Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 258/2017
Sh. Avinash Goel s/o of Shri Ishwer Prasad Goel
Resident of RZI-12 B, Old Som Bazar Gali,
Mahavir Enclave, Dabri,
Delhi-110045 ...Complainant
Versus
OP1- The Oriental Insurance Company Ltd.,
through Branch Manager,
CBO-21, 10184, Arya Samaj Road,
Karol Bagh, New Delhi-110005
OP2- M/s Vipul Medcorp (TPA) Pvt. Ltd.,
515, Udyog Vihar,
Phase-V, Gurgaon,
(Haryana)-122016 ...Opposite Parties
Date of filing: 03.11.2017
Date of Order: 05.07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Vyas Muni Rai
ORDER
1.1 Instant complaint u/s 12 of the Consumer Protection Act, 1986; has been filed by Sh. Avinash Goel (in short ‘complainant’) against (i) The Oriental Insurance Company Ltd. ( in short ‘OP-1’) (ii) M/s Vipul Medcorp (TPA) Pvt. Ltd. (in short ‘OP2’).
1.2. The medi-claim policy (Happy Family Floater) bearing no. 272203/48/2017/2119; having validity period from 17.02.2017 to 16.02.2018 was purchased by the complainant from OP1; OP2 is the TPA of the OP1; father of complainant, namely, Sh. Ishwer Prasad Goel, fell in the bathroom on 16.06.2017 and injured his left knee; complainant took him to the Ekansh Nursing Home and got admitted on the advice of the doctor.
1.3. On the day of admission of his father i.e. 16.06.2017, the complainant sent an intimation through email to OP2 about the hospitalization of his father (copy of email dated 16.06.2017 regarding intimation about hospitalization is at page-9 of the complainant’s paper book).
1.4. The complainant submitted his claim for Rs. 47,570/-; along with all original medi-claim documents to the OP2; through speed post on 21.06.2017 (letter dated 21.06.2017 having details of the nature of the documents is available at page-8 of the complainant’s paper book).
Complainant on 24.07.2017; checked his claim status on the website of the OP2; and found that OP2 raised some query, whereby OP-2, demanded some documents mentioned therein; the complainant replied to the said query by way of letter dated 26.07.2017; and sent required documents through speed post (copy of letter dated 26.07.2017 having details of the documents sent to OP2 is at page no. 32 of the complainant’s paper book; having proof of postal receipt affixed on the body of letter).
1.5. Subsequent thereof, when the complainant did not receive any claim cheque or correspondence/query; then on 04.08.2017, 23.09.2017 and 03.10.2017, the complainant checked his claim status again on the website of OP2; and found the status of the claim as ‘under process’; thereafter received no reply either from OP1 or OP2.
1.6. The complainant has alleged deficiency in service and unfair trade practice on the part of OPs; by acting dishonestly to the disadvantage of the complainant.
1.7. The complainant has prayed for directions to the opposite parties; to pay an amount of Rs. 47,570/- to the complainant under medical insurance policy; with interest @ 18% p.a. with effect from discharge from the hospital; and compensation to the tune of Rs. 50,000/- for causing harassment, mental tension and agony; apart from Rs. 25,000/- towards cost of litigation.
2.1. A composite reply has been filed on behalf of OP1 and OP2; under the signature of Sh. Sunil Kumar Gupta, Senior Divisional Manager, the Oriental Insurance Company Limited; OPs have taken the stand that complainant did not give reasonable time to process the claim; and has filed the complaint on 03.11.2017; and thus the same is immature, and the opposite parties should be allowed some more time to process the claim; and take a final decision; and has pleaded no deficiency on their part.
2.2. OP2 (TPA); after seeing the accidental injury of the patient; and treatment provided; was of opinion that no hospitalization was required; and the treatment could have been taken as an outpatient; OP2 wanted to verify the documents of the indoor patient; from Ekansh Nursing Home whereby father of the complainant was hospitalized; but it was refused by the hospital authorities; in support of this refusal investigation report dated 04.09.2017 has been submitted as annexure-R1 (report dated 04.09.2017/R1 is at page-5 of the OPs’ paper book)
2.3 Such non-cooperation on the part of hospital authorities; in providing the details of the patient; proved to be a hindrance in processing the claim of the complainant; moreover, the complainant also did not cooperate; in accompanying with representative of TPA; to the hospital for getting various documents verified or to share detail; OP2/TPA vide letter dated 08.01.2018; requested the hospital authorities to provide the details; as mentioned in the letter; but no response was received (copy of letter dated 08.01.2018 is at page-7/R-2 of OPs’ paper book).
2.4. The complainant has concealed actual age of the patient at the time of taking initial policy (for the period 2009 to 2010); and has continued to do the same till the last policy for the period 17.02.2017 to 16.02.2018; as in the PAN Card submitted by the complainant (page-50 of the complainant’s paper book); date of birth of complainant’s father is given as 25.09.1950; the age of the complainant at the time of taking the above mentioned policy in question should have been 66 years and not 62 years; the same is true for all the previous policy taken by the complainant; beginning from the policy year 2009 for the period 17.02.2009 to 16.02.2010; in which age has been mentioned as 54 years, which should have been 59 years (policy document is at page-8 annexure-R-3 of the OPs’ paper book); this mis-representation by the complainant; concealing/reducing age of the insured patient; in order to pay reduced premium; during the period of atleast 7 years; which is necessary to decide not only the premium to be taken from the complainant; but also deciding on restricting/providing the accident of cover to be given to the complainant; it is violation of condition no. ? of the Happy Family Floater policy (but which condition no. ? of the policy was violated has not been given in reply and space is left blank; variance in premium in various age/may be around Rs. 2,000/-.
2.5. Even; by taking a liberal view of the concealment; and charging of the difference in premium; during the previous years; together with penalty, no claim would otherwise become payable to the complainant; this is also because of the fact that the policy is subject to 10 % co-payment by the complainant; and further excess of 10% on each claim reported by the complainant.
2.6. The OP2/TPA is independent body, licensed by the Government Authorities as TPA; and is absolutely not under the control or work under direction of the OP1; allegations of deficiency in service; and unfair trade practice on the part of OPs have been denied.
3. In proceedings dated 08.05.2017; it is recorded that; complainant does not wish to file rejoinder.
4. Complainant has filed affidavit under his signature; based on the facts and features in the complaint & documents; OPs also filed affidavit under the signature of Sh. Sunil Kumar Gupta, Senior Divisional Manager, in the company of OP1; and the same is also on the line of reply & document.
5. Written arguments has been filed by the complainant which is repetition of his case; a composite written arguments has also been filed on behalf of OP1 & OP2 and the same has been signed by the Counsel for OPs.
6. We have considered and analyzed, rival contentions of the parties and documents on record.
7. It is admitted fact of the parties that complainant is holder of Happy Family Floater (medi-claim policy); initially policy no. 215100/48/2009/2146 having validity from 17.02.2009 to 16.02.2010; and the last policy bearing no. 272203/48/2017/2119; having validity period 17.02.2017 to 16.02.2018; and Mr. Avinash Goel (self); Mr. Ishwer Prasad Goel, Sashi Devi (dependent parents), Rashi Goel (spouse/unemployed), Garima Goel, Ayush (dependent children); sum insured is Rs. 3,00,000/-; having gross premium Rs. 32,046/- (copy of policy is at page-10-11 of the complainant’s paper book).
8. Complainant’s father Mr. Ishwer Prasad Goel; fell in the bathroom and got injured his left knee; on the advice of doctor; he was hospitalized; complainant vide his email dated 16.06.2017 addressed to OP2/TPA; gave intimation about hospitalization of his father (email dated 16.06.2017 is at page-9 of the complainant’s paper book); the complainant’s father was discharged from the Nursing Home on 19.06.2017 (copy of discharge summary is at page-19 of the complainant’s paper book).
9. Subsequent thereof, complainant submitted his claim dated 21.06.2017 to OP1 (copy of claim form is at page-12-13 of the complainant’s paper book); complainant vide his letter dated 21.06.2017; addressed to OP2/TPA; submitted necessary documents/treatment records of his father (copy of letter dated 21.06.2017; having postal receipt regarding proof of service; is at page-8 of the complainant’s paper book); details of hospital bills and treatment papers were also submitted (copy of hospital bills and details of treatment papers are at page-14 to 31 of the complainant’s paper book).
10. The complainant checked the status of his claim on the website of OP2/TPA; and found that certain queries were raised by OP2; with regard to the treatment of father of the complainant; (copy of the query description dated 24.07.2017 is at page-51 of the complainant’s paper book); the complainant, vide his letter dated 26.07.2017; having proof of service/postal receipt; submitted queried documents for reimbursement of claim (page-32 of the complainant’s paper book); treating doctor of the Nursing Home; also responded to the query of OP2/TPA; vide letter dated 25.07.2017 (copy of the same is at page-33 of the complainant’s paper book).
11. There is a consent letter dated 26.06.2017; from complainant to hospital administrator, Ekansh Nursing Home; authorizing representative of OP2/TPA for verification of hospital records of his father; and also to procure the medical records as required by TPA from the hospital; however, as per Investigator’s report dated 04.09.2017; hospital had not cooperated to assess the documents hospitalization details, & hospitalization was not confirmed; Investigator met owner (name not shared by him); owner was present with her mother in cabin; who confirmed the admission of patient but refused to provide IPD paper; and did not share the details of the patient’s hospitalization; and also refused to stamp and sign on reimbursement format; as well not verified supplied papers (Investigator’s report is at page-5-6 (overleaf)/R-1 with OPs’ paper book).
12. Further letter dated 08.01.2018 from OP2/TPA; addressed to Medical Superintendent, Ekansh Nursing Home; to the effect that; required information was not shared with the Investigator by hospital or staff; IPD papers were also not provided; this letter dated 08.01.2018 is stated to have been sent by Regd. AD post; but no postal receipt or service proof of this letter has been submitted by OP2; however, Investigator in his report dated 04.09.2017 (R-1/5 is mentioned that IPD already in file submitted by patient).
13. Further; relevant documents/treatment papers duly attested on 25.07.2017 by hospital/Nursing Home are also on record; if that is so, requiring the same by the Investigator; from the hospital again for processing the claim of the complainant amounts to harassment.
14. OPs in para no. 2 of their composite reply has emphasized to their letter dated 08.01.2018/Annexure R-2 and we have discussed about veracity of this letter in para no-12 of this order. In para no. 3 of their reply OPs have alleged the violation of condition no. ? (of the Happy Family Floater Policy by the complainant); neither condition number is mentioned; nor the policy having the terms & conditions has been filed or proved by OPs.
15. In their reply; OPs have alleged about the concealment of age of the father by the complainant; and have pleaded that; if the date of birth of his father is taken as 25.09.1950 (as per PAN card); the age of the complainant at the time of taking the last policy; should have been 66 years; and not 62 years; as mentioned in the last policy having validity period from 17.02.2017 to 16.02.2018; if that is so, age of the father of the complainant; was mentioned in all the policies from initial policy w.e.f. 17.02.2009 to 16.02.2010 till the last policy having validity w.e.f. 17.02.2017 to 16.02.2018 since policy documents; having the origin in the office of OPs; and OPs are the writer of policy documents; what prevented OPs; to call for the proof of date of birth from the insured persons; during all those years; for confirmation of proof of age of the father of the complainant.
From this, only inference can be drawn that OPs were oblivious and aware of these facts did not call for age proof; and waited for submission of claim; on the part of insured; if so happens in future and to allege/ dispute the issue of age; to deny and deprive the claim of insured as and when arises/ occasioned.
16. OPs in their reply; have also submitted that; they may be allowed some more time; to process the claim; and take a final decision; if that is so, what prevented OPs; to process the claim during pendency of the complaint for last couple of years; after taking documents if any, (though complainant has submitted all required documents); to process and clear the reimbursement claim of the complainant.
17. In Investigator’s opinion, hospitalization was not required; if so, it is for the treating doctor of the hospital/nursing home; to decide whether the patient requires hospitalization or not; there is nothing on record; to show that, complainant got admitted his father; of his own; without the advice of the doctor; nor there is such allegation on the part of OPs.
18. Investigator, in his report has clearly mentioned that I.P.D. papers were already submitted by the patient; then there was no occasion for the Investigator to require the same from the nursing home time and again.
19. Complainant’s consent letter dated 26.06.2017, addressed to hospital authority; requesting to show his father’s record to the representative of OP-2/TPA; also authorizing to procure the medical records by TPA; shows bona-fide on the part of complainant; and for non- co-operation; on the part of hospital; to this account; blame cannot be attributed on the complainant’s shoulder; additionally; OPs have also violated IRDA’s Regulations, 2002; with regard to time limit; in processing and finalizing the claim of the complainant.
20. OPs have not submitted copy of terms and conditions of the policy (a vital and material document forming a valid contract between the parties) on record; to substantiate their stand in para 2.5 of this order; which attracts deficiency of service and unfair trade practices on their part.
21. From the aforesaid discussions/deliberations; and careful analysis; we come to the conclusion; that the complainant has succeeded to establish his medical claim amounting to Rs. 47,570/-. Complainant claims Rs. 50,000/- as compensation from OPs; for causing harassment, mental agony, etc; however, in our considered opinion; compensation of Rs. 10,000/- will suffice in favour of the complainant; apart from Rs. 5,000/- litigation expenses.
22. Since, the insurer is OP1; and the contract of insurance policy is between OP1/insurer and the complainant/insured; it is for OP1 liable & to comply this order.
23. OP2/M/s Vipul Medcorp (TPA) Pvt. Ltd., acts on behalf of insurer/OP1; as facilitator and service provider only; the complaint against OP2/TPA is dismissed.
24. We direct the OP1; to pay Rs. 47,570/- the expenses under medi-claim insurance policy to the complainant; along with interest @ 6% p.a.; from the date of filing of the complaint till realization; Rs. 10,000/- as compensation; for mental agony and pain; apart from Rs. 5,000/- as litigation expenses; within 30 days from the receipt of this order.
However, if the aforesaid amount is not paid to the complainant by OP1; within 30 days from the receipt of this order; the medi-claim amount of Rs. 47,570/- shall carry interest @ 7% p.a.; instead of 6% on this amount.
25. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
26. Announced on this 5th July, 2023
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
