Delhi

North East

RBT/CC/153/2022

SARITA - Complainant(s)

Versus

New India Assurance Co. Ltd. - Opp.Party(s)

08 Jun 2023

ORDER

   DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

RBT/Complaint Case No.153/22

 

In the matter of:

 

	Smt. Sarita Wife of Shri Jagdish Sahai, Resident of M-417, Raghubir Nagar, Delhi-110027	Complainant
	Versus
1.       2.	The New India Assurance Company Ltd., D.O. Azad Pur, A-2/3, Lusa Tower, Azad Pur, Delhi- 110033   The E-Meditk (TPA) Services Ltd., Coporate Office, Plot No. 577, Udyog Vihar, Phase- V Gurgaon (Haryana) 122016	Opposite Parties

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                        DATE OF ORDER  :

01.08.2018 27.02.2023 08.06.2023

 

 

 

CORAM:

Surinder Kumar Sharma, President

Adarsh Nain, Member

 

 

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 12 of the Consumer  protection Act, 1986.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant had taken a medi-claim policy from the Opposite Party No. 1 vide Policy No. 32010034162800001498 and the same was valid from 08.03.2017 to 07.03.2018. As per the said policy, four family members of the Complainant were also covered including Complainant. Opposite Party No. 2 is a T.P.A of Opposite Party No. 1. The daughter of the Complainant namely Ms. Priya was suffering from Abscess on the right heel. She visited Ekansh Nursing Home on 01.08.2017, where doctor advised her to get admitted in the hospital for the surgery of heel. Her daughter got admitted in the said nursing home for the required treatment of Cellulitis with Suppuration Right Heel. On the same day, the Complainant gave intimation to the Opposite Party No. 2 regarding the hospitalization of daughter through e-mail dated 01.08.2017. After undergoing surgery, her daughter was discharged on 02.08.2017 from the nursing home. On 05.08.2017, Complainant submitted the claim form for Rs. 47,876/- along with all original documents to the Opposite Party No. 2 through speed post. Thereafter, the Complainant checked her claim status on the website of Opposite Party No. 2 where she found one query dated 10.08.2017, which was replied by way of letter dated 14.08.2017 through speed post. On 04.09.2017, the Complainant submitted the post-hospitalization claim for Rs. 7,058/- through speed post. Complainant did not receive any response from the Opposite Parties. On 13.12.2017, Complainant checked the claim status on the website of the Opposite party No. 2 where she found another query dated 11.12.2017, which was replied by way of letter dated 14.12.2017 through speed post. On 31.01.2018 the Complainant received a mail from Opposite Party No. 1 by which she was informed that the above said claim had been repudiated by the Opposite Party No. 2 with the reason as “4.3.1 Unless the Insured Person has Continuous Coverage in excess of twenty four months, expenses on treatment of the following illnesses are not payable: 15. Skin Disorders”. The Complainant sent a mail on 09.02.2018 along with the certificate issued by treating doctor and Complainant also requested to settle the claim as soon as possible. On 26.03.2018, the Complainant received a letter dated 20.03.2018 from Opposite Party No. 1 by which she was informed that the above said claim had been closed. The Complainant has prayed to direct the Opposite Parties to pay an amount of Rs. 54,934/- along with interest @ 18% p.a., Rs. 50,000/- on account of mental harassment and Rs. 25,000/- on account of litigation expenses.
2. None has appeared on behalf of the Opposite Party No. 2 despite notice served. Therefore, Opposite Party No. 2 was proceeded against ex-parte vide order dated 14.11.2018.

 

Case of the Opposite Party No. 1

3. Opposite Party No. 1 contested the case and filed its written statement. It is admitted by the Opposite Party No. 1 that an insurance policy was issued by it to the Complainant. It is stated that the claim of the Complainant was not maintainable as the daughter of the Complainant was suffering from skin disease and the same was not covered under policy for 24 month. It is stated that the daughter of the Complainant was suffering from Cellulitis with Suppuration skin disorder. It is stated that the complaint is without any merit and same deserves dismissal.

Evidence of the Complainant

4. The Complainant in support of her case filed her affidavit wherein she has supported the assertions made in the complaint.

Evidence of the Opposite Party No. 1

5. To support its case Opposite Party No. 1 has filed affidavit of Shri. Ramesh Chand Bairwa, Manager of Opposite Party No. 1 wherein, he has supported the case of the Opposite Party No. 1 as mentioned in the written statement.

Arguments & Conclusion

6. We have heard the Parties. We have also perused the file and written arguments filed by the Complainant and Opposite Party No. 1.
7. From the perusal of the record it is reveal that the following facts are admitted:-

1. That the Complainant purchased a mediclaim policy from Opposite Party No. 1 and the same was valid from 08.03.2017 to 07.03.2018.
2.  It is also admitted that Ms. Priya i.e. daughter of the Complainant was also covered under the said policy.
3. It is also not disputed that Ms. Priya was admitted at Ekansh Nursing Home on 01.08.2017 and after performing surgery in the hospital she was discharged on 02.08.2017.
4. It is also admitted that the Complainant has submitted the medical bills for reimbursement.

8. The claim of the Complainant was rejected by the Opposite Party No. 1 on the ground that the daughter of the Complainant is suffering from some skin disorder and which was not covered under the policy.

9. The only dispute is regarding the nature of the disease of the daughter of the Complainant.

10. The Complainant has filed discharge summary dated 02.08.2017 which was given at the time of discharging Ms. Priya from the hospital after the treatment. In the said discharge summary the diagnosis is mentioned as Cellulitis with Suppuration Right Heel. Now the question is that whether this ailment is skin disorder. The Opposite Party did not lead any evidence or record nor filed any material on record to show that the said ailment/disease is a skin disorder.

11. The perusal of the file shows that after the claim was filed by the Complainant, the Complainant was issued a letter dated 10.08.2017 whereby the Complainant was required to provide registration number of hospital/certificate from hospital along with mentioning the number of beds. The Complainant has made the compliance of the same vide letter dated 14.08.2017 and she has submitted the registration certificate of the Ekansh Nursing Home where the daughter of the Complainant was treated. In case the claim of the Complainant was not maintainable for the reason that the ailment of the daughter of the Complainant was regarding skin disorder and the same was not covered under the policy. In such situation the Opposite Party was no supposed to demand the registration certificate of the nursing home and it was supposed to reject the claim straightway. On the other hand the Opposite Party No. 1 had proceeded with the process of the claim and asked the Complainant to submit the above mentioned documents/certificate.

12. In view of the above discussion, we are of the opinion that the defense raised by the Opposite Party No.1 cannot be accepted. The complaint is allowed, Opposite Party No.1 is directed to pay an amount of Rs 54,934/- (treatment expenses) along with interest @ 6% p.a from the date of filing te complaint till recovery.  Opposite Party No.1 is also directed to pay an amount of Rs. 15,000/- on account of mental harassment and Rs. 10,000/- on account of litigation expenses along with interest @ 6% p.a from the date of this order till recovery.

13. Order announced on 08.06.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Adarsh Nain)		(Surinder Kumar Sharma)
(Member)		(President)