharge summary/medical record issued by Pushpanjali Medical centre. In view of above, the Opposite Party No. 1 has prayed for dismissal of the complaint.

 

 

Rejoinder to the written statement of Opposite Party No.1

5. The Complainant filed rejoinder to the written statement of Opposite Party 1 wherein the Complainant has denied the objection raised by the Opposite Party No. 1 and has reiterated the assertion made in the complaint.

Case of the Opposite Party No.2

6. Despite service of notice, none entered appearance on behalf of Opposite Party No. 2, hence, vide order dated 21.02.2023, Opposite Party No. 2 was proceeded ex-parte.

Case of the Opposite Party No. 3

7. The Opposite Party No. 3, treating hospital contested the case and filed its written statement. Opposite Party No. 3 had taken preliminary objections that the Complainant has not disclosed any allegations or grievances against Opposite Party No. 3. It is submitted that in absence of any grievances, the present complaint is not maintainable against Opposite Party No. 3 and deserves to be dismissed. However, it has been admitted that the Complainant’s wife was admitted that her hospitalisation was mandatory in view of her condition of dehydration. It is also submitted that patient was given proper diagnosis and treatment and no negligent act was committed. Hence, no deficiency on their part.

 

 

Rejoinder to the written statement of Opposite Party No. 3

8. The Complainant filed rejoinder to the written statement of Opposite Party No. 3, wherein the Complainant has denied the objection raised by the Opposite Party No. 3 and has reiterated the assertion made in the complaint.

Evidence of the Complainant

9. The Complainant, in support of his complaint, filed his evidence by way of affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party No.1

10. In order to prove its case Opposite Party No.1 filed affidavit of Mr. Pratap Singh, A.M of Opposite Party No.1 wherein he has supported the case of the Opposite Party as mentioned in the written statement.

Evidence of the Opposite Party No.3

11. In order to prove its case Opposite Party No.3 filed affidavit of Mr. Suresh Chand Kaushik, Marketing Head of Opposite Party No. 3 wherein he has supported the case of the Opposite Party No.3 as mentioned in the written statement.

Arguments & Conclusion

12. We have heard the Ld. Counsel for the Complainant as well as for Opposite Party No. 1 and Opposite Party No. 3. We have also perused the file and the written arguments filed by the parties.
13. It is the case of the Complainant that he had taken subject medical insurance policy from the Opposite Party No. 1. As his wife was admitted in Opposite Party No. 3 hospital 16.09.2019 and treated by Dr. Mukesh Ajmera for the ailments suffered and was discharged on 21.09.201, at the time of discharge, Rs. 76,024/- were incurred and claimed from Opposite Party No. 1 but the said claim was repudiated at the advice of TPA. The Complainant states that the Insurance company cleared only the interim claim of Rs.17,000/- during the course of admission in hospital. It is further stated that Complainant’s wife remained under treatment and supervision of the same doctor even after the discharge and the Complainant also claimed post and pre hospitalization expenses. It is alleged that Opposite Party No. 1 company vide letter dated 09.03.2020 to the Complainant repudiated his claim under policy exclusion clause 4.13 mentioning that admission was done for evaluation purpose which is not payable under the terms and conditions of the policy. Hence, the Opposite Party No.1 has been deficient in services for not settling his valid claim.
14. On the other hand, it has been contended by Opposite Party that the Complainant’s claim was not payable as per the terms and conditions of the policy and was rightly rejected on the ground of Clause 4.13. It is further contended that the TPA had sent the matter to the senior doctor for review and the claim was recommended as not payable. It is also submitted that they have approved the claim amount of Rs. 17,000/- on the basis of pre authorisation medical record. The Opposite Party No. 1 has also contended that Dr. Mukesh Ajmera wrote the letter dated 23.09.2019 on the basis of private consultancy/opinion and Opposite Party No. 1 has repudiated the claim on the basis of discharge summary/medical record issued by Pushpanjali Medical centre. In view of above, the Opposite Party No. 1 has prayed for dismissal of the complaint.
15. While Opposite Party No. 2 being TPA did not contest the case and was proceeded ex-parte. Opposite Party No. 3 being hospital contested the case and their contention is that the Complainant has not expressed any grievances against them in the complaint. However, they admitted to have treated the Complainant’s wife and issued discharge summary.
16. The perusal of record shows that there is no dispute regarding validity of the subject health policy issued to the Complainant by Opposite Party No. 1. It is also not disputed that the Complainant’s wife remained admitted for five days from 16.09.2019 to 21.09.2019 and treated by Dr. Mukesh Ajmera for the ailments suffered and incurred expenses to the tune of Rs. 76,024/-.
17. As per the repudiation letter, the Complainant’s claim was rejected by Opposite Party No. 1 under policy exclusion clause 4.13, mentioning that ;

“patient was admitted with low grade fever and in treatment chart, no specific treatment was done as the admission was done for evaluation purpose which is not payable under the terms and conditions of the policy.”

18. It has been argued on behalf of Complainant that after repudiation of the claim, the treating doctor namely Dr. Mukesh Ajmera wrote a letter to the TPA  citing his reasons for admitting the patient to the hospital. As per that letter dated 23.09.2019, it has been stated that hospitalisation of Complainant’s mandatory in view of her condition and she required multidisciplinary environment. While the Opposite Party No. 1 has contended that though, Dr. Mukesh Ajmera treated the patient in hospital but he has given his opinion on the basis of private consultancy/opinion. It is contended by the Opposite Party Insurance company that they have repudiated the claim on the basis of discharge summary issued by Opposite Party No. 3 hospital. It is further contended by Opposite Party No. 1 that TPA had sent the matter to the senior doctor for review and the claim was recommended as not payable.
19. The Opposite Party No. 1 has not led any evidence in support of their contention that senior doctor recommended the claim as ‘not payable’. Opposite Party No. 1 neither has filed any affidavit of the concerned Senior doctor proving his version not has filed any document in support of their stand that admission was not desired for and the condition of the policy was breached. On the other hand, the Complainant’s has corroborated his contention by filing copy of letter of Dr. Mukesh Ajmera, though in capacity of private consultant. Since, it is the same doctor who treated the patient during admission at the hospital, the contention of the Complainant is to be believed, particularly when Opposite Party No. 1 has failed to rebut the same.
20. The Complainant has also stated that Complainant’s wife remained under treatment and supervision of the same doctor even after the discharge and claimed post and pre hospitalization expenses to the tune of Rs. 9,980/- under the policy and Opposite Party No. 1 has not paid the same. We have perused the record and find that the Complainant has not led any evidence in support of the contention that such expenses were covered under the said policy. The Complainant has failed to show the terms and conditions of the subject policy mentioning such coverage as well as the duration of such coverage. Hence, post and pre hospitalization expenses to the tune of Rs. 9,980/- under the subject policy cannot be allowed.
21.  In view of above, we are of the considered view that the Complainant is entitled to the claim amount under the subject policy and Opposite Party No. 1 i.e. Insurance Company has been deficient in providing services by rejecting the valid claim of the Complainant, causing mental agony and torture to the Complainant.
22. Accordingly, we allow the complaint and direct the Opposite Party No. 1 i.e. National Insurance Company Limited to pay to the Complainant total claim amount of Rs. 76,024/- along with interest @ 9 % per annum from the date of institution of the complaint till recovery. The Opposite Party No. 1 is also directed to pay    Rs. 20,000/- towards compensation and Rs. 15,000/- towards litigation cost along with interest @ 9 % per annum from the date of this order till its recovery.
23. Order announced on 08.02.2024.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

 

(Anil Kumar Bamba)            Member

(Adarsh Nain)        Member

(Surinder Kumar Sharma) President