District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.103/2021.
Date of Institution: 25.2.2021.
Date of Order: 28.07.2023.
Deepak Nimesh aged about 50 years son of Shri Het Ram resident of flat No. 601, CH Plot No.27, The Mart Cooperative Society, sector-2, Faridabad.
…….Complainant……..
Versus
1. National Insurance Co. Ltd., Policy issuing office at: Branch Office SCO-96, Sector-16 market, Faridabad – 121002 through its Branch Manager/Authorized Signatory.
2. M/s.Park Mediclaim TPA Pvt. Ltd., 702, Vikrant Tower, Rajendra Place, New Delhi – 110 008 through its Authorized Signatory/Principal Officer.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. B.L.Gaur, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 30.05.2022.
ORDER:
The facts in brief of the complaint are that the complainant was regular mediclaim policy holder since long for himself and his wife and child, from opposite party No.1 and policy bearing No. 361102501810003493 valid from 29.07.2018 to 28.07.2019. On 10.04.2019, the complainant felt severe abdominal pain, abdominal discomfort, weakness and approached Asian Institute Medical Science, Faridabad, where the medical officer medico legally examined the complainant and advised for admission. Acceding the advice of the doctor, the complainant admitted in the hospital vide IPD No. AFB1P1910918 dated 10.04.2019 and discharged on 17.04.2019, where the complainant was diagnosed and received treatment. The Hospital Administration sent the intimation of his hospitalization to the opposite party and asked for cashless facility, but the opposite party did not pay any heed and refused to provide cashless facility. The Hospital Administration issued the final bill for Rs.1,32,786/- and the complainant had paid the same from his own pocket. Besides the above said final bill, the complainant also spent the amount on OPD, tests etc. Thereafter, the complainant submitted all the original documents and lodged his claim of Rs.1,93,300/- with the opposite parties bearing NO. NICDR2/218496 as well as also removed the quarries of the opposite parties and the opposite parties assured the complainant that the claimed amount would be disbursed but the opposite party did not disburse the claimed amount till date. The complainant time and again approached the opposite party and requested for the disbursement of the claimed amount, but firstly the opposite party avoided the matter on one pretext or the other and lastly the opposite parties vide its letter dated 05.11.2019 repudiated/denied the claim of the complainant on flimsy ground of clause 4.21 Drug/Alcohol Abuse, whereas, the complainant had no concern at all with any drug or alcohol since last more than 11 years, but they mentioned in their impuged letter dated 05.11.2019 that “Treatment arising out of disease/injury directly attributable to use of drugs/alcohol and intoxicating substance”. Whereas, the hospital administration duly issued the certificate vide which clear that the complainant was not alcoholic. The complainant was admitted on 10.04.2019 and remained admitted upto 17.04.2019 for chronic liver failure due to Hepatitis B not alcoholic disease. It was pertinent to mention that as per medical science, the disease “Hepatitis B” could not be occurred due to consumption of alcohol. The complainant sent legal notice dated 15.01.2020 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the claimed amount of Rs.1,93,000/- alongwith interest @ Rs. 12% per annum from the date of bill till actual realization to the complainant.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that at the very threshold of the allegations contained in the complaint, it was evident from relied upon medical documents, particularly prescription slip dated 05.04.2019 issued by Dr. Gurpreet Singh of Angad Medical Centre, Sector-21C, Faridabad the complainant was diagnosed as an old case of “diabetes Mellitus, Alcoholic liver disease & hyperglycemia” thus, the claim ofn the complainants stands non payable as per exclusion clause 4.21 (Drug/Alcohol Abuse – Treatment arising out of disease/injury directly attributable to use of drug/alcohol and intoxicating substances) of the insurance policy. As such, the issue under the present complaint did not fall under the peri pheri of the provisions and more particularly the word “deficiency” as defined under seciton2(11) & Word “Service” as defined section 2(42) and the word “Unfair Trade Practice” as defined section 2(47) of the Consumer Protection Act, 2019. The complainant neither had any cause of action nor locus standi in lodging of the present complaint before this Hon’ble Commission, reason being, as a matter of record, on 11.04.2019 a cashless request alongwith relied upon documents of the patient vide UHID No. 00073029 was received from Asian Hospital, Faridabad for patient Deepak Nrmesh i.e complaint who got admitted with c/o abdomen pain sever weakness, weight loss & jaundice for 10 days & the estimated expenses were Rs.90,000/-. Thereafter, during processing of the said claim, the opposite party No.2 had sought additional informations/clarification by causing request form vide dated 11.04.2019 to the treating hospital i.e.”1, All investigation reports done till date.2. Record of treatment taken before hospitalization. In turn, the treating hospital had forwarded response in reply thereto in the shape of investigation reports & prescription slip dated 05.04.2019 issued by Dr. Gurpreet Singh of Angad Medical centre, Sector-21C, Faridabad which was provided by the complainant to the treating hospital. After reviewing the documents at the end of opposite party No.2, it was revealed that the complainant was diagnosed as an old case of “diabetes Mellitus, Alcoholic liver disease & hyperglycemia” thus the said cashless request was rejected of the said hospitalization due to reason which was being reproduced as “since their liability was not established in view of alcoholic liver disease”. Thus the claim of the complainant stands non payable in view of the exclusion clause 4.21 of the insurance policy so issued in this regard. Hence, the cashless was rejected in view of said exclusion clause of the insurance policy vide “letter of intimation” dated 14.04.2019 with the remarks that “However, denial of cashless request was not the denial of treatment or admissibility of claim. Concerned member may please be informed that claim would be considered for reimbursement on merit, under the terms and conditions of the policy and the member was requested to submit all the documents to them after discharge from the hospital. Thereafter, the complainant had lodge his re-imbursement mediclaim with the opposite party No.2 vide his claim form so received by the opposite party No.2 on 18.05.2019, by enclosing entire treatment papers by alleging indoor treatment w.e.f. 10.04.2019 to 17.04.2019 therein with Asian Hospital, Faridabad under claim No. NICDR2/218496 by claiming Rs.1,93,651/- with diagnosis of Chronic Liver Failure, Hepatitis B Reactivation, Mild Congested gastric MucosaType-II DM, prostatic nodules PSA. After getting investigated the matter by opposite party No.2 from the treating hospital, during processing of the said claim at the end of the opposite party No.2 being the authorized agency of the opposite party No.1, it was revealed that the complainant was diagnosed as an old case of “diabetes Mellitus, Alcoholic liver disease & hyperglycemia” thus, the claim of complainant stands non payable as per exclusion clause 4.21 (Drug/Alcohol Abuse-Treatment arising out of disease/injury directly attributable to use of drug/alcohol and intoxicating substances) of the insurance policy. Hence, the insurance company had arrived at the decision in treating such claim as “Repudiated” vide letter dated 05.11.2019, which decision could not be termed unconscionable at all. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Notice issued to opposite party No.2 on dated 30.04.2022 not received back either served or unserved. Case called several times since morning but none appeared on behalf of opposite party No.2. Mandatory period of 30 days expired. Hence, opposite party No.2 was hereby proceeded against exparte vide order dated 30.05.2022.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
To establish his case the complainant has led in his evidence, Ex.CW1/ A – affidavit of Deepak Nirmesh, Ex.C-1 – policy, Ex.C-2 – discharge summary, Ex.C-3(colly) –Final bill, Ex.C-4 – repudiation letter, Ex.C-4 – legal notice,, Ex.C-6 & 7– postal receipts.
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties Ex..R1 – affidavit of Shri Rameshwar Dass, Assistant Manager, M/s. National Insurance Co. Ltd., Divisional offie-1, 5C/1&2, BP Railway Road, Neelam Chowk, NIT, Faridabad., Ex.R-2 – letter dated 11.4.2019 regarding query for the cashless request for hospitalization under policy No. 361102/501/10003493, Ex.R-3 – prescription, Ex.R-4 – letter dated 14.04.2019, Ex.R-5 – Claim form, Ex.R-6 – discharge summary, Ex.R-7 – Final bill summary,, Ex.R-8 – Scope of investigation, Ex.R-9 - letter dated 15.4.2019, Ex.R-10 – Verification report,, Ex.R-11 – Standard investigation report, Ex.R-12 – Third party administrator health services, Ex.R-13 - letter dated 30.09.2019,, Ex.R-14 – revised report, Ex.R-15 - letter dated 05.11.2019.
6. In this case, the complaint was filed by the complainant with the prayer to pay the claimed amount of Rs.1,93,000/- alongwith interest @ Rs. 12% per annum from the date of bill till actual realization to the complainant. It is evident from Ex.C1 that the complainant was regular mediclaim policy holder since long for himself and his wife and child, from opposite party No.1 and policy bearing No. 361102501810003493 valid from 29.07.2018 to 28.07.2019. The complainant admitted in the hospital vide IPD No. AFB1P1910918 dated 10.04.2019 and discharged on 17.04.2019, where the complainant was diagnosed and received treatment. The Hospital Administration issued the final bill for Rs.1,32,786/- and the complainant had paid the same from his own pocket. The complainant submitted all the original documents and lodged his claim of Rs.1,93,300/- with the opposite parties bearing NO. NICDR2/218496 as well as also removed the quarries of the opposite parties and the opposite parties assured the complainant that the claimed amount would be disbursed but the opposite party did not disburse the claimed amount till date. The opposite parties vide its letter dated 05.11.2019 repudiated/denied the claim of the complainant on flimsy ground of clause 4.21 Drug/Alcohol Abuse, whereas, the complainant had no concern at all with any drug or alcohol since last more than 11 years, but they mentioned in their impugned letter dated 05.11.2019 that “Treatment arising out of disease/injury directly attributable to use of drugs/alcohol and intoxicating substance”.
7. During the course of the arguments , counsel for the complainant has produced certificate dated 20.12.2019 vide Ex.A issued by Dr. R.C.Soni, Sr. Consultant, Gastroenterology Department, in which it has been mentioned that “Mr. Deepak Nimesh was admitted through emergency department in Asian Institute of medical sciences Sector-21A, Faridabad on 10.04.2019 vide UHID No. UHID-00073028 IPD No. AFBIPI910918 and discharge don 17.04.2019..
During hospitalization patient diagnosis are Acute on chronic liver failure, Hepatitis B reactivation.
In this case etiology of liver disease hepatitis B.
However patient declined for Alcoholic history as not using alcohol since last 10 years (self-declaration attached)”
Counsel for the complainant has also produced Overview Symptoms Treatments regarding Hepatitis B vide Ex. B during the arguments.
8. After going through the evidence led by the parties as well as the certificate dated 20.12.2019, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 28.07.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
