BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 262 of 2020
Date of Institution : 20.10.2020
Date of Decision : 25.05.2023
Parveen Kumar Sarraf aged about 51 years son of Shri Prem Sarraf, resident of H. No. 170, E- Block, Sirsa, Tehsil and District Sirsa C/o M/s L.B. Electronics, Sadar Bazaar Sirsa, District Sirsa.
……Complainant.
Versus.
1. National Insurance Company Ltd. through its Divisional Manager, Divisional Office, Sangwan Chowk, Sirsa.
2. M/s Medsave Health Insurance PTA Ltd. through its Director, SCO 66, 2nd Floor, Sector 40C, Chandigarh (Email- …….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Ms. Sonam Goyal, Advocate for the complainant.
Sh. A.S. Kalra, Advocate for opposite party no.1.
Opposite party no.2 already exparte.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant had purchased two different insurance policies from the op no.1 namely Parivar Medi Claim policy bearing no. 420700501910000005 valid w.e.f. 11.04.2019 to 10.04.2020 for a floater sum insured of Rs. three lacs and the other policy namely National Medi Claim policy bearing No. 420700501810000106 valid w.e.f. 11.10.2018 to 10.10.2019 for a total insured value of Rs. three lacs i.e. Rs. two lacs as sum insured and Rs. one lac as cumulative bonus. The complainant had paid a premium amount of Rs.11,172/- and Rs.9366/- respectively and the policies provide cashless treatment to the insured. It is further averred that these policies were in continuous renewal of the earlier policies of the complainant under the same insurance scheme since last more than 10 years. That unfortunately complainant had fallen ill and had undergone heart surgery rom Apollo Hospital, Bangalore and remained admitted there from 29.04.2019 to 06.05.2019. He had applied for a claim of cashless treatment of his above surgery from the hospital and was assured for 100% cashless treatment under the policies. That at the time of discharge, the complainant was told by the hospital that out of the total bill amount of Rs.6,38,327/- only a sum of Rs.2,10,000/- has been settled by the insurance company/ TPA i.e. the ops under the cashless policy and the remaining amount of Rs.4,28,327/- is chargeable from the complainant. The complainant was astonished to see this but forced with the circumstances he paid the amount to the hospital and was discharged. It is further averred that complainant raised a claim for reimbursement of the above said amount paid by him directly at the hospital and submitted all the required documents but surprisingly the complainant was intimated vide copy of letter dated 15.11.2019 issued by op no.2 to the op no.1 that the op no.2 i.e. TPA has rejected the claim of complainant stating that the amount has already been settled in cashless under policy No. 420700501810000106 and the maximum amount has already been paid. That while repudiating his claim, it has not been considered that he had taken two separate policies as detailed above and total claim amount of two policies is Rs. six lacs. The complainant had spent a sum of Rs.6,38,327/- on his treatment that too at the penal recognized hospital of the insurance company but he has been granted only claim amount of Rs.2,10,000/- as cashless and thus a sum of Rs.4,28,327/- was paid by him out of his pocket and complainant is legally entitled to reimbursement of the amount of Rs.3,90,000/- i.e. remaining insured amount from ops. That act and conduct of the ops clearly amounts to deficiency in service on account of which complainant has suffered unnecessary harassment and mental agony. The complainant also got issued legal notice to the ops on 04.04.2020 but to no effect. Hence, this complaint.
3. On notice, op no.1 appeared and filed written version raising preliminary objections that complaint is not maintainable in the present form and that there is no deficiency in service in any manner on the part of answering op no.1 as TPA op no.2 has decided the claim lodged by complainant as per law and there was no role of op no.1 in adjudication and decision made by op no.2 and present complaint is without any cause of action against op no.1, hence complaint against op no.1 is liable to be dismissed. It is further submitted that complainant has concealed true and material facts from this Commission as claim lodged by complainant for policy no. 42070050191000005 was settled in cashless on GIPSA Package under policy no. 420700501810000106 and maximum amount was already paid and complainant was duly informed vide letter dated 15.11.2019 and that complainant is estopped by his own act and conduct to file the present complaint against op no.1 as complainant failed to submit the requisite documents to op no.2 as required by them. It is further submitted that in reply dated 10.10.2019 submitted by complainant to the query of op no.2, it is admitted that for the same patient and same disease claim no. 20190427B009CH0030 was settled by Medsave TPA op no.2. As per term and conditions of the policy, it was the duty of complainant to submit requisite documents, information. Whatever was admissible and payable according to the policy term and conditions has been paid. On merits, the pleas taken in the preliminary objections are reiterated and the contents of complaint are also denied to be wrong. It is submitted that whatever was admissible and payable according to the policy term and conditions has been paid. With regard to the contention of any payment of Rs.4,28,327/-, it is submitted that as per order of rejection passed by op no.2, main claim 2019427B009CH00305 settled in cashless on GIPSA PKG under policy No. 420700501810000206, hence maximum amount already paid and query was raised by op no.2 from complainant and prayer for dismissal of complaint made.
4. Op no.2 did not appear despite notice sent to op no.2 through registered cover and as after stipulated period none appeared on behalf of op no.2 therefore, op no.2 was proceeded against exparte.
5. The complainant in evidence has tendered his affidavit Ex. CW1 and copies of documents Ex. C1 to Ex.C14.
6. On the other hand, op no.1 has tendered affidavit of Sh. V.K. Gumber, Sr. Divisional Manager as Ex.R1 and copies of documents as Ex. R2 to Ex.R9.
7. We have heard learned counsel for the complainant as well as learned counsel for op no.1 and have perused the case file carefully.
8. It is proved fact on record that complainant purchased two insurance policies from op no.1 i.e. Parivar Mediclaim Policy bearing No. 420700501910000005 valid from 11.04.2019 to 10.04.2020 for a floater sum insured amount of Rs. three lacs and second policy namely National Medi claim policy bearing No. 420700501810000106 valid from 11.10.2018 to 10.10.2019 for total insured amount of Rs. three lacs i.e. Rs. two lacs as sum insured and Rs. one lac as cumulative bonus. According to the complainant, these policies were in continuous renewal of the earlier policies of the complainant purchased by him since last more than ten years. The complainant has also placed on file previous policies as Ex.C1 to Ex.C3 and policy number 420700501810000106 valid from 11.10.2018 to 10.10.2019 as Ex.C5 and policy number 420700501910000005 as Ex.C7. From Ex.C1 to Ex.C5, it is evident that complainant has been purchasing National Mediclaim policy from the op no.1 since 11.10.2014. So, the total insured amount of both the policies in question i.e. National Medi claim policy bearing No. 420700501810000106 valid from 11.10.2018 to 10.10.2019 which complainant has been purchasing from 2014 and the policy no. 420700501910000005 which was valid from 11.04.2019 to 10.04.2020 is Rs. six lacs. The complainant has claimed reimbursement from the ops for the treatment i.e. heart surgery from Apollo Hospital, Bangalore where he remained admitted from 29.04.2019 to 06.05.2019 and has also claimed that out of Rs.6,38,327/- spent by him on his said treatment only an amount of Rs.2,10,000/- has been settled by the ops under cashless policy and remaining amount was paid by complainant to the hospital. Thus, complainant has claimed remaining amount of Rs.3,90,000/- from the ops. In this regard complainant has also placed on file final interim bill of Apollo Hospital, Bangalore alongwith discharge summary Ex.C8 which reveals that out of total bill amount of Rs.6,38,327/- regarding treatment of complainant, an amount of Rs.2,10,000/- was settled and paid and remaining amount of Rs.4,28,327/- was paid to the hospital by the complainant. The ops have placed on file claim settlement sheets as Ex.R8 and Ex.R9 according to which the claim amount of Rs.17,000/- and Rs.2,10,000/- have been paid to the complainant on 05.09.2019. However, the ops have not shown any reason for settlement of claim for the amount of Rs.2,10,000/- and Rs.17,000/- and for deduction of the remaining amount. Since the complainant has purchased two mediclaim insurance policies for the sum insured amount of Rs. three lacs each and hospital has prepared the bill for the amount of Rs.6,38,327/- i.e. more than the sum insured amount of Rs. six lacs, therefore, ops were liable to reimburse the amount of sum insured of Rs. six lacs to the complainant regarding both the policies in question and not of one policy only. Though op no.2 in its letter dated 15.11.2019 Ex.C11 has mentioned that maximum amount already paid but same is wrong and incorrect because sum insured amount of even one policy is Rs. three lacs whereas only an amount of Rs.2,27,000/- has been paid. Even if one bill of the total amount of Rs.6,38,327/- was generated by the hospital and claim amount of Rs.4,50,000/- has been sought by complainant through one claim form (which is more than sum insured amount of one policy) but the ops should have considered the fact that complainant has availed two medi claim insurance policies from them and therefore, the ops should have settled the claim of the complainant on the basis of sum insured amount of two policies in question. No justified reason for repudiation of remaining claim of complainant has been shown and mentioned by the ops in the repudiation letter. So, the repudiation of genuine claim of the complainant is wrong, illegal and arbitrary and is not justified at all. Therefore, complainant is entitled to remaining claim amount of Rs.3,73,000/- from op no.1 being insurer of the complainant.
9. In view of our above discussion, we allow this complaint and direct the opposite party no.1 to pay remaining claim amount of Rs.3,73,000/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the above said amount of Rs.3,73,000/- alongwith interest @6% per annum from the date of this order till actual realization from op no.1. We also direct the op no.1 to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President,
Dated: 25.05.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
