DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No. 126/2020

Date of Institution: 08.09.2020

Judgment Reserved on: 18.01.2024

Judgment Passed on: 18.01.2024

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

Order By: Shri S.S. Malhotra (President)

JUDGMENT

1. By this judgment, the Commission shall dispose off the complaint of the complainant alleging deficiency in service on the part of OP while allowing mediclaim partially.
2. Before coming to the facts of the case it is a matter of record that complainant originally filed the complaint against the Oriental Insurance Company as OP1and its TPA i.e. Health India Insurance as OP2 however subsequently the complainant filed an application for impleading Sir Ganga Ram Hospital as OP3 where the treatment was taken and that application was allowed and notice was sent to all the three OPs. Therefore cause title shows the name of parties as per amended memo of parties.
3. Coming to the facts of the complaint it is interalia stated by the complainant that he purchased Health Insurance Policy (mediclaim insurance policy-Happy Family Floater Policy 2015) having sum assured as Rs.3 lakh in the year 2015 and it was being renewed from time to time and during the existence of this policy the complainant suffered cardiac arrest on 06.02.2020 and was taken to Sir Ganga Ram Hospital, New Delhi for checkup where doctor referred certain tests which were conducted and after the same, the angiography was done on 10.02.2020 and after going through the reports, he was suggested for angioplasty and accordingly complainant was admitted  there same day i.e. on 10.02.2020 and after angioplasty, he was discharged on 12.02.2020 and he spent Rs.2,20,795/- on his treatment & when he lodged the claim for Rs.2,20,795/- alongwith original bills for the hospitalisation and also for medicines for sum of Rs.8,503/- the OP vide order dated 02.05.2020 approved claim of complainant only partially i.e. to the extent of Rs.1,11,348/- and repudiated the claim of Rs.1,16,950/- without assigning any reason and from the perusal of approval letter dated 02.05.2020 it is clear that OP did not approve the claim of Rs.1,16,950/- which expenses were towards Bio Chemistry, Medical Records, Package Charges and Pharmacy Charges etc and it is alleged this denial of claim arbitrarily and illegally in violation of the legal contract. He wrote various emails thereafter but no proper reply was ever given and as such he filed the present complaint seeking directions to the OP to reimburse Rs.1,86,950/- which includes Rs.50,000/- towards mental & physical harassment and Rs.20,000/- towards litigation cost with interest @9% p.a.
4. The OPs were served and OP3 received the copy of the complaint and filed its written statement. OP2 did not appear and was proceeded ex-parte, OP1 received paper-book on 23.09.2022 & no reply was filed by OP1. Therefore vide order dated 08.02.2023 when OP1 sought another opportunity to file reply, the Commission then ordered that since more than 45 days after having received the paper-book, has expired the opportunity to OP1 to file written statement stands closed. Further it is also matter of record that although, the written statement of OP3 is on record yet during the arguments on 18.01.2024 Ld. Counsel for complainant orally informed the Commission that she does not want any relief against OP3 and as such there would be no necessity to mention the fact of the written statement filed by OP3. There is no reply of OP1. As per record OP2 is running ex-parte.
5. Coming to the facts of the case & particularly observing that OP1 has partially allowed the claim it stands proved that the policy, the admission of the complainant in hospital, complainant spent Rs.2,20,795/- in the treatment, he was discharged from the hospital and remaining amount was not disbursed all these things are not disputed. The only dispute is that certain deductions have been made by the OP. In absence of any reply of the OP on record, the Commission is not in a position to appreciate as to why these deductions were made. Not only the OP1 has not filed the reply but the OP1 has not appeared even at the stage of arguments so that its version on legal aspect could have been appreciated. The complainant however submits that certain amount have been deducted on account of the Bio Chemistry, Medical Records, Package Charges and Pharmacy Charges. It was the duty of the OP to explain the Commission as to how these charges were not included in their approval, while considering the claim or whether such expenses were covered in exclusion clause and if they were covered under the exclusion clause, then that part of the agreement would have been brought to the notice of the Commission but nothing has been done by the OP1. Therefore Commission is of the view that there is deficiency on the part of OP1 and as such OP1 is liable to pay the balance amount Rs.1,17,950/- with interest @9% p.a to the complainant alongwith compensation Rs.10,000/- towards mental & physical harassment and litigation cost of Rs.5,000/-.

This Order is to be complied within 30 days from the date of receiving the copy of the order & in case the OP1 would not pay the amount within 30 days the rate of interest would be @15% from the date of filing the case upto the date of realization on the entire amount.    

The complaint against OP2 & OP3 is dismissed.     

Copy of the Order be supplied/sent to both the Parties free of cost as per rules.

Announced on 18.01.2024.

File be consigned to Record Room.