Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No.106 /24.05.2018
Vijay Kumar Gupta s/o Late K. M. Tayal
R/o 240, Second Floor, Dayanad Vihar,
Vikas Marg, Extension, Delhi-110092 …Complainant
Versus
OP1- National Insurance Company Limited
D(P) Block, Second and Third Floor,
Pitampura, LSC, New Delhi-110088
OP2-MD India Health Insurance PTA Pvt. Ltd.
Ground Floor, 18/13, WEA, Ganga Plaza,
Pusa Lane, Karol Bagh, New Delh-110005 ...Opposite Party
Date of filing: 24.05.2018
Coram: Date of Order: 09.07.2024
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
FINAL ORDER
Inder Jeet Singh , President
It is scheduled today for order (item no.18)
1.1. (Introduction to case of parties) –The complainant has grievances of deficiency of services and unfair trade practice trade practice against OPs for want of reimbursement of medical claim of his son hospitalized/ treated on 07.06.2017 and also on 01.07.2017-02.07.2017 despite the complainant has been subscribing Pariwar Mediclaim Policy for more than 10 years. The OP1 is Insurer and OP2 is TPA.
1.2. The OP1 filed its written statement and denied allegations of deficiency of services and unfair trade practice trade practice on the ground firstly, the hospitalization/treatment on 16.06.2017 was for around 7 hours, it cannot be construed hospitalization as per policy terms since there should be hospitalization of at-least 24 hours. Secondly, no claim was lodged for hospitalization expenses of 01.07.2017-02.07.2017.
2.1. (Case of complainant) –The complainant has been subscribing mediclaim policy known as National Pariwar Mediclaim for the last 10 years and lastly it was get renewed from 07.05.2017 to 06.05.2018 vide policy no. 307700501710000695 against premium of Rs. 17,586/- [hereinafter referred as policy or insurance policy]. The family of complainant is covered under the policy. As per policy, the expenses related to hospitalization, medication and other tests incurred by the customer are to be paid by the insurer/OP1.
2.2. On 16.06.2017, during the validity of insurance policy, the complainant’s son Anant Gupta was taken to Fortis Hospital, where doctor recommended complainant’s son to get injection Ristova (medicine) in two intervals. On that basis the complainant’s son was firstly admitted to day care on 17.06.2017, where he was kept for medicine, management and supervision for around 6 hours and thereafter on 01.07.2017 for one day, he was discharged on the following day on 02.07.2017. The hospital had issued discharged summary document on 17.06.2017 and 02.07.2017 besides inpatient bills dated 17.06.2017 and 02.06.2017. The paragraph 8 of the complaint enumerates that amount of Rs.55,200/- was spent for injection Ristova 500 mg on 16.06.2017, Rs. 350/- for test (CBC) conducted on 29.06.2017 and Rs. 55,200/- spent on 30.06.2017 for injection Ristova 500 mg RA.
The complainant approached OPs for reimbursement of amount/expenses of Rs. 1,10,750/-, being covered under the policy especial clause no. 1.2.2, but it was not refunded despite oral requests and personal visits of the complainant. Thence, the complainant sent legal/demand notice dated 01.03.2018, seeking amount. The OP1 replied the notice while denying the claim but OP2 has not responded despite service. The actions of OPs is wrong and illegal, in fact, complainant is sick and tired of such conduct of the OPs. It is deficiency of services of the highest order and also unfair trade practice of highest degree. That is why the present complaint for reimbursement of amount of Rs. 1,10,750/-, interest of Rs. 24,365/- computed at the rate of 24%pa from July 2017 to May 2018 and also pendent-lite and future interest, damages of Rs. 5 lakh in lieu of mental agony, pain and trauma suffered by the complainant at the ends of OPs besides other reliefs.
2.3. The complaint is accompanied with copies of – mediclaim policy dated 02.05.2017, prospectus of Pariwar Mediclaim policy, prescription/recommendation dated 16.06.2017/18.06.2017 by the doctor, discharge summaries of 17.06.2017 and 02.07.2017 , in-patient bills, invoices of injection and tests, legal notice dated 01.03.2018 with postal receipt and track report. In addition, the complainant also filed further documents of denial of claim letter dated 22.07.2017, request for reopening of the claim dated 12.06.2018 and denial of claim dated 13.06.2018.
3.1 (Case of OP1)- The complaint is opposed by the OP1 that complaint is vague and false; the claim of complainant was not covering within the terms of policy. The parties are bound by the terms and conditions of policy (reference is placed on Reliance Life Insurance Co. Vs. Madhavcharya, RP. No. 2011/2009, dod 02.02.2010 NC). It is National Pariwar Mediclaim policy in the name of complainant Vijay Kumar covering four persons. The complaint fails to make out case of deficiency of services or of unfair trade practice.
3.2. In this case the hospitalization was done for the purposes of administration of medicine/drug, for which claim is not payable. As per claim documents it is observed by the TPA that the patient was admitted for less than 24 hours on 17.06.2017 and the admission was just for 7 hours, for which claim was filed by the complainant. This claim was not payable. The TPA works independently and on the basis of claim documents, the TPA did not find claim payable in terms of policy condition as minimum period of 24 consecutive hours are required.
The complainant has not filed any claim for admission in the hospital for period from 01.07.2017 to 02.07.2017, let the complainant be asked to approach the TPA for the same. The complaint is abuse of process of law and it is liable to be dismissed.
3.3 The reply is accompanied with Pariwar Mediclaim for policy terms and conditions, discharge summary dated 17.06.2017 and claim form.
3.4 ( Case of OP2)- The notice on this complaint was issued to OP2/TPA, however, it failed to cause appearance or to file written statement, therefore, for want of appearance the OP2 was proceeded ex-parte on 02.11.2018.
4. (Replication of complainant) –The complainant filed rejoinder, which is reply to the written statement as well as explanations by referring the documents as well as the complaint. The clause 1.2.2 covers the claim of treatment, hospitalization, medication and tests. The policy clearly maintains that in case patient is admitted for complete one day, then expenses relation to hospitalization and medication and other tests incurred by the customer, has to be paid by the OP with regard to admission of complainant’s son on 01.07.2017 and his discharge on 02.07.2017, the complainant approached the OP for claiming the expenses as per coverage in the policy but complainant was not heard. The complaint is correct.
5.1. (Evidence)-In order to prove the complaint, the complainant led his evidence on the pattern of complaint and rejoinder with documents.
5.2. The OP1 also led its evidence through Ms. Kanchan R. Negi, Admin. Officer and the evidence is replica of written statement with documents.
6.1 (Final hearing)-Both the parties were given opportunity to file their written arguments, therefore, the complainant as well as the OP1 filed their written arguments, each of the written arguments are blend of pleading and written statement.
6.2. The parties were also given opportunity to make oral submission, therefore, Sh. Arman Gupta, Advocate for complainant and Sh. Vikas Shaukeen, Advocate for OP1 made the oral submissions.
6.3 The submissions of both the sides are not repeated here as the same will be considered, analyzed and assessed while appreciating their case and drawing the conclusions, besides the OP2 remained absent throughout despite some of the documents were correspondence with OP2.
7.1 (Findings)-The case of the complainant and of OP1 are considered keeping in view the material on record either the pleadings, evidence inclusive of documentary record. After taking stock of all such material, the following conclusions are drawn:-
(i) There is no dispute of issue of insurance policy in the name of complainant and it covers four persons inclusive of complainant’s son Sh. Anant Gupta. There is also no dispute that the complainant’s son was administered injection on 17.06.2017 and on 01.07.2017/02.07.2017 at Fortis Hospital during the currency of insurance policy.
(ii) It is admitted case of the parties that on 17.06.2017, the complainant’s son Anant Gupta was administered injection Ristova (medicine) and its was pursuant to prescriptions that two injections were to be administered at the interval, the first injection was administrated on 17.06.2017. However, the complainant’s son was kept in the day care centre for about 6 hours-7 hours; it cannot be considered hospitalisation for the the purposes of policy and reimbursement, since hospitalisation ought to be at least for 24 hours.
The day care in the hospital is alike mini-hospitalization and patient was kept for administration of medicine of special nature, constant observations on the patient, management etc. and the in-patient bill issued itself infers that the complainant’s son was hospitalized. As per clause 1.2.2 of the insurance policy, pre-hospitalization shall be considered as part of the hospitalization claim. Whereas, in the situation in hand the complainant’s son Anant Gupta was in-patient, he was kept in day care but for 6-7 hours, it is to be construed /treated as equivalent to hospitalization.
It would have been improper by keeping the patient for 24 hours, when requirement is less either because of advancement of technique/equipments and trends, advance nature/quality of medicine; as well as keeping the patient for long would not be health oriented in the atmosphere of hospital. However, gravity of ailment does not decreases.
(iii) The OPs have declined the entire claim but there were components of charges of injection and other expenses as of in-patient bills. The circumstances are suggesting that although the patient remained in the day care for 6 hour-7 hour for the purposes of treatment etc, it would not disentitle the complainant for the claim of medicine and other charges by invoking clause of 24 hours, which would be contrary to the objective of insurance policy in totality.
(iv) The complainant has placed on the record additional payment claim/application acknowledged by OP2 as well as draft repudiation letter for approval and it mentions claimed amount of Rs. 1,17,220/- and date of repudiation is 22.07.2017, besides request for reconsideration of additional payment claim. To say, it establishes that the complainant was just reimbursed an amount of Rs. 7,330/- by the insurer/TPA out of claim of Rs. 1,17,220/-. The claim also includes bills and expenses of hospitalization of 01.07.2017-02.07.2017.
Since the TPA/OP2 was already approached by the complainant prior to filing of the complaint, therefore, the plea of OP1 is not acceptable to ask the complainant to approach TPA/OP2. Moreover, the testimony of the complainant remained unchallenged in respect of his averments against OP2.
(v) The complainant has proved that he had lodged the claims with the OPs, however, the amount of Rs. 1,10,750/- as claimed was not reimbursed.
(vi) The aforementioned conclusion also proves that for want of reimbursement of valid claim, it amounts to shortcoming and deficiency of services.
The complainant is held entitled for amount of Rs. 1,10,750/- from the OP1/Insurer.
7.2. The complainant has claimed interest at the rate of 24%pa for period prior to filing of the complaint as well as for the period subsequent their bill. There is no clause in the insurance contract for the interest, therefore, complainant’s request for interest of Rs. 24,365/- prior to the date of filing of the complaint is declined.
Simultaneously, it is also fact that complainant had parted with the money despite having insurance cover, therefore, it would be appropriate to compensate him in lieu of depriving of the amount, thus simple interest at the rate of 5%pa from the date of complaint till realization of amount of Rs. 1,10,750/- is allowed in favour of the complainant and against the OP.
7.3. The complainant also claim damages of Rs. 5 lakh in lieu of trauma, mental pain and agony but no specific evidence has been led to compute as to how huge amount of Rs. 5 lakh for damages is assessed. Since there was deficiency of services on the part of OPs to reimburse the valid claim and for which the complainant was trying hard, therefore, compensation of Rs. 10,000/- is determined in favour of complainant and against the OP1.
At the stage of final argument, complainant had requested that although cost and other relief were not quantified/specified but the complainant was constraint to file the complaint to seek his valid claim, the complainant may be awarded appropriate costs and other directions in his favour and against the OPs. The request of complainant is plausible that legal notice was served and after exhausting that remedy, the complaint was filed, therefore, cost of Rs. 7,000/- in favour of complainant and against OP1 is determined.
7.4 Since the TPA/OP2 is facilitator in the settlement of claim and as per the case of OP1, it appears that OP1 has been accepting whatever was suggested by OP2, without imbibing its own responsibility. However, the statutory role of OP2 is of facilitator for the processing of the claim, OP2 is not insurer, therefore, complaint against OP2 is dismissed.
8.1 So, the complaint is allowed in favour of complainant and against OP1 to pay/reimburse amount of Rs. 1,10,750/- alongwith interest at the rate of 5%pa from the date of complaint (24.05.2018) till realization of the amount to the complainant, besides damages of Rs. 10,000/- and cost of Rs. 7,000/- The amount will be payable within 45 days from the date of this order, failing which the OP1 will be liable to pay the enhanced simple interest at the rate of 7%pa on amount of Rs. 1,10,750/-.
8.2 The complaint against OP2, as discussed, stands dismissed.
9. Announced on this 09th day of July 2024 [आषाढ़ 18, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliance, besides to upload on the website of this Commission.
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