Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 413/2014
Charat Aggarwal s/o Late Sh. Jagdish Chander,
Resident of 66, Saket Kunj Apartment, Sector-9, Rohini,
Delhi-110085 …Complainant
Versus
OP1- National Insurance Company Ltd.,
23/23B, EMCA House, 4th Floor, Ansari Road,
Darya Ganj, New Dehli-110002.
OP2- The Safeway Medi-claim Services Pvt. Ltd.
6/2, 1st Floor, Kirti Nagar, Industrial Area, Near S.B.I,
New Delhi-110015. ...Opposite Parties
Date of filing: 05.12.2014
Date of Order: 11. 07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Inder Jeet Singh, President
ORDER
1. (consumer dispute of parties) - The complaint was filed with allegations of deficiencies of services and unfair trade practice as complainant/insured was not reimbursed his medical bills of Rs. 79,465/- for his treatment. The complaint was filed on 05.12.2014, however, during the pending of complaint, the complainant was handed over cheque of Rs. 65,513/- on 25.01.2016. Then, balance amount of medical bills was left of Rs. 13,942/-, but there were recalculations by OP (vide proceedings dated 07.02.2017) that amount comes to Rs. 12,700/- and OP was proposing to settle for Rs. 10399/-, which was not acceptable as per proceedings dated 16.11.2018 and 23.05.2019 since there were other relief claimed.
1.2 The complaint was opposed that there was neither deficiency of service nor unfair trade practice and the OP was released legitimate claim of Rs. 65,513/- and the remaining amount of Rs. 10,399/- was inadmissible under the policy and it was disapproved. In addition, the complainant failed to furnish requisite documents so enable the OP to release the said claim amount, the complainant is at fault.
2. (case of complainant) - Briefly, the complainant took medi-claim policy no. 354100/48/12/8500003562 valid from 26.02.2013 to 25.02.2014 from OP1. OP2 is TPA of OP1. The complainant was suffering from Acute Respiratory Tract Infection with vitamin-D deficiency with left supra cyst swelling and admitted Ekansh Nursing Home, where doctor advised him for admission and treatment. He was admitted on 10.07.2013. He informed OP2 of his hospitalization through email dated 12.07.2013, which was acknowledged by OP2. He was discharged on 16.07.2013. He submitted his claims form for Rs.79,465/- with all original medical documents to OP2 through speed post. The Executive of OP2 visited the complainant on 15.10.2013 at the place of complainant for verification and inspection, the complainant co-operated them. The complainant was advised and assured that his claim will be settled after Diwali but no result. The complainant awaited for some time and then contacted call centre of OP2 but there was no satisfactory response. Then complainant was constrained to send legal notice dated 25.12.2013 but neither they have responded nor settled the claim. They have no intension to process the claim with ulterior motive. That is why, the complaint was filed for reimbursement of medical claim of Rs. 79,465/-, compensation of Rs. 50,000/- for harassment and agony, and cost of Rs. 25,000/- besides other consequential relief.
3. (case of OP1) - The OP1 requests that it had issued Pariwar Mediclaim Policy, and the parties are bound by conditions of policy. The OP1 considered the claim of complainant and also approved admissible amount of Rs. 65,513/-. The remaining amount of Rs. 10399/- was disapproved as hospitalisation for treatment of Cyst was not required. The complainant failed to complete the formality to enable the OP to release the claim, since for want of discharge voucher and copy of cancelled cheque by OP, the legitimate amount of Rs. 65,513/- could not be released. The complaint is pre-mature. Under these circumstances there was no question of reply to legal notice. Complaint is liable to be dismissed.
4.1 (Evidence of parties) - The complainant led his evidence by filing detailed affidavit, duly supported by the record filed with the complaint, namely copy of insurance policy, discharge summary, email, furnishing of claim form with covering letter, medical treatment record and copy of legal notice.
4.2. OP led its evidence by filing affidavit of Sh. Sanjeev Sharma, Assistant Manager (Legal) and the affidavit is supplemented with the record of terms and conditions of policy, copy of medical opinion of its doctor/investigator and claim process sheet. The affidavit as mentions detail about tender of cheque of Rs. 65,513/- to the complainant during the pending of complaint.
5. (final hearing) - Both the sides filed their respective written arguments, which are on the lines of complaint and evidence led by them. Sh. Tanuj Sharma, Advocate for complainant and Sh. Sanjay Kumar, Advocate for OP1 appeared and made the oral submissions
6.1 (Findings)- The contentions of both the sides are considered, keeping in view the material on record in the form of documentary evidence and other narrations, apart from the proceedings.
At the outset, the complaint was filed for reimbursement of medical bills of Rs. 79,465/-, out of which amount of Rs. 65,513/- stand paid to the complainant during the pending of complaint. The remaining amount is Rs. 13,942/- as per complaint but according to OP inadmissible amount was Rs. 10,399/- or Rs.12,700/-. This dispute will be determined along-with the issues raised.
6.2. The hospitalization of complainant and medical expenses are not disputed by the OP but the rival plea is that complainant could manage 'operation for excision under LA of soft tissue swelling in supra-public region is a day care procedure and hospitalization was not required for this purpose'. Cost of such treatment was excluded since it was not within purview of this policy. And OP relies upon the medical advices received from its doctor/investigator.
On the other side the complainant relies upon the medical record, inclusive of discharge summary and letter dated 10.07.2013 that the admission was warranted for appropriate surgery and admission was on the advises of Surgeon, which have been recorded in the summary. To say, on the one side the admission of complainant was on examination of patient physically and the treating doctor/surgeon opined that admission is required for surgery, which was also carried. The OP takes cognizance of advises/opinion given by its doctor/ investigator. Thus, one opinion is of treating doctor and another opinion is without physical examination of patient/complainant. Since in the health care issue, the opinion given by doctor/surgeon expert that too on examination of the complainant that admission as indoor patient is required, that opinion carries more weight and it cannot be ignored.
6.3 The OP has vehemently emphasized in the written statement that the complainant could not furnish the requisite documents to enable release of legitimate claim, whereas the complainant has not proved any document as to when such record was sought from the complainant. On the other side, complainant has furnished all the record with the claim form. Moreover, the complainant had sent legal notice dated 25.12.2013, which was served upon the OPs, had there been requisition of the record, documents could have also been asked by way of reply but the OP contends that there was no need of the reply of the legal notice. OP has also not disclosed as to when the amount of Rs. Rs. 65,513/- was approved, requiring those documents.
6.4. This complaint was filed on 05.12.2014 and the written statement is of 23.02.2015. The OP has filed report of its investigation agency/services (Annexure- R2) and it is of 10.02.2015, which is few days prior to filing of written statement of 23.02.2015. It means, the OP after receipt of its doctor/investigator opinion, it opposed the complaint on the basis of advises received. Dad there been settlement of the claim immediately after lodging the claim and the OP had approved sum of Rs. 65,513/-, the same would have been informed to the OP. This proves that the amount was determined and offered after the complaint was filed by the complainant.
7.1 The aforementioned conclusions establishes that facts stand proved are that complainant was advised admission for treatment and during that hospitalisation the surgery was performed. However, his valid claim was not considered and partly amount was tendered during the pending complaint. There is deficiency of services.
The complainant claims balance of amount of Rs. 13,942/- since out of Rs. 79,465/-, the complainant was paid Rs. 65,513/- on 26.01.2016. The OP could not establish as to how amount of Rs. 10,399/- is inadmissible or Rs. 12,700/- was the recalculated amount. Therefore, the complainant is held entitled for refund of unpaid medical bills amount of Rs13,942/- against OP1.
7.2 The complainant claims compensation of Rs. 50,000/- on account of harassment and agony. It is apparent that OP has not settled the claim within the stipulated period provided in the policy. It took the plea that requisite papers were not furnished, which OP failed to prove as to when those papers were asked for, despite it had taken opinion of its doctor/investigator on 10.2.2015, a few days prior to filing the written statement. Whether, amount of Rs.65,513/- was without such opinion. This shows conduct of OP as well as it is trying to justify as if amount of settled earlier. The circumstances are suggesting that complainant deserves compensation, therefore, compensation of Rs.25.000/- are awarded in favour of complainant and against OP1.
7.3 The complainant claims cost of Rs. 25,000/- besides other consequential relief. Since, complainant has to file the complaint to seek reimbursement of valid claim, had it been settled and paid, it would not required to file complaint. Hence, costs of Rs.10,000/- is allowed in favour of complaint and OP1.
The complainant had to part with money for treatment and it also remained unpaid for want of settlement of claim. Thus, interest @ 6% per annum is allowed on amount of Rs.13,942/- from the date of complaint till realisation of amount in favour of complaint and against OP1.
8. Accordingly, the complaint is allowed in favour of complainant and against the OP1 to refund/ reimburse balance amount of Rs.13,942/- along-with simple interest @ 6%pa from the date of complaint till realization of amount; apart from to pay compensation of Rs.25,000/- & costs of Rs.10,000/- to complainant.
OP is also directed to return/pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, the interest will be 8% per annum on amount of Rs.13,942/-
9. Announced on this 11th July, 2023 [आषाढ़ 20, 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
