| Final Order / Judgement | CONSUMER DISPUTES REDRESSAL COMMISSION – X GOVERNMENT OF N.C.T. OF DELHI Udyog Sadan, C – 22 & 23, Institutional Area (Behind Qutub Hotel) New Delhi – 110016 Case No.80/18 Veena Wadhawan (since deceased) (Wife of R.K. Wadhawan) E-48, Ground Floor Greater Kailash-II New Delhi. …..COMPLAINANT Vs. 1. New India Assurance Co. Ltd. 22, Mother House, Yusuf Sarai Commercial Complex, IInd Floor Near Green Park, Metro Station New Delhi-110003 2.Raksha TPA Pvt. Ltd. C/o Escorts Corporate Centre 15/5, Mathura Road, Faridabad Haryana …..RESPONDENTS Date of Institution-22.09.2015 Date of Order- 19.04.2024 O R D E R RITU GARODIA-MEMBER - The complaint pertains to deficiency of service in the part of OP in repudiating the claim of complainant.
- The complainant took a health insurance policy bearing No.311502/34/12/01/00001553 valid up to 31.10.2013. During the validity period of the policy, the complainant was admitted in the Institute of Liver & Biliary Science, New Delhi on 11.03.2013 wherein the complainant had been advised to undergo treatment of disease called Hepatitis-C (Lever Infection) and was discharged from the hospital on 12.03.2013.
- Upon discharge, the complainant has filed her original claim for Rs.3,60,623/-(which was further revised to Rs.3,74,401/-). OP-1, insurance company, had segregated the said claim into different claims and had assigned separate claim numbers. Vide letter dated 25.07.2013, OP-2, The third party administrator, informed the status of the claim. The complainant raised objection vide letter dated 02.08.2013.
- Since the treatment of the complainant was ongoing, a fresh claim for Rs.64,466.83 had been submitted by the complainant vide letter dated 03.08.2013 with all original bills/test reports which was acknowledged by Raksha TPA on 16.08.2013.
- The complainant had a meeting with Branch Manager of OP-1 & 2. It is alleged that OP-2, TPA, accepted the loss of original claim papers and requested the complainant to submit a photocopy of bills duly acknowledged by the treating hospital alongwith an affidavit. The hospital bills belongs to reputed government hospital. The details of claim is as below -
| Claim Amount (Rs.) | Date of Submission of claim | Amount received agst. Claim | Date of receipt of claim. | -
| -
(original claim filed for Rs.3,60,623/-) | -
-
| -
| -
| -
| -
| -
| -
| -
| | -
| | -
| |
- The complainant alleges that against claim of Rs.4,38,867/-, OP has allowed a claim amount of Rs.51,211/-. The complainant submit that the policy was being maintained for last 15 years. Several reminders were sent to OP, but to no avail.
- The complainant prays for settlement of claim amount of Rs.1,02,436.82/-Rs. 5,00,000/- for damages and Rs.7500/- for litigation.
- OP-1 in its reply raised the preliminary objection that the complaint is barred by limitation. The cause of action first arose in March and August, 2013 and complaint was filed on September 2015.
- OP-1 submits that claims which were payable as per the terms and conditions of the policy were paid. OP has filed a detailed chart showing amount approved and paid.
- Notice was issued to OP-2 but none appeared. OP-2 was proceeded ex-parte vide order dated 01.06.2016.
- The complainant has filed rejoinder repeating the averments made in the complaint.
- The complainant has filed the evidence by way of affidavit and exhibited the following documents:
- Copy of first policy is exhibited as Annexure-1.
- Copy of claim is exhibited as Annexure-2.
- Copy of Affidavit submitted is enclosed as Annexure-3.
- OP-1 has filed evidence by way of affidavit and has annexed letters dated 17.05.2013, 14.06.2013, 18.02.2016 and on 17.03.2016 and the claim history.
- The Commission has considered the material and documents on record. The policy shows that the complainant and his wife were covered from 01.11.2012 to 31.10.2013 for sum insured of Rs.1,50,000/- each. The complainant now deceased was hospitalized in Institute of Liver and Biliary Science on 11.3.2013 and was discharged on 12.03.2013. A claim was filed which was duly received by OP on 23.04.2013.
- OP-1 has filed a letter dated 17.3.2013 by OP-2 and addressed to OP-1 along with the following break-ups :
FILE SEND TO DO REPORT | S. NO | Claim no. | Member Id | Policy No. | Insured name | Patient name | Relation | Doctor’s Opinion | Claim Status | 1 | 90221314016231 | N003738 | 31150234120100001553 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | THE MAXIMUM SUM INSURED HAS BEEN EXHAUSHED HENCE THIS CLAIM STANDS NON TENABLE, CLD | Claim recommended for Non-Pay. | 2 | 90221314016472 | N003738 | 31150234120100001494 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | Claim is recommended repudiated as sum insured is exhausted chronic liver disease | Claim recommended for Non-Pay. | 3 | 90221314016475 | N003738 | 31150234120100001494 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | Claim is recommended repudiated as sum insured is exhausted chronic liver disease | Claim recommended for Non-Pay. | 4 | 90221314016480 | N003738 | 31150234120100001494 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | Claim is recommended repudiated as sum insured is exhausted chronic liver disease | Claim recommended for Non-Pay. | 5 | 90221314020554 | N003738 | 31150234120100001553 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | THE MAXIMUM SUM INSURED HAS BEEN EXHAUSHED HENCE THIS CLAIM STANDS NON TENABLE, CLD | Claim recommended for Non-Pay. | 6 | 90221314022068 | N9012835064 | 31150234121600000024 | Mrs. Bala Passi | Mrs. Bala Passi | Self | As per claim document pt admitted with diagnosed case cataract rt eye and treated surgically. On scrutiny of claim documents it is noticed disease fall under two years exclusion as per clause 403, hence, claim is repudiated and stands non payable cataract rt eye. | Claim recommended for Non-Pay. | 7 | 90221314023125 | N2110380 | 31150234120100001466 | Mr. A Prakash Chopra | Mrs. Shubh Chopra | Wife | This claim has been repudiated since the sum insured limit for this ailment has been exhausted. CATARACT LT EYE | Claim recommended for Non-Pay. |
- OP-1 has filed dated 14.06.2013 which has been sent by OP-2 to OP-1. The letter is accompanied status of claim as follows:-
S. No. | Claim No. | Member ID | Policy number | Insured Name | Patient Name | Relation | Doctors Opinion | Claim Status | 1 | 90221314010644 | N077309 | 31150234110100002562 | Mr. Anil Sakhuja | Mr. Anil Sakhuja | Self | POST HOSPITALIZATION THE DEDUCTIONS ARE AS PER ROOM ENTITLEMENT CATEGORY SO THAT AMOUNT IS NOT PAYABLE IN POST HOSPITALISATION CLAIM HENCE THIS CLAIM STAND NO N TENEABLE RT. INGUINAL HERNIOPLASTY | Claim Recommended or Non-Pay | 2 | 90221314016229 | N003738 | 31150234120100001553 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | On scrutiny of the documents it is observed that patient is a k/c/o of CLD, hospitalization under day care for Intravenous albumin infusion whereas as per policy clause 3.4 albumin infusion is non-covered under day care procedure hence claim recommended for repudiation CLD | Claim Recommended or Non-Pay | 3 | 90221314016234 | N003738 | 31150234120100001553 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | On scrutiny of the claim documents it is observed that patient is a k/c/o of CLD, hospitalized under day care for Intravenous albumin infusion whereas as per policy clause 3.4 albumin infusion is non-covered under day care procedure hence claim recommended for repudiation CLD | Claim Recommended or Non-Pay | 4 | 90221314016236 | N003738 | 31150234120100001553 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | On scrutiny of the claim documents it is observed that patient is a k/c/o of CLD, hospitalized under day care for Intravenous albumin infusion whereas as per policy clause 3.4 albumin infusion is non-covered under day care procedure hence claim recommended for repudiation CLD | Claim Recommended or Non-Pay | 5 | 90221314020552 | N003738 | 31150234120100001553 | Mr. R.K. Wadhwan | Mrs. Veena Wadhwan | Wife | On scrutiny of the claim documents it is observed that patient is a k/c/o of CLD, hospitalized under day care for Intravenous albumin infusion whereas as per policy clause 3.4 albumin infusion is non-covered under day care procedure hence claim recommended for repudiation CLD | Claim Recommended or Non-Pay | 6 | 90221314030638 | N9012947758 | 31150234120100000309 | Mr. I.D. Sharma | Mr. I.D. Sharma | Self | Present claim is pre & post claim dated (11/03/2013-17/03/2013) as limit is already exhausted in main claim. Hence claim is repudiated & recommended nonpayable. CAD, TIA, DVD for PTCA | Claim Recommended or Non-Pay |
- The complainant had filed a letter from OP-2 dated 25.07.2013 which give details of multiple claim filed by the complainant and the status of said claim. The table is reproduced as follow :
S.No. | Claim No. | Claimed Amount | Status | -
| 90221314007042 | Rs.11421/- | Settled for Rs.4784/- and amount remitted through NEFT. | -
| 90221314016455 | Rs.40443/- | The claim is lying under query for submission of (1) Original investigation reports or lab tests during hospitalization dated 11.03.2013. (2) Echo plain Films dated 11/03/2013. (3)Original pre-numbered, pre-printed duly signed and stamped receipt against final bill of the hospital liver and bilary science no. dp45844 for Rs.15000/- | -
| 90221314016229 | Rs.58309/- | Pateint is a known case of chornic liver disease and was, hospitalized under day care for intervenous albumin infusion whereas as per clause 3.4 albumin infusion is not covered under day care procedure, hence, the claim has been recommended for repudiation. | -
| 90221314016231 | Rs.39021/- | Claim has been recommended for repudiation as albumin infusion is not covered under day care procedure as per clause 3.4 | -
| 90221314016236 | Rs.50809/- | Claim has been recommended for repudiation as albumin infusion is not covered under day care procedure as per clause 3.4 | -
| 90221314016234 | Rs.42477/- | Claim has been recommended for repudiation as albumin infusion is not covered under day care procedure as per clause 3.4 | -
| 90221314016225 | Rs.4273/- | Settled for Rs.3555/- and amount remitted through NEFT. | -
| 90221314020554 | Rs.11380/- | Claim has been recommended for repudiation as albumin infusion is not covered under day care procedure as per clause 3.4 | -
| 90221314020548 | Rs.13066/- | Settled for Rs.10106/- and amount remitted through NEFT. | -
| 90221314020552 | Rs.1535/- | Claim has been recommended for repudiation as albumin infusion is not covered under day care procedure as per clause 3.4 | -
| 90221314020547 | Rs.10061/- | Settled for Rs.8551/- and amount remitted through NEFT. | -
| 90221314020558 | Rs.4259/- | Claim has been recommended for repudiation as albumin infusion is not covered under day care procedure as per clause 3.4 |
- OP-1 has filed dated 18.02.2016 which has been sent by OP-2 to OP-1. The letter is accompanied status of claim as follows:-
-
S.No | Claim no. | Status | Policy no. | Admission date | Discharge Date | Claimed amount | Settled amount | Deduction | NEFT No./Date | Original File | 1 | 90221314016475 | Recommended for repudiation | 31150234110100001494 | 3.Sep.2012 | 28.Sep.2012 | 41995 | | | Sum Insured Exhausted under policy no. 31150234110100001494 | Claim file was forwarded to your esteemed office dated 17/05/2013. Copy of acknowledgement is attached. | 2 | 90221314016472 | Recommended for repudiation | 31150234110100001494 | 10.Oct.2012 | 10.Oct.2013 | 54528 | | | Sum Insured Exhausted under policy no. 31150234110100001494 | Claim file was forwarded to your esteemed office dated 17/05/2013. Copy of acknowledgement is attached. | 3 | 90221314016480 | Recommended for repudiation | 31150234110100001494 | 10.Oct.2012 | 10.Oct.2013 | 42742 | | | Sum Insured Exhausted under policy no. 31150234110100001494 | Claim file was forwarded to your esteemed office dated 17/05/2013. Copy of acknowledgement is attached. | 4 | 90221314016229 | Recommended for repudiation | 31150234120100001553 | 04.Feb.2013 | 04.Feb.2013 | 58309 | 0 | NA | Patient is a k/c/o of CLD, and was hospitalized under day care for intravenous albumin infusion whereas albumin infusion is not listed under the day care procedures permitted under the policy. Further, the claim bill does not fall under pre hospitalization period of 30 days for the | Claim file was forwarded to your esteemed office dated 14/06/2013. Copy of acknowledgement is attached. | 5 | 90221314016231 | Recommended for repudiation | 31150234120100001553 | 01.Jan.2013 | 01.Jan.2013 | 39021 | 0 | NA | Patient is a k/c/o of CLD, and was hospitalized under day care for intravenous albumin infusion whereas albumin infusion is not listed under the day care procedures permitted under the policy. Further, the claim bill does not fall under pre hospitalization period of 30 days for the | Claim file was forwarded to your esteemed office dated 17/05/2013. Copy of acknowledgement is attached. | 6 | 90221314016225 | Recommended for repudiation | 31150234120100001553 | 07.Apr.2013 | 07.Apr.2013 | 4273 | 3225 | Rs.627/- (15% co-payment) + Rs.49+42/- consumables | Claim was settled for Rs.3555/- vide NEFT No. STP13G486305 dated 13-Jun-2013 | Claim was forwarded to your esteemed office dated 20/03/2015. | 7 | 90221314016236 | Recommended for repudiation | 31150234120100001553 | 12.Nov.2012 | 12.Nov.2012 | 50809 | 0 | NA | Patient is a k/c/o of CLD, and was hospitalized under day care for intravenous albumin infusion whereas albumin infusion is not listed under the day care procedures permitted under the policy. Further, the claim bill does not fall under pre hospitalization period of 30 days for the main hospitalization dated 11.03.2013 to 12.03.2013 | Claim file was forwarded to your esteemed office dated 14/06/2013. Copy of acknowledgment is attached. | 8 | 90221314016234 | Recommended for repudiation | 31150234120100001553 | 15.Dec.2012 | 15.Dec.2012 | 42477 | 0 | NA | Patient is a k/c/o of CLD, and was hospitalized under day care for intravenous albumin infusion whereas albumin infusion is not listed under the day care procedures permitted under the policy. Further, the claim bill does not fall under pre hospitalization period of 30 days for the main hospitalization dated 11.03.2013 to 12.03.2013 | Claim file was forwarded to your esteemed office dated 14/06/2013. Copy of acknowledgement is attached. | 9 | 90221314016455 | Recommended for repudiation | 31150234120100001553 | 11.Mar.2013 | 11.Mar.2013 | 40443 | 0 | NA | Comprises of main hospitalization bill dated 11-Mar-2013 to 12 | Claim file was forwarded to your esteemed office dated 17/03/2016.. Copy of acknowledgement is attached. |
- Claim no.90221314016455 shows that the claim of Rs.40,443/-is pending for submission of documents. However, the same claim vide letter dated 18.02.2016 has been recommended for repudiation as it is a part of the main bill dated 11.03.2013.
- Claim no.90221314016231 shows that the claim of Rs.39,021/- vide letter dated 17.03.2013 was recommended for non-pay as the maximum sum assured has been exhausted. The same claim vide letter dated 25.07.2013 was recommended for repudiation as albumin infusion is not covered.
- Claim no. 90221314020554 for Rs.11,380/- was recommended for non-pay as the maximum sum assured has been exhausted. The same claim vide letter dated 25.07.2013 was recommended for repudiation as albumin infusion is not covered.
- The OP has repudiated claims on various occasions, citing different reasons. Some claims were denied due to exhausted insured limits and the same claims were rejected because they were not covered under terms and conditions of the policy. It's evident from medical records that the complainant received treatment at the Institute of Liver and Biliary Sciences in New Delhi for chronic hepatitis C. However, the OP has not provided any documentation indicating that hepatitis C treatment is not covered under the policy. OP has not clarified the amount paid to complainant under different heads.
- Top of Form
- Bottom of Form
- Hence, we find OP-1 guilty in deficiency in service in not paying the claim of the complainant and direct it to refund:
- Rs. 1.02.436.82/- with 9% interest from the date of complaint till its realization.
- Rs.20,000/- as compensation for mental harassment.
- Rs.5,000/- towards litigation expenses.
- Order to be uploaded on website. File be consigned to record room.
| |
