Haryana

Ambala

CC/186/2019

Smt Sunita - Complainant(s)

Versus

OIC - Opp.Party(s)

Arvind Goel

05 May 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                          Complaint case No.:   186 of 2019.

                                                          Date of Institution         :     28.05.2019.

                                                          Date of decision   :     05.05.2021.

 

Smt. Sunila W/o Shri Suresh Kumar Viz, R/o 87, Krishna Nagar, Ambala Cantt.

 

          ……. Complainant.

                                                Versus

 

1. Oriental Insurance Company Limited, Life Insurance Building, Ground Floor, Near Aggarsain Chowk, Ambala City, through its Divisional Manager.

 

2. M/s Raksha Health Insurance TPA Pvt. Ltd., C/o Escort Corporation Centre, 15/5, Mathura Road, Faridabad, Haryana-121003, through its Branch Incharge.

 

3. M/s Raksha Health Insurance TPA Pvt. Ltd., SCO 359-360, Ist Floor, Sector 44-D, Chandigarh-160047, through its Branch Incharge.

               ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.          

                            

Present:       Shri Arvind Goel, Advocate, counsel for complainant.

Shri Rajiv Sachdeva, Advocate, counsel for the OP No.1.

OPs No.2 & 3 already exparte vide order dated 17.07.2019.

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay Rs. 5,00,000/- i.e. the claim amount alongwith interest @ 24% per annum, from the date of submission of papers till its realisation.
2. To pay Rs.50,000/- as compensation for the mental agony & physical harassment suffered by her.

                                                OR

                   Any other relief which this Hon’ble Commission may deem fit.

 

                    Brief facts of the case are that the that Shri Suresh Kumar Vij, husband of complainant for the first time took a Medi-Claim insurance policy bearing policy No. 261101/48/2015/1451, for the period from 18.12.2014 to 17.12.2015, from OP No. 1 at Ambala City. Shri Suresh Kumar Vij, his wife Smt. Sunila (complainant) and master Tuneer (child) were duly covered under the said policy. Shri Suresh Kumar Vij, got renewed the policy every year. The husband of the complainant by paying the premium of Rs.19,587/-, got renewed the policy for the period from 22.12.2017 to 21.12.2018 and the risk covered under the policy was of Rs.5,00,000/-. Complainant was advised by the doctors to undergo replacement of knees and she contacted with the officials of OPs, regarding claim, they advised for selection of hospital, out of the list of the hospitals, mentioned in the insured’s guide book. As per the booklet provided by OPs, ORTHONOVA Joint & Trauma Hospital (P) Ltd, Nakodar Road, Near Nari Niketan Jaladhar City, was on the penal of the OPs. Accordingly, on 01.11.2018, complainant got operated by the doctor of the ORTHONOVA Joint & Trauma Hospital (P) Ltd, Nakodar Road, Near Nari Niketan Jaladhar City. Complainant remained admitted in the said hospital for the period from 31.10.2018 to 12.11.2018, as indoor patient and on her treatment she incurred total expenses of Rs.5,52,200/- (paid Rs.3,25,000/- to the hospital and paid Rs. 2,27,000/-, for medicines). Complainant submitted the claim form and the medical bills along with relevant documents with the OPs. Inspite of the fact that ORTHONOVA Joint & Trauma Hospital Private Limited, Nakodar Road, Near Nari Niketan Jaladhar City is on the penal of the OPs but the OP No.2, vide letter dated 03.01.2019, demanded some irrelevant papers/documents related to the said hospital. The documents demanding by the OP No.2, had no concern with the settlement of claim of the complainant. Complainant requested the OPs to settle the claim but they paid no heed to his genuine request. Complainant got served a legal notice dated 15.03.2019, upon the OPs. Complainant received a reply dated 27.03.2019 from the OP No.1 and reply dated 22.03.2019 from the OP No.2, vide which they again demanded the irrelevant documents. By not paying the genuine claim of the complainant, the OPs have committed deficiency in service. Hence, the present complaint.

2.                Upon notice, OP No.1 appeared through counsel and filed written version raising preliminary objections regarding maintainability, jurisdiction,  cause of action, suppression of material facts, not come with the clean hands and barred by principles of estoppels, wavier and acquiescence, etc. On merits, it is stated that OP No.2 & 3 are the service provider of the answering opposite party and are fully authorized to settle/repudiate the claim as per terms and conditions of the policy.  M/s Raksha Health Insurance TPA Pvt. Ltd. sent letters on 19^th December 2018, 3^rd January 2019 & final reminder on 18^th January 2018 to Shri Suresh Kumar Viz, 87 Krishna Nagar, Ambala, Haryana 133001, whereby, he was requested to submit the following documents/information for processing the claim of the complainant:-

xii.     Kindly provide the complete set of Indoor case papers and vital charting.

xiii.    Kindly provide ORTHONOVA Hospital registration certificate/inpatient          facility certificate.

xiv. Original investigation reports All Reports DONE DURING     HOSPITALIZATION, ALL XRAY REPORTS (PRE-POST) dated       31.10.2018

xv.     Breakup of main hospital bill on Hospital Letter Head.

xvi.    Kindly provide letter from treating doctor with specific reason for prolonged stay in the hospital.

xvii.   Kindly provide purchase invoice and Sticker for implant used in the        surgery.

xviii.  Kindly provide Pre and Post Procedure X-ray films.

xix.    Kindly provide detailed discharge summary mentioning Final diagnosis, presenting complaints, Vitals at the time of admission, course in hospital,       treatment given and advice on discharge.

xx.     Kindly provide original pre-numbered, Preprinted duly signed and           stamped Receipt against the Final Hospital Bill.

xxi.    Kindly provide written consent for obtaining your indoor case papers from      the Hospital for claim settlement.

xxii.   Kindly provide Self Attested copy of Aadhar Card of Patient.

 

          It was further stated that in the final reminder dated 18^th January 2019, it was specifically mentioned that:- The claim will be repudiated if no reply is received within 15 days after the final remainder. The complainant failed to provide the requisite documents as such the OPs have rightly repudiated the claim as per the terms and conditions of the policy and information regarding the same was given to the husband to the complainant vide letter dated 27.03.2019.  The rest of the allegations levelled by the complainant were denied for want of knowledge and prayer has been made for dismissal of the present complaint with costs.

3.                 Upon notice, none appeared on behalf of the OPs No.2 and 3 before this Commission, therefore, they were proceeded against ex-parte vide order dated 17.07.2019.

4.                The learned counsel for the complainant tendered affidavit of the complainant as Annexure CA alongwith documents as Annexure C-1 to C-27 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OP No.1 tendered affidavits of Shri Ashish Bhatnagar, Branch Manager, The Oriental Insurance Company, Ambala and Dr. Rakesh Kalra, M/s Raksha Health Insurance TPA Pvt. Ltd., SCO-39, First Floor, Sector-26, Chandigarh as Annexure OP1/A and OP1/B respectively alongwith documents as Annexure OP1/1 to OP1/7 and closed the evidence on behalf of OP No.1.

5.                We have heard the learned counsel for the complainant and learned counsel for the OP No.1 and carefully gone through the case file and also the written arguments filed by the learned counsel for the complainant and learned counsel for the OP No.1. 

6.                At the outset, the learned counsel for the OP No.1 has vehemently argued that the policy in question was taken by Shri Suresh Kumar and the present complaint has been filed by Smt. Sunila. Since, Smt. Sunila is not the consumer of the OP No.1 therefore, the complaint filed by her against the OP No.1 is not maintainable and is liable to be dismissed on this score only.  To this effect, the learned counsel for the complainant has submitted that under the policy in question the complainant is duly insured with the OP No.1. Smt. Sunila being insured is competent to file a complaint against the OP No.1.

7.                Perusal of policy document Annexure C-4 reveals that Shri Suresh Kumar and Smt. Sunila were duly insured under the policy in question, for the period from 22.12.2018 to 21.12.2019.  As envisaged in Section 2 (1)(d) of the Consumer Protection Act, 1986, Smt. Sunila being a insured/ beneficiary, has a right to file a complaint before this Commission, for redressal of her grievance against the insurance company. Therefore, the argument put forth by the learned counsel for the OP No.1 is rejected being devoid of merits. 

8.       Now coming to the merits of the case.

9.       The learned counsel for the complainant has argued that the complainant provided all the necessary documents regarding her treatment to OPs. He had taken the treatment from ORTHONOVA Hospital, which was on the penal of the OP No.1. In order to settle the claim, the OP No.1, instead of asking the complainant to provide information about the hospital, could have easily get the information from the hospital itself. By demanding the irrelevant documents/information and by closing the claim as ‘no claim’, the OPs have committed deficiency in service. The OPs are thus liable to reimburse the amount which the complainant has actually incurred on her medical expenses. They are also liable to compensate the complainant for the mental agony and physical harassment caused to her. In support of his contention the learned counsel for the complainant has placed reliance on the case titled as M/s ICICI prudential Life Insurance Company Limited & Ors Vs. Arunjeet Thakur decided on 29.04.2013 by the Hon’ble Himachal Pradesh State Consumer Disputes Redressal Commission, Shimla, wherein it has been held that:- no documents are required to be submitted to the insurer to enable it to verify the claim. Normal practice followed by the insurers is to depute some investigator or surveyor for the verification of the claim. Almost all the insurers have their branches in all the towns and cities of the country. On the basis of copies of papers supplied by the insured, they could have very easily verified the claim. So, the filing of claim of respondent by the appellants on the pretext of non-submission of original documents was nothing, but a poly to avoid payment to insurance money. He further placed reliance on the order dated 12.01.2017, passed by the Hon’ble Gujarat State Consumer Disputes Redressal Commission, Ahmadabad, in the case of Mayurbhai Hasmukhbhai Gondaliya Vs. Oriental Insurance Company Limited, wherein it was held that:- it is not at all expected from the insured to make any inquiry regarding registration of the hospital, qualification of the nursing staff etc., before taking the treatment. If at all, there is any violation regarding terms and conditions of the insurance policy it is on the part of the concerned doctor or hospital but for that the consumer cannot suffer. Terms and conditions of the policy must be in consolation with the provisions of the Consumer Protection Act and Medical Council Rules-Agreements in restraint of legal proceedings void. In such matters terms applicable. Repudiation of the claim by the insurance company is hereby condemned.

                    The complainant has averred that he had taken the treatment from ORTHONOVA Joint & Trauma Hospital Private Limited, Nakodar Road, Near Nari Niketan Jaladhar City, which is on the penal of the OP No.1. This fact has not been denied by the OP No.1. Since, the complainant has taken the treatment from the hospital, which is on the penal of the OP No.1, therefore to settle the claim the OP No.1, instead of asking the complainant to provide the information regarding the hospital, could have easily get the information from the said hospital itself. Taking all the facts and circumstances into consideration and the law laid down by superior Commissions in the case of M/s ICICI prudential Life Insurance Company Limited & Ors. Vs. Arunjeet Thakur and Mayurbhai Hasmukhbhai Gondaliya Vs. Oriental Insurance Company Limited (Supra), we do not hesitate to hold that the OP No.1 was wrong in closing the claim of the complainant as ‘no claim’. The OP No.1 is thus liable to pay the amount, which the complainant had incurred on her treatment as per the terms of the conditions of the policy. From the perusal of bills Annexure C-7 to C-20, it is evident that complainant had spent a sum of Rs.5,52,200/- on her treatment. Perusal of policy document Annexure C-4, reveals that risk covered was for a sum of Rs.500,000/-. Therefore, as per the policy, the OP No.1 being the insurer was liable to pay a sum of Rs.5,00,000/-. By not paying the said amount the OP No.1, has committed deficiency in service, therefore it is not only liable to pay the claim amount of Rs.5,00,000/- to the complainant but is also liable to compensate the complainant for the mental agony and physical harassment suffered by her.

                   It may be stated here that the OPs No.2 and 3 are working for and on behalf of OP No.1 and the claim amount has to be paid by the insurance company only, therefore no liability to pay the claim amount can be fasten against the OPs No.2 and 3 and as such the complaint filed by the complainant against them is liable to be dismissed.

10.              In view of the aforesaid discussion, we hereby dismiss the present complaint against the OPs No.2 and 3 and allow the same against the OP No.1 and direct it in the following manner:-

1. To pay Rs.5,00,000/- to the complainant along with interest @ 5% per annum w.e.f. 28.05.2019 i.e. the date of filing of the present complaint till its realization.
2. To pay Rs.5,000/- as compensation to complainant for mental agony and physical harassment suffered by her and also litigation expenses.

 

                   The OP No.1 is further directed to comply with the aforesaid directions within the period of 45 days from the date of receipt of the certified copy of this order. Certified copies of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :05.05.2021.

 

 

                                       (Ruby Sharma)                         (Neena Sandhu)

                                          Member                                 President