DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST

       GOVT. OF NCT OF DELHI

      CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

CC No: 905/2016

D.No._______________________                               Dated: _______________

IN THE MATTER OF:

Smt. SHANTA DEVI,

W/o SH. RAM KUMAR GUPTA,

R/o A-68, RAJOURI GARDEN,

NEW DELHI-110027.                                                    … COMPLAINANT

             Versus

1. NATIONAL INSURANCE CO. LTD.,

    THROUGH ITS CHAIRMAN & M.D.,

    HEAD OFFICE-3, MIDDLETON STREET,

    KOLKATA, WEST BENGAL-700071.

    ALSO AT: THROUGH ITS BRANCH MANAGER,

    DIVISION No.-14, PLOT No.-5, D (P) BLOCK,

    2^nd & 3^rd FLOOR, LSC PITAM PURA,

    NEW DELHI-110088.

    ALSO AT: THROUGH ITS BRANCH MANAGER,

    B-11, VARDHMAN PLAZA, 2^nd FLOOR,

    SECTOR-16, NOIDA-201301.

    ALSO AT: THROUGH ITS REGIONAL OFFICE:

    DELHI REGIONAL OFFICE-2,

    2^nd FLOOR, CORE 3 SCOPE MINAR,

    LAXMI NAGAR, DELHI-110092.

2. FORTIS HOSPITAL (PERFORMA PARTY),

    A BLOCK, SHALIMAR BAGH,

    DELHI-110088.                                                …OPPOSITE PARTY (ies)

CORAM: SH. M.K. GUPTA, PRESIDENT

               SH. BARIQ AHMED, MEMBER

     MS. USHA KHANNA, MEMBER

                                                                   Date of Institution: 15.09.2016

                                                                     Date of decision: 17.03.2020

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SH. M.K. GUPTA, PRESIDENT

ORDER

1.       The complainant has filed the present complaint against OPs under Section 12 of the Consumer Protection Act, 1986 thereby alleging that the complainant and her husband Sh. Ram Kumar Gupta purchased a Mediclaim Policy bearing no.361303/48/13/8500000 929 being hospitalization benefit policy from OP-1 on 15.08.1999 being policy no. 360200/8500298/99 and since then same policy had been renewed every year and the renewed policy for the year-2013 was Mediclaim Policy no. 361303/48/13/85000 00929 and the said policy was issued by OP-1 against money consideration which was duly paid by the complainant. On 17.07.2014, the complainant fell on the floor from her standing position without any external cause or reason and was immediately rushed to Dr. Rajeev Chawla who examined the complainant and concluded that this was on account of her precarious health condition i.e. T-2 DM, poorly controlled diabetes mellitus with Hypertension Grade-III, Obesity leading to severe OSA and advised immediate hospitalization and he further opined that the patient needed Bariatric surgery. Thereafter, the complainant was referred to Fortis Hospital i.e. OP-2 and the complainant was admitted on 17.07.2014 and the hospital clinical diagnosis revealed that the complainant was suffering from ‘poorly controlled diabetes mellitus

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          with hypertension, osteoarthritis and morbid obesity (BMI-41.4 Kg/m) and the complainant was also suffering with backache, stress incontinence reflux acidity, snoring, joint pains, lower limb venous insufficiency’. The complainant further alleged that the complainant was evaluated for bariatric metabolic surgery and thus evaluated for laparoscopic Roux–en–Y Gastric Bypass and the surgery was done at the hospital on 18.07.2014 for Laparoscopic Roux–en–Y Gastric Bypass and the patient was discharged on 21.07.2014 and the complainant made a payment of Rs.4,01,250/- through cheque bearing no. 799048 dated 17.07.2014 drawn on Yes Bank, New Delhi in favour of Fortis Healthcare Ltd. towards the hospitalization and treatment etc., charges and the same is duly received and acknowledged by the hospital and at the time of taking the treatment and surgery the complainant was having a valid, current and active policy being policy no. 361303/48/13/8500000 929 and the treatment meted to her is/was covered by the policy. After the treatment was over the complainant filed a detailed medical claim with OP amounting to Rs.4,10,633/- i.e. the amount paid to the hospital and also payment made for consultancy and medication and to the utter shock and surprise of the complainant the claim filed was repudiated by the office of OP-1 vide letter dated 26.02.2015 without application of mind and without going through the facts and circumstances of the claim and in most arbitrary and

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          mechanical manner. The complainant further alleged that it was observed that the claim was declined on account of the treatment being of obesity and its complications and OP-1 failed to appreciate that the condition of the patient i.e. the complainant was very precarious as the complainant was suffering from various ailments for which urgent treatment/surgery was required and for which the complainant was fully covered in the policy and treatment was purely on account of existing complications and to ensure that the complainant does not develop complications which may well latter could have proved to be life threatening and the treatment/surgery underwent by the complainant was on the advice of the doctor for curing/treating the ailment and it is beyond any stretch of imagination that at the age of 67 years any person will go for a cosmetic surgery and the treatment was purely on account of the treatment for the ailments of her precarious health condition i.e. T-2 DM, poorly controlled diabetes mellitus with Hypertension Grade-III, obesity leading to severe OSA and advice immediately hospitalization and to avoid the life threatening future complications associated with the ailments. The complainant further alleged that OP-1 vide its letter dated 26.02.2015 furnished the reasons for repudiating the claim which were/are flimsy, contrary to the facts and circumstances of the case and unsustainable and contrary to the provisions of the insurance and on account of denial to pay the claim amount to the complainant by

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          OP-1, the complainant was made to suffer irreparable loss, discomfort, agony and financial constraint and hardship. Thereafter, the complainant approached through her husband vide letter dated 07.01.2016 the Consumer Relationship Management Department of OP-1 and brought to the notice the circumstances under which the complainant was required hospitalization, treatment and the surgery thereof and other circumstances of the case and the same was replied by OP-1 vide letter dated 21.01.2016 and again vide letter dated 21.03.2016 the Senior Officials of OP-1 were intimated about the facts and circumstances of the case and were requested to look into the matter however, OP-1 vide letter dated 04.04.2016, the complainant was informed that the claim was reviewed by the highest level in office of OP-1 and confirmed the action taken vide letter dated 26.02.2015 inter alia repudiating the claim. The complainant further alleged that the complainant sent a legal notice dated 05.07.2016 through her Counsel to  OPs by speed post and courier which was duly received by OPs but no reply has been given on behalf of OPs since then to the said notice and the action of OP-1 in refusing the legal claim amounts to deficiency in service on the part of OP-1. 

2.       On these allegations the complainant has filed the complaint praying for direction to OP-1 to release the claim amount i.e. Rs.4,10,633/- alongwith interest @ 18% p.a. from the date of lodging the claim as well as compensation of Rs.1,00,000/- for

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          causing mental agony and harassment and also sought Rs.55,000/- as  cost of proceeding.

3.       OPs have been contesting the complaint and filed reply/written statement. In its reply, OP-1 submitted that the complaint is not maintainable and is liable to be dismissed and further submitted that OP-1 had issued to Sh. Ram Kumar Gupta i.e. the husband of the complainant a Mediclaim Policy bearing no. 361303/48/13/ 8500000929 granting Mediclaim cover to the complainant for a sum of Rs.3,00,000/- and the insurance was granted subject to terms & conditions as stated in the policy. OP-1 further submitted that the treatment was inter alia taken on account of diabetes and its complications which is excluded from the scope of insurance cover granted to the complainant and the patient needed Bariatric Surgery and the treatment for this surgery is also excluded from the scope of insurance policy. OP-1 further submitted that the treatment was taken because of obesity and its complications which is excluded from the scope of insurance cover granted to the complainant and the complainant was suffering from diabetes for the last 2 years which was a pre-existing disease and the same does not fall within the purview of scope of craved to the certificate dated 01.07.2014 issued by the Fortis Hospital i.e. OP-2 and the claim has been repudiated as per Contract of Insurance entered into between the insured and insurer. OP-1 further submitted that there is no deficiency in service on the part of OP-1.

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4.       In its written statement, OP-2 submitted that the complainant was admitted in Fortis Hospital for her treatment on 17.07.2014 and was discharged on 21.07.2014 and the complainant was admitted for the problem of poorly controlled diabetes mellitus with hypertension, osteoarthritis with morbid obesity and the complainant underwent Laparoscopic Roux-en-Y Gastric Bypass on 18.07.2014 after proper counselling and tests conducted by OP-2 and that Bariatric Surgery of the complainant was done and same was successful and the complainant was discharged on 21.07.2014 from the hospital with her consent. OP-2 further submitted that at the time of discharge of the complainant, OP-2 raised a bill of Rs.4,11,250/- towards the treatment provided to the complainant and the same was accepted by the complainant and OP had given a discount to the complainant and the complainant had deposited an amount of Rs.4,01,250/- through cheque with OP-2.

5.       The complainant filed separate replications and denied the submissions of OP-1 and further submitted that OP-1 has taken a misleading plea.

6.       In order to prove her case, the complainant filed her affidavit in evidence and also filed written arguments. The complainant also placed on record copy of insurance policy for the period from 14.08.2013 TO 13.08.2014 (mid-night) in favour of Sh. Ram Kumar Gupta and Smt. Shanta Devi for insurance cover of Rs.5,00,000/-

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          each, copy of Pre-Authorization Request Form issued by MDIndia Healthcare Services (TPA) Pvt. Ltd., copy of the Original Brochure of the policy, copy of IPD Registration Form dated 17.07.2014 issued by Fortis Hospital, copy of Day Care/Inpatient Admission Counselling issued by OP-2, copy of treatment slip dated 17.07.2014 issued by Dr. Rajeev Chawla of North Delhi Diabetes Centre, copy of Bill-Cum-Receipt dated 01.07.2014 of Rs.1,550/- issued by OP-2, copy of Detailed Bill dated 21.07.2014 of Rs.4,01,250/- issued by OP-2, copy of Consent on Discharge issued by OP-2, copy of discharge summary issued by OP-2, copy of her Current Profile issued by OP-2, copy of X-Ray Chest (AP View) Portable issued by OP-2, copies of Laboratory Reports, copies of cash memos no. 005769 dated 21.07.2014 of Rs.6,421/- & no. 006114 dated 31.07.2014 of Rs.1,360/- issued by Vikas Chemist, New Delhi, copy of bill no. 419 dated 25.07.2014 of Rs.52/- issued by Helpline Plus Pharmacy, Delhi, copy of cheque no. 799048 dated 17.07.2014 of Rs.4,01,250/- in favour of Fortis Healthcare Ltd. drawn on YES Bank, New Delhi, copy of repudiation letter dated 26.02.2015 sent by OP-1 to the complainant, copy of letter dated 07.01.2016 sent by the complainant to the Customer Relationship Management Department, Kolkata alongwith postal receipt, copy of repudiation letter dated nil sent by OP-1 to the complainant, copy of reminder-1 sent by the complainant to the Customer Relationship Management Department, Kolkata alongwith postal receipt, copy of

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          repudiation letter dated 04.04.2016 and copy of legal notice dated 05.07.2016 sent by the complainant through her Counsel to OPs by Speed Post/Courier alongwith postal receipts and courier receipts and tracking reports.

  7.     On the other hand, Sh. Rajneesh Kumar, Administrative Officer of OP-1 and Sh. Mahipal Bhanot, Authorized Signatory of OP-2 filed their separate affidavits in evidence. OP-2 also placed on record copy of discharge summary, copy of examinations and investigations report, copy of consent on discharge, copy of bill dated 21.07.2013 of Rs.4,01,250/-, copy of detailed bill dated 21.07.2014 of Rs.4,01,250/- and copy of Power of Attorney. OPs also filed their written arguments.

8.       This forum has considered the case of the complainant as well as OPs in the light of evidences and documents placed on record by the parties. The case of the complainant has remained consistent and there is nothing on record to disbelieve the case of the complainant. The documents and evidence of the parties shows that the complainant was hospitalized in Fortis Hospital, Shalimar Bagh, Delhi for the treatment of poorly controlled diabetes Mellitus with hypertension, osteoarthritis and morbid obesity (BMI-41.4 Kg/m), Laparoscopic Roux-en-Y Gastric Bypass. This fact is not disputed by OP-1. The sole defence taken by OP-1 is that the complainant has concealed the material fact that she was suffering from pre-existing disease for the last 2 years and as such the claim rightly

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          repudiated by OP-1. This contention/defence of OP-1 is resisted vehemently by the complainant.

9.       We have considered the point in issue. The defence of OP-1 is of no value to OP-1. OP-1 has failed to prove the fact that for cosmetic surgery the complainant underwent hospitalization, treatment and surgery in OP-2 hospital. OP-1 has not disputed the age of the complainant as 67 years. Thus, the defence taken by OP-1 cannot be considered. Thus, it appears that OP-1 has taken a false and bogus defence and in these circumstances, this Forum is of opinion that OP-1 was not justified in denying the claim of the complainant. Thus, OP-1 is held guilty of deficiency in service and unfair trade practice.

10.     Thus, holding guilty for the same, we direct OP-1 to: -

ii) To pay to the complainant an amount of Rs.1,00,000/- as compensation for causing harassment and mental agony.

11.   The above amount shall be paid by OP-1 to the complainant within 30 days from the date of receiving copy of this order failing which OP-1 shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of receiving copy of this order till the

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        date of payment. If OP-1 fails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25/27 of the Consumer Protection Act, 1986.

12.  Let a copy of this order be sent to each party free of cost as per     regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room. 

Announced on this 17^th day of March, 2020.

 BARIQ AHMED                       USHA KHANNA                       M.K. GUPTA

   (MEMBER)                               (MEMBER)                         (PRESIDENT)

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UPLOADED BY: SATYENDRA JEET