BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 220 of 2020
Date of Institution : 05.10.2020
Date of Decision : 30.05.2024
Sunita Rani aged 29 years wife of Sh. Sandeep Kumar d/o Sh. Rohtash, resident of village Handi Khera, District Sirsa, Haryana.
……Complainant.
Versus.
1. Oriental Insurance Company Limited, Registered Office : Oriental house, A-15/27, Asaf Ali road, New Delhi- 110002 Ms Beena Dhawan Chief Manager, customer service department, 4th Floor, Agarwal House Asaf Ali road, New Delhi – 110002.
2. Ms Medi Assist India Pvt. Ltd. (TPA) Registered Office : 4th Floor, Aarpee Chambers, shagbaug, off andheri – Kurla road, Next to time square, marol, Andheri East, Mumbai- 400059.
3. The Oriental Insurance Company Limited (branch office) opposite Janta Bhawan, Janta Bhawan road, Sirsa, Haryana.
4. Dr. (Mrs) Aruna Jyani, Jyani Maternity & Children Hospital, opposite Surkhab Tourism, Hisar road, Sirsa (Haryana) Ph. 01666-297454.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………MEMBER
Present: Sh. Mukesh Arya, Advocate for the complainant.
Sh. K.L. Gagneja, Advocate for opposite parties no. 1 and 3.
Sh. Ashish Singla, Advocate for opposite party no.4.
Opposite party no.2 exparte vide order dated 13.10.2022.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that she was covered under the medical policy no. 1245004820203052 and she was legally entitled for reimbursement of any medical claim being an employee with an ID no. 121876 at Axis Bank Branch Vaidwala, District Sirsa, Haryana. That complainant was operated upon by Dr. (Mrs.) Aruna Jyani on 03.02.2020 for the delivery of a female child and consequently she was discharged on 06.02.2020 after complete medication and treatment for the time being. It is further averred that for all of treatment and medication the complainant had to bear approximately Rs.30,000/- which was paid to the aforesaid doctor then and there before her discharge. That complainant applied for reimbursement of aforesaid expenses to op no.2 and as per rules of application for the aforesaid reimbursement, the complainant uploaded all the documents on the website/ internet application under the name and style of “medibuddy” for aforesaid reimbursement within stipulated period. That upon completion of aforesaid formalities by complainant, she was instructed by the aforesaid company for uploading of the qualification of the operating doctor which was duly satisfied by complainant by submitting the registration number HN011121 of aforesaid doctor. It is further averred that to the utter surprise of complainant, the aforesaid claim was rejected for want of degree and certificate of the operating doctor which was denied by aforesaid doctor upon demand by complainant, consequently complainant could not produce the same before Ms Medi Assist India Pvt. Ltd. (TPA) which is no way a fault of complainant. That aforesaid rejection of reimbursement is a matter of conflict between the aforesaid notice and Medical Council of India which is/ has been never a concern of the complainant because a prudent person the complainant has performed all her duties with respect to the aforesaid insurance honestly and diligently. It is further averred that it is simply a malpractice of encroachment of the complainant’s entitlement on the part of the aforesaid noticee which is against their working ethics and moral and complainant has to bear irreparable loss of mental, physical and economical harassment leading her to unnecessary stress at her working place and home. Hence, this complaint seeking direction to the ops to make payment of Rs.30,000/- alongwith interest at the rate of @18% per annum till final realization and also to pay an amount of Rs.20,000/- as compensation for harassment and to pay litigation expenses.
3. On notice, ops no.1, 3 and 4 appeared. Ops no.1 and 3 filed written statement and submitted that complainant was having a Group Mediclaim policy under arrangement with Axis Bank Ltd. valid from 01.10.2019 to 30.09.2020 for sum assured amount of Rs.4,00,000/-. This being a corporate policy, the offices of the ops at Delhi and Sirsa have no records pertaining to the above policy. The complainant gave birth to a female child in Jayani Maternity Hospital but answering ops have no records pertaining to this fact. It is further submitted that complainant/ insured persons are entitled for the reimbursement of the medical expenses but their entitlement is subject to the terms and conditions of the mediclaim insurance policy. As per terms and conditions of the insurance policy, the insured person shall submit to the TPA all original bills, receipts and other documents upon which a claim is based and shall also give the TPA/ company such additional information and assistance as the TPA/ company may require. On receipt of the claim, on 22.04.2020 the complainant was requested by TPA to furnish/ provide copy of cancel cheque with pre-printed name of primary beneficiary with IFSC code, original pre-numbered final hospital bill with pre-numbered payment receipt, Government ID proof of patient, complete filled up discharge card signed and stamped by treating hospital/ doctor and IRDA claim form A and claim form B filled up by patient and hospital authority. It is further submitted that later on several queries were raised and reminders were sent to the complainant by TPA on 22.04.2020, 24.04.2020, 27.04.2020, 29.04.2020 and lastly on 30.04.2020 with the requests to provide the qualification of treating doctor with degree certificate alongwith other required documents for the quick settlement of the claim. But the complainant failed to provide the required documents resulting into denial of the claim and as per clause, the claim of complainant had been denied. Remaining contents of complaint are also denied and prayer for dismissal of complaint made.
4. Op no.2 failed to appear despite delivery of notice sent through registered cover and as such op no.2 was proceeded against exparte.
5. Op no.4 also filed written version raising certain preliminary objections. It is submitted that it is wrong to say that answering op had charged a sum of Rs.30,000/- from complainant. The answering op had charged only a sum of Rs.23,000/- vide bill Nos. 3047 and 3048 dated 06.02.2020 out of which Rs.3000/- were paid to the visiting Anesthetic Dr. Rahul Mittal who was called for anesthesia. The original bills were handed over to the complainant. It is further submitted that it is very surprising to ask a doctor for her degree and certificate etc. to be submitted for reimbursement of medical claim from insurance company. The HMC registration number as well as qualification of answering op is well mentioned on the letter head of the Doctor OPD slip and the printed discharge card with summary of all investigations and treatment of the patient i.e. complainant. Moreover, it is none of the business of complainant or insurance company/ TPA to ask answering op to submit record of her qualification etc. The answering op had already handed over to complainant all the required documents for insurance claim such as OPD slips and all investigation reports and a signed discharge card, treatment notes and on call specialist anesthetist doctor notes and the original bill and cash receipt etc. It is further submitted that answering op is a well qualified MBBS Medical and Surgical Graduate (Rajasthan University in 1988), Ex-Rajasthan Civil Medical Services Class I post and R.M.O. of a Maternity and Welfare Centre, Jaipur and SMO of Janta Maternity Hospital, Sirsa and now independently running her own maternity and children hospital. She is a permanent life member of the national body of the Federation of Obstetrics & Gynaecological Sciences of India, Mumbai. There is no conflict amongst the insurance company or answering op or Medical Council of India. The MCI was in no way concerned with the aforesaid matter of complainant’s claim nor is answering op concerned with the same. Moreover, the MCI stood dissolved since 2019 and is not existent and answering op has not received any email or letter etc. from MCI in this regard. It is further submitted that answering op is not at all concerned with the sanction and approval of reimbursement of medical claim of complainant. She has ethically performed her professional duties quite well with utmost care and due diligence and complainant has no claim against answering op. The answering op is not at all responsible for any alleged loss/ harassment to the complainant. With these averments, dismissal of complaint prayed for.
6. The complainant in evidence has tendered her affidavit Ex.C1 and documents Ex.C2 to Ex.C14.
7. On the other hand, ops no.1 and 3 have tendered affidavit of Ms. Puja Tapwal, Incharge as Ex.R1 and documents Ex.R2 to Ex.R8. Op no.4 has tendered her affidavit Ex.R9 and documents Ex.R10 to Ex.R16.
8. We have heard learned counsel for the parties and have gone through the case file carefully.
9. It is an admitted fact between complainant and ops no.1 and 3 insurance company that complainant was having a Group Mediclaim policy under arrangement with Axis Bank Ltd. vide policy No. 124500/48/2020/3052 valid from 01.10.2019 to 30.09.2020 for sum assured amount of Rs.4,00,000/-. It is also an admitted fact that during the period of policy on 03.02.2020 complainant was operated upon by Dr. Aruna Jyani op no.4 for delivery of a female child and she was discharged from the hospital on 06.02.2020 and complainant claims that she had to bear approximately Rs.30,000/- which was paid to the aforesaid doctor. The complainant also claims that for reimbursement of the above said amount from ops no.1 and 3 she applied for the reimbursement to the TPA of insurance company namely Ms Medi Assist India Pvt. Ltd. and uploaded all the documents pertaining to aforesaid treatment and expenses on the website/ internet application under the name and style of “Medibuddy”. However, the said TPA op no.2 despite notice has failed to appear and opted to be proceeded against exparte. The claim of complainant has been denied by ops no.1 and 3 for non submission of above said documents alongwith degree and certificate of doctor op no.4. However, ops no.1 and 3 have not justified on record that as to why degree and certificate of doctor was required for reimbursement of claim. Moreover, ops no.1 and 3 cannot demand degree of the doctor from the complainant. The registration number etc. of the doctor are mentioned on bill/ treatment record and according to complainant all the required documents were already uploaded by her on the website of TPA of insurance company which has opted to be proceeded against exparte. It cannot be said that complainant who is to seek reimbursement of his medical bills will not submit the required documents and as TPA to whom documents were submitted by complainant is exparte, therefore, ops no.1 and 3 cannot take the plea that documents were not submitted by complainant and they were liable to confirm the said fact from its TPA but ops no.1 and 3 have failed to do so. Since the op no.4 has placed on file copies of her degree/ certificate etc. and even copies of bills etc. are also on file, so the ops no.1 and 3 are liable to reimburse the expenses spent by complainant on her delivery/ post delivery treatment. It is proved from copy of bill Ex.C6 that complainant paid an amount of Rs.23,000/- to the op no.4 doctor and as such complainant is entitled to reimbursement of Rs.23,000/- from ops no.1 and 3. At the most the ops no.1 and 3 can again ask the complainant to provide copy of cancel cheque with pre printed name of primary beneficiary with IFSC code, however, ops no.1 and 3 will not ask the complainant for submission of any other documents since she has already supplied all the documents to op no.2 and copies of bills, degree and certificate of op no.4 are already on file.
10. In view of our above discussion, we allow the present complaint qua ops no.1 to 3 and direct the opposite parties no.1 to 3 to pay the claim amount of Rs.23,000/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 05.10.2020 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops no.1 and 3 to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. However, no liability of op no.4 towards complainant is made out and as such complaint qua op no.4 stands dismissed. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 30.05.2024. District Consumer Disputes
Redressal Commission, Sirsa.
