BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 306 of 2022
Date of Institution : 05.05.2022
Date of Decision : 03.08.2023
Subhash Chander son of Sh. Om Parkash Aggarwal (Since deceased) now represented by his legal heir and nominee Smt. Prem Lata Aggarwal- widow of Subhash Chander, resident of Gali Masjid Wali, Noharia Bazar, Sirsa, Tehsil and District Sirsa (Haryana).
……Complainant.
Versus.
1. National Insurance Company Limited, through its Divisional Manager, Sangwan Chowk, Sirsa- 125055.
2. Vipul Med Corp TPA Private Limited, First Floor, SCI 98, Industrial Area, Phase-2, Chandigarh- 160022.
….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. Anil Bansal, Advocate for the complainant.
Sh. Parteek Chawala, Advocate for opposite parties.
ORDER
Initially the complainant Subhash Chander has filed the present complaint against the opposite parties (hereinafter referred as ops) and now after his death on 11.01.2023 his wife and nominee Smt. Prem Lata is pursuing the present complaint by moving an application.
2. In brief, the case of complainant is that Subhash Chander had purchased a National Parivar Medi Claim Insurance Policy for his family i.e. for himself and his wife namely Prem Lata Aggarwal on 07.06.2021 from op no.1 and a total sum of Rs.30,182/- was also paid as premium for the same which was duly accepted by op no.1. That a consolidated medi claim policy was issued by op no.1 vide policy number 420700502110000012 dated 7.6.2021 and health cards were also issued by op no.2 for both of them and policy was enforceable from 11.06.2021 to 10.06.2022 against the sum insured amount of Rs.5,00,000/- each. It is further averred that op no.1 assured the complainant that all expenses for health problems/ treatment during the period of policy would be borne by ops and claim of such expenses would be cashless and paid at the earliest. That complainant had been taking Medi-claim insurance policy from National Insurance Company Limited, Sirsa since 2014 without any break and no need ever occurred for lodging any claim during previous occasions of insurance. That in first week of September, 2021 i.e. on 06.09.2021 complainant suddenly developed uneasiness, stiffness and pain in the body and he immediately rushed to Sanjivani Hospital, Sirsa for check up. The treating doctor namely Dr. Pankaj Garg advised certain tests viz. CBC, X Ray Chest PA, ECH, Cervical Lymph node test, ESR & Urine tests and other various tests and complainant took treatment from said Hospital from 06.09.2021 to 23.09.2021 but as health of complainant was not improving much therefore on 27.09.2021 he rushed to Rajiv Gandhi Cancer Institute and Research Centre, Delhi for intensive check-up and treatment. The treating doctors namely Dr. Ullas Batra and Dr. Anurag Mehta advised/ got conducted many advanced tests viz. CBC, ECG, Echo, Color Doppler, Whole body PET CT, PFT, KFT, LFT, Biopsy test etc. from 27.09.2021 to 29.09.2021 and got treatment from above mentioned hospital of Delhi. Thereafter on 08.10.2021 complainant again visited above said Institute for follow up but this time he was admitted in the Hospital in emergency and was discharged on 9.10.2021 and got indoor treatment for the disease diagnosed as “Hodgkin’s Lymphoma with RVD & SVT i.e. type of Cancer”. That complainant incurred Rs.1,28,089/- from his pocket on his treatment from Sirsa and Delhi Hospital during 06.09.2021 to 09.10.2021 i.e. pre hospitalization expenses of Rs.79,787/- and hospitalization expenses of Rs.48,302/-. It is further averred that during Hospitalization in Delhi, cashless of Rs.25,000/- was approved by op no.2 against initial estimate of Hospital of Rs.54,850/- but no amount was ever disbursed by ops. That after discharge from above said Institute, Delhi complainant sent/ submitted his insurance claim of Rs.1,28,089/- for reimbursement of amount on 06.11.2021 alongwith claim form, original bills, receipts, reports, discharge summary and all other necessary required treatment papers to op no.2 which was acknowledged by op no.2 vide email dated 16.11.2021 and thereafter requested ops time and again through emails dated 01.12.2021, 08.12.2021, 11.12.2021, 29.12.2021, 12.01.2022, 13.01.2022 and 25.01.2022 for settlement of his claim. That vide mail dated 13.01.2022 sent by op no.1 to complainant it has been specifically stated that his claim is under process and he will receive the recovery amount soon and that claim is approved and settled by TPA & Branch office, but till date no payment has been given to complainant by ops for his genuine claim. It is further averred that ultimately under compelling circumstances and after waiting for sufficient long time, the complainant got served a legal notice to ops on 02.03.2022 but to no effect. That ops are gross negligent in not settling the claim of complainant and inordinate delay is being caused for reimbursement of claim of Rs.1,28,089/- especially when the insurance was cashless and this is clear deficiency of service on the part of ops due to which complainant has suffered unnecessary harassment and mental agony. Hence, this complaint.
3. On notice, ops appeared and filed written statement taking certain preliminary objections. It is submitted that a written policy is issued by answering ops which explains the list of inclusions alongwith exclusions and terms and conditions, moreover, each and every claim is governed by the policy rules. That reimbursement amount as provided by complainant is wrong and incorrect. The ops after considering the entire copy of bills and receipts made some necessary deductions as explained and detailed in the policy and approved the reimbursement amount of Rs.98,588/- on 16.06.2022. It is further submitted that against the ICU charges of Rs.16,200/- amount of Rs.10000/- was approved, against the lab charges of Rs.91,283/- (which includes amount of Res.79,787/- of pre-hospitalization), amount of Rs.74,113/- (which includes amount of Rs.60,297/- of pre-hospitalization) was approved, against pharmacy charges of Rs.10,636/-, amount of Rs.7925/- was approved and against other charges of the amount of Rs.1770/-, amount of Rs.1650/- was approved and as such out of total claimed amount of Rs.1,28,088/- amount of Rs.98,588/- was approved. The deductions made are with respect to the guidelines of the National Parivaar mediclaim policy which is provided to all the policy holders at the time of selling the policy and all the claims are approved considering the terms and conditions stated in it. It is further submitted that policy holder is required to submit all the documents within a period of 15 days after getting discharged from the hospital, but the complainant was late by almost a period of 20 days and the documents that are to be reached to the ops’ office by 25.10.2021 reached on 16.11.2021. The claim was however approved time barred which increased the formalities and approvals for the company due to the delay by the complainant. Moreover, the claim was approved by ops on 16.06.2022 of the total value of Rs.98,588/- and was intimated to the complainant by the op time and again but complainant did not accept the reimbursed amount and carried forward with the case in greed of the complete amount asked for. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex.C1 and copies of documents Ex.C2 to Ex.C66.
5. On the other hand, ops have tendered affidavit of Sh. V.K. Gumber, District Manager as Ex.R1 and document Ex.R2.
6. We have heard learned counsel for the parties and have gone through the case file carefully.
7. At the very outset, we would like to mention here that originally the complainant Subhash Chander has sought reimbursement of amount of Rs.1,28,089/- spent on his treatment from the opposite parties and after his death on 11.01.2023 as per death certificate placed on file by his widow namely Smt. Prem Lata, she has been permitted to pursue with the present complaint being widow and legal heir of deceased Subhash Chander on the application of said Smt. Prem Lata.
8. There is no dispute of the fact that said Sh. Subhash Chander now deceased obtained National Parivar Mediclaim policy from the opposite party no.1 for the sum insured amount of Rs.5,00,000/- for himself and for his wife Smt. Prem Lata for the period 11.06.2021 to 10.06.2022 after paying premium amount of Rs.30,182/- which fact is also proved from the policy schedule placed on file by complainant as Ex.C2. The complainant claims to have purchased the said policy from op no.1 since 2014. There is also no dispute about the fact that insured Subhash Chander took treatment from Sanjivani Hospital, Sirsa as well as from Rajiv Gandhi Cancer Institute and Research Centre, Delhi from the period 06.09.2021 to 09.10.2021 and an amount of Rs.1,28,089/- was spent on the treatment of Sh. Subhash Chander since deceased which was incurred by them. The claim for the reimbursement of the amount of Rs.1,28,089/- was lodged by original complainant Subhash Chander on 06.11.2021 after discharge from the hospital, but however, the ops have approved the claim to the tune of Rs.98,588/- on 16.06.2022 and according to the ops deductions of the remaining amount have been made as per clauses of the policy in question and complainant did not accept the said approved amount. It is proved on record that as per policy the treatment of insured persons was cashless but despite that ops have not provided cashless treatment to the complainant Subhash Chander though against the initial estimate of Hospital to the tune of Rs.54,850/-, cashless of Rs.25,000/- was approved by op no.2 and even this amount of Rs.25,000/- approved by op no.2 was not paid and as such there is deficiency in service on the part of ops. Further the ops have also taken long time for approval of the above said amount of Rs.98,588/- which has been approved on 06.06.2022 only despite the fact that complainant sent various emails to the ops and therefore, ops have caused delay as well as unnecessary harassment to the complainant who was already under mental trauma due to above said ailment and complainant had to serve a legal notice upon the ops for his genuine claim. The ops claim that they have approved the claim amount of Rs.98,588/- after necessary deductions as per clauses of the policy in question and as such complainant is entitled to the above said amount of Rs.98,588/- as per clauses of the policy in question but however, she is also entitled to compensation for harassment as the treatment was cashless and moreover ops have not paid the said amount in time to the complainant when he was in need of money for his treatment. Even the original complainant Subhash Chander has expired on 11.01.2023 and he did not receive the claim amount from ops during his life time and he remained unpleasant during his life time and suffered more at the hands of ops due to act and conduct of the ops despite the fact that they have paid huge amount of Rs.30,182/- as premium to the insurance company op no.1. Therefore, the op no.1 should have acted immediately on the genuine claim of the complainant but they have failed to do so. Though ops have made deductions from the amount of Rs.1,28,088/- as per clauses of the policy but however, at the same time it is also proved that ops have caused unnecessary harassment and deficiency in service to the complainant’s family by not paying the claim amount in time though the treatment was cashless. The ops have blamed the complainant for sending the documents after 20 days but have not explained and justified the delay on their part for approval of the claim of complainant as claim has been approved only on 16.06.2022 i.e. after filing of present complainant. The ops have approved the claim of complainant for the said amount of Rs.98,588/- only after serving of legal notice dated 02.03.2022 to the ops and after filing of present complaint on 05.05.2022. So, in our considered view the complainant besides claim amount of Rs.98,588/- as per clauses of the policy is also entitled to interest on that amount alongwith compensation for unnecessary harassment.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties (particularly insurer i.e. op no.1) to pay the claim amount of Rs.98,588/- to the complainant Smt. Prem Lata wife of Sh. Subhash Chander (original complainant) alongwith interest @6% per annum from the date of filing of present complaint i.e. 05.05.2022 till actual payment within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.25,000/- as compensation for harassment to the complainant and also to pay further amount of Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President,
Dated: 03.08.2023. District Consumer Disputes
Redressal Commission, Sirsa.
