Delhi

East Delhi

CC/186/2014

TARUN - Complainant(s)

Versus

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

05 Sep 2017

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.       186/2014

                                                                                                   Date of Institution               18/02/2014

                                                                                                   Order reserved on               05/09/2017        

                                                                                                   Date of Order                        07/09/2017                                                                                     

 

In matter of

Mr Tarun Chawla, adult   

R/o- 1/7002, Shivaji Park,

Shahdara Delhi 110032..………………….……………...…………….Complainant

                             

                                      Vs

 

1-M/s Oriental Insurance Co. Ltd. 

City Branch Office-16,

3^rd Floor, Jeevan Bharti Building,

New Delhi 110001

 

2-E-Medictek,

H.O.-Plot no. 577,

Udhyog Vihar, PH V,

Gurgaon…………………………………………..……………..….…………..Opponents

 

Quorum   Sh Sukhdev  Singh        President

                   Dr P N Tiwari                 Member

                                                                                                          

Order by Dr P N Tiwari  Member  

 

Brief -                                                                                               

Complainant / Policy holder had filed this complaint u/s 12 of the Consumer Protection Act, 1986 for deficiency in service of OP for nonpayment of hospital bill of his father/insured under mediclaim policy by OP/OIC.

Facts of the case-

Complainant was a mediclaim policy holder since 2009 under Happy Family Floater Policy from OP1 and TPA was as OP2. It was stated that no family member was suffering from any ailment from his first policy started from 16/01/2009 vide policy no. 215601/48/2009/3918 and no one had any pre exiting disease and the same facts were stated in policy proposal form (Ex. CW1/1) and policy details from 2009 onward (Ex. CW1/2 to Ex. CW1/6). The mediclaim policy was for complainant, his father Sh. Jugal Kishore Chawla and mother Smt. Sheela Chawla for sum assured (SA) one lakh to all.    

It was stated that his father/insured Sh Jugal Kishore Chawla was admitted in St Stephens Hospital on 07/03/2011 and was discharged on 17/03/2011. The claim documents were submitted to OP2 on 14/06/2011 under claim policy no. 215601/48/2011/4910 in accordance to hospital bill and other medicines expenditure (Ex. CW1/7), but OP2 did not clear the claim and even repeated inquiry and fulfilling all the required papers. Later OP2 put his claim as “NO CLAIM” on 14/06/2011 (Ex. CW1/8). Hence, complainant filed this complaint on 18/02/2014 for reimbursement of treatment cost a sum of Rs 35,000/- with compensation of Rs 50,000/- for mental agony and Rs 20,000/- for litigation charges.

Later complainant also filed an application for condoning delay of about eight months on dated 13/03/2014 after filing his complaint narrating delay in filing this complaint due to admission of his father at Sir Ganga Ram Hospital and despite of repeated visit to OP2, his claim was not paid.   

After receiving notice, both OPs put their appearance and copy of condonation application was supplied. Both the OPs replied stating that the application did not have any sufficient ground for condoning the delay of over 8 months as his first claim pertained to St Stephen’s Hospital as per Ex CW1/7 where treatment documents required for claim process were not submitted by complainant even sending three reminders and claim was put as No Claim on 20/08/2011, where as he did not apply for any other claim so condonation application and complaint may also be dismissed.

Complainant thereafter wished for Mediation process, so the matter was referred to Govt Mediation Centre vide Mediation Case no. 240/2014 dated 03/11/2014, but process failed (Ex CW1/9).  

The case was also put in the National Lok Adalat held in this Forum on dated 06/12/2014. The OP counsel did not agree for any compromise as there was no deficiency in their services, so did not agree for settlement.   

Both OPs submitted written statement. All the contentions of deficiency in the services alleged by complainant were denied. OP1 submitted that the present complaint was barred by time under Sec. 24 A of the Consumer Protection Act, so complaint to be dismissed as it had been filed beyond the limitation period of two years. It was also stated that claim documents had to be submitted by the claimant/insured/complainant within 7 days from the discharge from hospital whereas in this case, documents were submitted incomplete after 82 days which clearly violated conditions for claim process. OP2 had issued three reminders to the complainant for submitting all the required documents for processing his claim as per dates 14/06/2011, 08/08/2011 and 20/08/2011 which were on record (Ex. OPW1/1, 2 and 3), but no required documents were submitted by complainant so his claim was put under “No Claim”. It was their standard claim process to put claim as no claim if claimant fails to comply the intimations.  So, it could not be said as the claim was rejected or any deficiency in their service.

It was further stated that his first policy was from 16/01/2009 vide policy no. 215601/48/2009/3918 for sum assured one lakh and in year 2010 –11 it was enhanced to 1.5 lakh. It was again enhanced to 4 lakh from 2012 onward.

 

It was stated that as per policy terms and condition clause 5.5 claim documents have to be submitted by the complainant within 7 days after discharge from the hospital, but here no claim documents were submitted as per clause 5.5 even sending three reminders to the complainant.  

 

It was also stated that complainant was diagnosed for D/V, BE IMSC (Both Eye Immature Senile Cataract, DM T2, with COPD, with Old Koch’s with B/L Bronchiactasis with Aspergilloma (as per discharge summary). His cataract surgery was deffered due to High blood Sugar and only conservative treatment was given. OP1 stated that as per their proposal form, claimant had not disclosed any facts about old ailments of insured. So, his claim was put in ‘NO CLAIM’ category due to non compliance of three reminders sent by OP2.

OP2/TPA submitted their written statement and denied allegations of complainant as wrong and incorrect.  It was stated that OP2 were Third Party Agent of OP1 as per the license from IRDA and had to facilitate the claim process for OP1 under the terms and condition of the policy. As per Honble Supreme Court in “Prem Nath Motors vs Anurag Mittal in AIR 2009 SC 567, it was held

-“that under section 230 of the Contract Act, an agent is not liable for the act of a disclosed principle”.

OP2 stated in their reply under para 8 that certain documents were required for claim process, but complainant did not submit any required documents till his claim was put under No Claim and claim process was closed on 20/08/2011.

 

Complainant filed his rejoinder and evidences on affidavit where he himself affirmed on oath that all the facts were correct and true as per his complaint which had been submitted on behalf of his father/ claimant.

OP 1 also submitted their evidence on affidavit through Mrs Beena Dhawan, Manager claims with OP1 and affirmed on oath that all the procedures adopted by them were as per the IRDA guidelines and putting the claim on No Claim was as per the terms and conditions of the policy.

 

It was also stated in their affidavit that under clause 5.5, essential requirement of documents were mandatory and also claimant was insured / his father and not the complainant. Complainant had submitted incorrect policy proposal form and all the material facts were hidden by him for his father’s health. It was also stated that complainant had not mentioned / disclosed in his complaint about admission of his father in Sir Ganga Ram Hospital from 16/04/2012 to 27/04/2012 for treatment of Diabetes mellitus, Pulmonary Koch’s, Aspergilosis in Lower Respiratory Tract Infection as discharge summary was submitted (Ex. OPW1/3). Hence, there was no deficiency in their services and putting claim under No Claim was justified as per terms and condition of the policy.  

 

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

Before coming to the conclusion of this case, we framed three issues as under –

1. Whether insured took treatment actually for his acute ailment under its complications?
2. Whether policy proposal form was rightly filled by the complainant?
3. Whether non clearance of claim was justified by OP2?  

1-Whether insured took treatment actually for his acute ailment under its complications –

We have scrutinized the discharge summary from St Stephens Hospital vide IP no. 1138559/2 where complainant’s father / insured was admitted here from 07/03/2011 to 17/03/2011 (Ex. CW1/7) which reads as –

Diagnosis

“BE IMSC with DMT2, with COPD with Old Koch’s with Bronchiectasis with Aspergilloma”

 

Complaint and History

D/V

 

Clinical Findings

VN, RE-CF-2MT, LE CF 3MT, IPO – BE 14.6 mmHg.  

 

After analyzing the abbreviations used by the treating hospital/ St Stephens Hospital, it is clear that claimant/ complainant’s father was admitted for operating his Cataract operation as his complaint was D/V- meaning – Diminishing Vision.

But the main diagnosis was for treating superadded bacterial infection in old lesions of Pulmonary Tuberculosis in lower parts of lungs known as Bronchiectesis with Aspergilloma in known case of Diabetes Mellitus. This observation has been proved by the different lab reports written in the discharge summary. The final advise was – “Cataract operation was not done due to high Blood Sugar. All the treatment given as indoor patient and advised after discharge establishes treatment for complication of Pulmonary Tuberculosis (Bronchiectesis) and its medical / conservative line of treatment. But treating hospital wrote medical abbreviations for the reason best known to them.

As far as Eye check up findings are concerned, they were mere OPD based examination of both Eyes and had normal vision in BE- IMSC (Both Eye ImMature Senile Cataract). So there was no eye related complication present in the claimant at that time.

OP had also submitted another discharge summary of Sir Ganga Ram Hospital where complainant’s father was admitted from 16/04/2012 to 17/0-4/2012 for taking treatment for DM. The discharge summary reads as – “History of Pulmonary Tuberculosis 12 years back and three years back and taken full course of ATT ( Anti Tuberculosis Treatment). 

Both discharge summaries have same diagnosis and line of treatment except in St. Stephen’s Hospital, chief complaints and diagnosis pertains to Ophthalmology and treatment was for the complications of old pulmonary tuberculosis as Bronchiectasis with Aspergilloma (collection of fungal growth in lungs). This hospital used medical abbreviations to misguide OP for claim purpose.      

Hence it clearly proves that complainant has intentionally hidden all material facts before the Forum and also before the Insurer/OP.

 

2-Whether policy proposal form was rightly filled by the complainant?

It was clearly evident from the Policy proposal form that all the mandatory columns were written as ‘NO’ and declaration had been signed by the complainant and on the basis of these informations, OP had issued the policy in good faith. So under this issue, it can be said that complainant had full knowledge of all the ailments of his father which he was suffering at the time of filling the policy proposal form. That being so it is clearly evident from the facts that policy form was not correctly filled by the complainant.       

3-Whether non clearance of claim was justified by OP2? 

Here complainant has not complied with the requirements of claim process by submitting treatments documents even on repeated reminders.

Hence, after seeing entire facts and evidences on record and properly analyzing medical facts, neither OP1 nor OP2 were at fault or had done any deficient services towards complainant. Treating Hospital/St Stephens Hospital has used medical abbreviations which itself is a deficient practice to confuse OP probably for passing the claim by wrong way. So, using abbreviations is a wrong medical practice in writing findings and diagnosis.   

There were three reminder notices sent by OP for claim process, but complainant did not comply the notices and so claim was put in NO CLAIM category on dated 20/08/2011.

 

As ‘NO CLAIM’ means claim was not rejected by OP, so, we direct complainant to submit all the required treatment documents within 15 days to OP2 for processing claim and thereafter OP2 will pursue the claim process. Claim status will be submitted by OP1 to this Forum in 45 days from the receiving of all claim documents from complainant.

 

Copy of this order be sent to the parties as per Act and file be consigned to Record Room.

 

(Dr) P N Tiwari  Member                                                                     Sukhdev Singh  President