Delhi

East Delhi

CC/968/2014

RAKESH KUMAR - Complainant(s)

Versus

O.I.C - Opp.Party(s)

04 May 2018

ORDER

              DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.      968/2014

                                                                                                   Date of Institution              16/10/2014

                                                                                                   Order reserved on               04/05/2018        

                                                                                                   Date of Order                        08/05/2018                                                                                     

 

In matter of -

Mr Rakesh Kumar, adult     

R/o- A-8/437 (now A-8/721)

Gali no. 8, A Block, Harijan Basti,

East Gokul Pur, Delhi – 110094                                          Complainant

 

                                      Vs

1-The Manager

Oriental Insurance Co. Ltd.

BO- 12 B&C, 25 Gopala Tower

Rajendra Palace, New Delhi

 

2-The Medical Superintendent

Max Superspeciality Hospital

108 A, Indraprastha Extn.,

Patpargunj, Delhi 110092 ….………………….….….…………..Opponents

 

Complainant’s Advocates……………..Mr. Prem Priyavardhan & Jagvir Singh,  Advocates

Opponent’s Advocate……………………Mr. Bhupesh Chandna,  Advocate 

 

Quorum                                              Sh Sukhdev  Singh        President

                                                              Dr P N Tiwari                 Member

                                                              Mrs Harpreet Kaur       Member                                                                                             

 

Order by Dr P N Tiwari  Member –

 

Brief Facts of the case                                                                                                 

Complainant took ‘Happy Family Floater mediclaim policy for himself vide policy no. 221201/48/2014/3993 for a sum insured Rs 3 Lacs having its tenure from 25/03/2014 to 24/03/2015 (Ex CW1/1). During continuity of this policy, complainant met with an accident and sustained injury over both legs on 13/06/2014 midnight so was admitted at GTB hospital, Delhi where Police was informed and FIR was registered vide FIR no. 419/14 at PS Jyoti Nagar, Delhi (Ex CW1/2) and MLC report was made as C-2159/2014 (Ex CW1/3). Later in afternoon of 13/06/2014 complainant got admitted in Max Hospital at Patpargunj, Delhi and was discharged on 19/06/2014 (Ex CW1/4). It was stated that relatives of complainant contacted TPA desk at OP2/hospital and handed over all the required policy documents and ID of complainant for getting cashless facility on the same date. When no cashless approval was received inquired from OP2 who told that OP2 forgot to send the request to OP1 so OP2 did not get any approval and complainant had to clear the hospital bill. As cashless was not available so treatment bill of Rs 2,16,389/- was paid by complainant. Complainant stated that due to severe injury, his both legs were amputated and till filing of this complaint, had treatment expenditure of over Res 3.5 Lacs approx. Despite of repeated visit to OP1 office, his claim was not paid so sent legal notice (Ex CW1/5) for reimbursement of treatment expenditure. Later OP replied to legal notice and stated that complainant was under the influence of alcohol so his claim was rejected (Ex CW1/6).

Complainant then filed his complaint and claimed reimbursement of Rs 3 Lacs as sum assured to Policy  with compensation of Rs 1.5 Lacs as mental and financial agony jointly by OP1 and 2 with litigation cost Rs 40,000/-.

OP1/OIC submitted written statement and denied all the facts as wrong and incorrect as alleged in complaint. It was admitted that OP1 had issued the claim policy which was in second year (ref. Ex CW1/1) as Happy Family Floater Policy with all terms and conditions (Ex OP1W/2) and as complainant was driving his vehicle under the influence of Alcohol at midnight vide MLC report no. C-2159/14 prepared at GTB hospital, Delhi (Ex OP1W/1). It was also stated that complainant had never approached OP1 at any stage after discharge from OP2 hospital for getting his claim passed. Now he had filed his complaint for reimbursement of treatment expenditure and claimed exorbitant and irrational amount from OP1 against policy terms and condition which require proper filing of all the required treatment documents, medicines bills. policy copy with proper attested by the treating doctor.

So when no claim was lodged with OP1, complainant could not claim reimbursement of his treatment bill. 

OP2/ Max hospital also filed their written statement and admitted that complainant was treated at OP2 hospital as a Medico Legal case. Complainant was initially treated at GTB hospital, Delhi and FIR was also prepared at GTB hospital. It was stated that there was no deficiency on their part as complainant was treated as per the standard protocol.  There was no record as complainant had not filed documents for cashless from OP1 and details of TPA with complaint. It was stated that due to severe crush injury in both legs, amputation was done to save his life as an emergency case on the same day (13/06/2014). It was also stated that cashless was denied by OP1 with remark as “patient consumed alcohol at the time of accident”, so cashless was denied under exclusion clause 4.8 of the policy. Hence no deficiency in services could be said against OP2/hospital.  

Complainant filed rejoinder to written statement filed by OP1 and denied all the replies of OP1 except admitting issuing of policy by OP1, denied all the replies. Complainant also submitted evidence on affidavit and reaffirmed on oath that all the facts and exhibits on record were correct and true and re asserted that due to none sending of cashless request by OP2 to OP1 suffered huge harassment and mental agony in paying the huge hospital bill.

Complainant also filed rejoinder to written statement submitted by OP2 and denied replies filed as wrong and incorrect. It was stated that OP2 did not send cashless request to OP1 despite submitting all the claim documents on the date of admission in OP2 (13/06/2014) and due to carelessness of OP2, had to pay huge treatment bill. Hence OP2 was careless in their services in providing cashless in case of severe accidental injury in his both legs which resulted amputation leading to cripple whole life. 

OP1 /OIC filed evidences on affidavit through Md. Mandakini Balodhi, Div. Manager with OP1 reaffirmed on oath that the said policy was issued by them and claim was rejected on the ground of Alcohol intake at the time of accident which was evident by MLC report from Govt Hospital and FIR was registered. It was admitted that complainant did not apply for cashless or ever claim was lodged within seven days after discharge from the hospital as per the terms and condition of the policy where all the required documents had to be submitted by the complainant.  So the cashless was denied under exclusion clause 4.8 on the basis of MLC report. 

So OP1 was neither deficient in their services nor negligent or careless in their act and the complaint would be dismissed. 

OP2/hospital filed detailed evidences on affidavit through Medical Supdt. Mrs Dr. Indranil Mukhopadhyay and affirmed on oath that there was no deficiency in their treatment protocol and every step of line of treatment chosen by the treating doctor was explained to the relatives (brother and others) timely and all had given consent. OP2 obtained all necessary treatment documents from GTB hospital and MLC report (Ex OP2/1), a copy of FIR and all treatment records as evidences had been submitted before this Forum and stated to be correct as per their records and knowledge. Hence there was neither deficiency nor negligence in their line of treatment. Hence this complaint be dismissed.

 

Complainant and OP1 filed their written submission and taken on record. 

Arguments were heard from both party’s counsels and after perusal of file, order was reserved.

Failure to submit the requisition form for cashless request to OP1 and claim rejection letter from OP1, establishes that OP2 did not submit any such documents to OP1 which clearly proves deficiency in their services at TPA desk. That is why complainant had to pay entire hospital bill by himself after undergoing major surgical operation where his both legs were amputed.

Since OP2/Max Hospital have not facilitated the consumer in getting the cashless facility, so they are deficient in their services. Therefore liability is fastened upon them.

Hence after considering all facts and evidences on record and implications of grievous injury from accident, we are of the opinion that this complaint has merit so we pass the following order as under—

1. OP2 shall pay Rs 30,000/-towards compensation to the complainant due to deficiency of OP2 causing mental agony and harassment in 30 days from the date of receiving this order.  This will include litigation charges also.
2. Complainant is directed to file his claim before OP1 within 30 days and then OP1 shall proceed in accordance to the claim process and shall finalise within sixty days.
3. If order is not complied in the time essence, complainant shall be constraint to recover the awarded amount with 9% interest till realized.      
4. There shall be no order to cost at this stage.

Copy of this order be sent to the parties as Regulation 18 of the Consumer Protection Regulations 2005 (in short the CPR) and file be consigned to Record Room under Regulation 20(1) of the CPR.  

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                      Sukhdev Singh  President