District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 193/2022.
Date of Institution:06.04.2022
Date of Order:09.06.2023.
Sh. Nand Kishore Chawla, S/o Sh. Jai Gopal Chawla @ Gopal Chawla, aged about 62 years, R/o House No. 1591, Sector-23A, Faridabad, Haryana – 121005.
…….Complainant……..
Versus
1. National Insurance Co. Ltd., Branch Office-2, SCO-96, Ist floor, Sector-16 Market, Faridabad – 121002 through its Manager.
2. Safeway Insurance TPA Pvt. Ltd., 815, Vishwa Sadan, District Centre, Janak Puri, New Delhi, Delhi – 110 058.
…Opposite parties
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Ms. Monica Dutta, counsel for the complainant.
Sh. Anuj Gupta, counsel for opposite party for opposite party No.1.
Opposite party No.2 become proforma opposite party vide order dated 31.10.2022
ORDER:
The facts in brief of the complaint are that the complainant had taken mediclaim policy from the opposite party No.1 since 12.11.2017 and the complainant was getting renewed his policy time to time and at present the complainant was having policy No. 361102/50/20/10005765 valid from 12.11.2020 to 11.11.2021 and the policy type was of National Parivar Mediclaim and the same was for the insured sum of Rs.6,00,000/-. On 05.09.2021 the complainant suffered problems of dengue NS 1 with Thrombocytopenia with DM II with hepatomegaly with prostatomegaly and due that problem the complainant admitted in Vibral Hospital Pvt. Ltd. Sector-21D, HUDA Market, Faridabad and before admission the complainant gave all the documents to the hospital but the opposite party No.2, who was the TPA of opposite party No.1 did not provide the cashless facility to the complainant and ultimately the complainant paid all the medical charges/expenses i.e. Rs.1,45,340.33 to the said hospital. Copy of all the bills alongwith investigation reports had already submitted with him the opposite party No.2. The complainant admitted in the said hospital on 05.09.2021 and was discharged on 14.09.2021 vide discharge summary I.P.D NO. 5336 The complainant completed all the formalities of him both the opposite parties Nos.1 & 2 and submitted all the requisite reports and even after submitting the same the complainant did not receive his medical treatment charges. After that the complainant contacted many a times to him both the opposite parties but you had not paid any heed to the legitimate request of the complainant and avoided to pay the treatment charges/expenses illegally and unlawfully to the complainant. The complainant sent legal notice dated 25.2.2022 to the opposite party through
registered post 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 above said claimed amount of Rs.1,45,340.33 towards treatment charges of the complainant alongwith interest till its realization.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 25,000 /-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 this is settled law that “where there is suppression of material fact the complainant was not entitled for any relief as prayed for.” The claim of the complainant was got investigated by the opposite party No.2 through Dr. Digvijay Singh, who physically visited the hospital and checked indoor treatment papers record and found that:
i) Hemoglobin was getting decreased during hospitalization & even on the day before discharge hemoglobin was lower than the first day report.
ii) Total Leucocyte Count(TLC) was normal on the first day & got increased during hospitalization.
iii) Platelet count was normal on the first day of report and got decreased during hospitalization, which shows patient did not had thrombocytopenia on the day of admission.
iv) Patient did not had any high grade fever at the time of admission.
v) The documents were full of medico technical discrepancies indicating unwanted admission supported by vague and unauthentic reports to justify the stay and make financial benefits through insurance policy.
After receiving the claim form of the complainant same was processed by the term of doctor of opposite party No.2 during investigation team of doctors of opposite party No.2 observed that the documents were full of medico technical discrepancies indicating unwanted admission supported by vague and unauthentic reports to justify the stay and make financial benefits through insurance policy.
On the basis of the above facts, the team of the doctors of opposite party No.2 opiniedthat “This claim was not admissible as per policy terms and conditions. Hence, this file was being repudiated by invoking clause 2.13 of the policy, due to aforesaid clause of the insurance policy which was a binding contract between the insurer and insured, claim of the complainant was not found payable within the scope of the insurance policy in question. So vide letter dated 02.07.2022 the answering opposite party informed the complainant about repudiation of his claim with reason in clear words. The complainant had actively concealed about repudiation letter in which the reason was elaborately explained. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Shri Abhishek Goswami, counsel for the complainant has made a statement that I want to make opposite party No.2 as proforma opposite party vide order dated 31.10.2022.
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.
6. In this case the complaint was filed by the complainant against opposite parties–National Insurance Co. Ltd.. with the prayer to: a) pay the above said claimed amount of Rs.1,45,340.33 towards treatment charges of the complainant alongwith interest till its realization. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 25,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.PW1/A – affidavit of Nand Kishore Chawla, Ex.C-1& 2 – CKYC & KRA KTC Form, Ex.C-3 & 4 – Claim Form Part A, Ex.C-5 – Claim Form – Part B, Ex.C-6 – details of insured, Ex.C-7 – Identity card,, Ex.C-8 to 10 – emails, Ex.C-11 - letter dated 06.09.2021 regarding intimation of pt. Nand Kishor Chawla , Ex.C-12 – Final Bill Ex.C-13 – receipts,, Ex.C-14 – details – D.O.A 05.09.2021 , D.O.D 14.09.2021, Ex.C-15 to 22 – test, Ex.C-23 & 24– prescriptions, Ex.C-25 - USG Whole Abdomen, ex.C-26 – photo,, Ex.C-27 to 61 – tests, Ex.C-62 to 67 – B.Sugar Chart, Ex.C-68 to-84 – prescriptions,, Ex.C-85 to 86– receipts, Ex.C-87 to 94 – prescription, Ex.C-95 – certificate of Dr. R.D.Negi,, Ex.C-96 – discharge summary,,Ex.C-97 – letter dated 19.10.2021 regarding additional information required,, Ex.C-98 –to 102 emails, Ex.C-103 to 107 – Standard investigation report, Ex.C-108 to 111 – legal notice, Ex.C-112 – postal receipt. Ex.C-113 – Adhaar card.
On the other hand, counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 – affidavit
of Sharat Kashyap (Dy. Manager), National Insurance Co. Ltd.,N.L.V. 2E/9 Jhandewalan Extension, Delhi, Ex.R-1 – Standard Investigation Report,, Ex.R-2 – repudiation letter dated 02.07.2022, Ex.R-3 – policy.
7. In this case, the complainant has obtained insurance policy No. 361102/50/20/10005765 valid from 12.12.2020 to 11.11.2021 from opposite party for the sum insured of Rs.6,00,000/-. The complainant admitted in Vibral Hospital Pvt. Ltd., Sector-21D, HUDA Market, Faridabad with the problems of Dengue NS 1 with Thrombocytopenia with DM II with Hepatomegaly with prostatomegaly on 05.09.2021 and paid Rs.1,45,340.33 to the said hospital. Opposite party has repudiated the claim of the complainant vide letter dated 02.07.2022 on the ground that “ it was observed upon our investigation that the hospital is not maintain records properly and does not full the criterion as given in the policy. The investing report has been attached for your reference, Therefore , this claim is not admissible as per policy terms and conditions and as per clause 2.13 of the policy which states that “hospital means any institution established for in patient care and day care treatment of disease/injuries and which has been registered as a hospital with the localauthorities under the clinical establishments act 2010 or under the enactment 2010. As per investigation report vide Ex.C-103 in which it has been mentioned that “ the documents are full of medico technical discrepancies indicating unwanted admission supported by vague and unauthentic reports to justify the stay and make financial benefits through insurance policy. On the basis of the available facts, discrepancies were noted in hospital records. The documents seems to be modified and manipulated. Hence, claim is not genuine and rejected.
8. After going through the evidence led by the parties, the Commission is of the opinion that as per discharge summary vide Ex.C-96 the complainant admitted in Vibral Hospital Pvt. Ltd., Sector-21D, HUDA Market, Faridabad with
the problems of Dengue NS 1 with Thrombocytopenia with DM II with Hepatomegaly with prostatomegaly and as per the report it has been found that the dengue is positive. Hence, the reason for the repudiation of the complainant is not justified. Resultantly, the complaint is allowed. Opposite party No.1 is directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party No.1 is also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alongwith 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: 09.06..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.
