District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.422/2019.
Date of Institution: 29.08.2019..
Date of Order: 09.09.2022.
Sh. Sunil Kumar Shah s/o Sh. Atma Ram Shah age 49 years R/o H.No. 560 Sector-7/B, Faridabad (Haryana) – 121006 mobile No. 9999308403. …….Complainant……..
Versus
1. National Insurance Company Ltd., Branch office-II, SCO-96, Sector-16 Market, Near IDBI Bank, Faridabad- 121007 (Haryana).
2. Park Mediclaim Insurance TPA Pvt. Ltd. Office at 702, Vikrant Tower, Rajendra Palace, New Delhi – 110 008. Through its Managing Director/Directors/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. Rajender Mittal, counsel for the complainant.
Sh. Sanjeev Bansal, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 4.4.2022.
ORDER:
The facts in brief of the complaint are that the complainant Sh. Sunil Kumar Shah got himself insured against mediclaim policy vide policy No. 361102501710006536, valid form 24.11.2017 to 23.11.2018 from the opposite party No.1. On 05.10.2018, the complainant was having the problem of swelling and pain in left side of face extra orally and he was taken to QRG Medicare Ltd., Plot No.1, Sector-16, Faridabad (Haryana) where he was admitted for his treatment by the doctors of QRG Medicare Ltd. On 05.10.2018, where various tests were done by the concerned doctor sand treatment was given to the complainant and the complainant was operated for his above said problem and he was discharged on 12.10.2018 from the hospital, hence the complainant remained admitted in the hospital for 7 days as a patient. The complainant had spent a amount of Rs.81,103/- upon his treatment in that hospital which includes the hospital charges as well as the bills of medicines etc. The complainant during the period when he was admitted in the hospital, the cashless facility was denied by the opposite parties and the opposite parties had assured that the complainant had to deposit the mediclaim bills in the hospital and he could be reimbursed later, on submission of his claim to the opposite parties. The complainant had submitted mediclaim forms for reimbursement of the amount which was spent by the complainant upon his treatment through the opposite party No.2 which were duly received by opposite party No.2 and the original documents as required by the opposite parties were submitted by the complainant alongwith the claim form s but the opposite parties despite the repeated request of the complainant did not reimburse the amount in question for which the opposite parties were legally bound to do so. After sometime the complainant had received a letter dated 29.01.2019, reference No. NICDR2/203295/P-1 issued by the opposite party No.2, in which the opposite party No.2 had demanded some documents and accordingly the complainant had further deposited the required documents with opposite party No.2 within time but to the utter surprise of the complainant the opposite parties did not reimburse the claim even after receiving the entire required original documents which were still with the opposite parties. The complainant was very much surprised and shocked as the opposite parties had not released the payment of the mediclaim bills for which the opposite parties were legally and morally bound. The complainant had personally visited in the office of the opposite parties time and again but the opposite parties did not release the payment of the complainant despite his repeated legitimate request rather the opposite parties kept on dilly delaying the matter on one pretext or the other. The complainant was very much surprised when he received a false letter dated 15.07.2019 issued by opposite party NO.1 containing therein as per TPA’s recommendations they were closing the file as no claim, as they had not providing documents been asked vide their various letters. The complainant sent legal notice dated 08.8.2019 to the opposite party 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) release the amount of Rs.81,103/- which was paid by the complainant by his own pocket to the hospital authorities alongwith interest @ 24% p.a. to the complainant form the date of due till actual payment.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 21,000 /-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 the complainant was stopped by his act, conduct, omission and commissions from filing the present complaint because the claim of the complainant was carried out at QRG Medicare Limited Faridabad on 12.12.2018 when a copy of IPD records was obtained and its bears the following remarks:- (a) on 6.10.2018 complainant seen by Dr. Dhar: History of Tooth Extraction 10 to 15 days back and pain + swelling left side of face for six days, (b) on 07.10.2018 complainant case seen surgery team (Dr. Probal Roi): Face correction left side, history of tooth extraction and the above record of history would hvae been provided by the patient himself and he was fully conscious during the period of hospitalization. In view of the above facts and finding complaint was reminded on 25.12.2018, 17.01.2019, 7.2.2019 and 5.3.2019 with final reminder cum closure letter was issued with the request to the complainant to submit the records of treatment taken after Tooth Extraction and thereafter file was recommended for closure on 14.3.2019. Thereafter the claim file back to the TPA after reply of the insured for review and complainant was again to requested to provide the records of the treatment related to Tooth extraction 10 to 15 days back on 24.4.2019,1.5.2019 and 9.5.2019 (final reminder and no response was received from the complainant side and claim file was again recommended for closure on 4.6.2019 and file of the complainant had been closed for want to clarification as such the complaint of the complainant was liable to be dismissed on the question of pre-mature as the claim of the complainant was closed on the ground of clarification. 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 10.3.2022 not received back either served or unserved. Tracking details filed in which it had been mentioned that “Item Delivery Confirmed”. Case called several time since morning but none appeared on behalf of opposite party No.2. Therefore opposite party No.2 was hereby proceeded against exparte vide order dated 4.4.2022.
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) release the amount of Rs.81,103/- which was paid by the complainant by his own pocket to the hospital authorities alongwith interest @ 24% p.a. to the complainant form the date of due till actual payment. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 21,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Shri Sunil Kumar Shah, Ex.C-1 – insurance policy, Ex.C-2 – Discharge summary, Ex. C-3 – Case summary, Ex.C-4 – treatment record, Ex.C-5 – Final Bill of supply summary, Ex.C6 – Tax invoice, Ex.C-7 – payment slip, Ex/C-8 – letter dated 29.01.2019, Ex.C-9 – No claim letter, Ex.C-10 – legal notice, Ex.C-11 & 12– postal receipts.
On the other hand, counsel for the opposite party No.1 strongly
agitated and opposed. As per the evidence of the opposite party Ex.R/A – affidavit of Shri Lakhan Pal, Asstt. Manager,Ex.RX - letter datead 12.10.2018.
7. It is evident from letter vide Ex.RX wherein it has been mentioned that complainant was requested to provide the records of the treatment related to Tooth extraction 10 to 15 days back on 24.4.2019,1.5.2019 and 9.5.2019 (final reminder and no response was received from the complainant side and claim file was again recommended for closure on 4.6.2019 and file of the complainant had been closed for want to clarification.
8. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite parties, jointly & severally, are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. No compensaiton has been given to the complainant because the opposite parties wrote several letters to the complainant to supply the records of the tratment related to Tooth extraction.The opposite parties are also directed to pay 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. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 09.09.2022 (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.
