DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 406/2016
D.No._________________________ Dated: _________________
IN THE MATTER OF:
MOHAN MADAAN DECEASED THROUGH LR’s,
SH. JATIN MADAAN,
S/o LATE SH. MOHAN MADAAN,
R/o D-13/7, SECTOR-7,
ROHINI, DELHI-110085. … COMPLAINANT
Versus
1. THE ORIENTAL INSURANCE CO. LTD.,
REGD. OFFICE AT: ORIENTAL HOUSE,
A-25/27, ASAF ALI ROAD,
NEW DELHI-110002.
ALSO AT: SH. S GOPA KUMAR,
GENERAL MANAGER,
ORIENTAL HOUSE, A-25/27, ASAF ALI ROAD,
NEW DELHI-110002.
2. MEDI ASSIST TPA PVT. LTD.
B-20, SECTOR-2, NEAR SECTOR-15,
METRO STATION, OPP. HCL,NOIDA-201301.
3. JAIPUR GOLDEN HOSPITAL,
SECTOR-3, ROHINI,
NEW DELHI-110085. … OPPOSITE PARTY(IES)
CORAM:SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 31.03.2016
Date of decision: 14.11.2019
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against OPs under Section 12 of the Consumer Protection Act, 1986 thereby alleging
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that the complainant purchased a Happy Family Floater Mediclaim policy bearing no. 272900/48/2015/20543 from OP-1 and the complainant and his family members which include his wife Mrs. Sudesh Madaan and his son namely JatinMadaan are covered under the said policy for the period from 01.03.2015 to 29.02.2016 and the complainant has purchased policy for safety of his family members and has paid premium of Rs.6,830/- through cheque to OP-1 towards the said policy and the cheque was enchased. In the 1st week of August, the complainant’s son got ill with no sensation on his face and was advised by Dr. Anil Handa to go through Brain’s MRI SCAN etc. to know the cause, then the son of the complainant went to NASA MRI Imaging Centre situated in 38, Pocket-C-9, Sector-8, Rohini, Delhi and the bill of Rs.10,500/- was paid for Brain MRI test etc. On the basis of MRI Scan report he was further referred to specialist doctor to treat the same on urgent basis, hence accordingly on 04.08.2015, the complainant went to Jaipur Golden Hospital, Delhi for treatment and was advised to get admitted immediately for the treatment and as OP-1 has various list of hospitals where in cashless facility is available including Jaipur Golden Hospital, Delhi and at the same time OP-3 is linked with insurance company to avail such benefits took the policy details from the complainant and applied for approval from OP-1 & OP-2 and the complainant was shocked to know that the same was denied by OP-1 and OP-2 which made the complainant to bear the
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whole hospitalization expenses of Rs.83,800/- out of his pocket, despite having an insurance cover for Rs.5,00,000/-, which clearly violates the terms & conditions of the policy. On 19.08.2015, the complainant has filed the claim and submitted all original documents to OP-2 and he tried to know the status of claim and OP-2 started making excuses that it is under process. On 29.09.2015, the complainant got a mail in which OP-2 has raised the queries on the same claim asking “provide certificate from treating doctor mentioning medical indications and justification for 6 days hospitalization and why patient could not be treated on OPD basis and provide original doctor prescription advising admission and provide student ID proof and address proof of the claimant. On 26.12.2015, the complainant was again shocked to see the message from OP-2 on denial of the said claim and then the complainant checked the denial reason as “Denial Clause 3.1: Denial reason 3.1 insured person: means person (s) named on the schedule of the policy which includes family comprising of the proposer, his/her legally wedded spouse, dependent unemployed children (upto two only) between 3 (three months) to the age of 26 years, the dependent children may also include unmarried daughters including divorce and widowed daughters provided the maximum number of dependent children under the entire policy does not exceed two and the person should not be more than 80 years of age and the entry age for the policy is before 79 years of age. ii) denial
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clause 4.10: denial clause reason: expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period or expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission, referral fee to family doctors, out station consultants/ surgeons fees, doctor’s home visit charges/attendant/nursing charges during the pre and post hospitalization period etc. and iii) denial clause: remarks denial reason: on perusal of claim documents attached, it is noted that the patient was admitted as a case of GB Syndrome, B/L facial palsy, LL Myopathy and underwent conservative management for the same and as per investigation done in this case, it is found that the patient is himself a lawyer and is practicing at Rohini, Delhi and as per the policy terms & conditions, only dependent and unemployed children are covered. Also during hospitalization mainly investigations were done and patient was given medications in oral tablet form only. Hence, the present claim is falling under exclusion and the claim is being denied and we also reserve the right to repudiate the claim on grounds available to us subsequently.” The complainant further alleged that OP-1 has failed to release the claim despite repeated requests of the complainant and approach of OP-1 amounts to deficiency in services and unfair trade practice.
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2. On these allegations the complainant has filed the present complaint praying for direction to OPs to give claim of Rs.84,264/- alongwith interest @ 18% p.a. as the complainant has paid the premium to OP-1 as well as compensation of Rs.1,00,000/- for causing damages for mental pain, agony, harassment and has also sought Rs.50,000/- towards cost of litigation.
3. Only OP-3 has been contesting the complaint and has filed reply. In its reply, OP-3 submitted that the complaint is not maintainable and is liable to be dismissed and there is no deficiency in service on the part of OP-3.
4. Whereas despite service of notice on 03.05.2016 as per track reports, OP-1 & OP-2 failed to appear and contest the case and have been proceeded ex-parte vide order dated 18.10.2016.
5. The complainant filed replication and denied the contentions of OP-3.
6. During pendency of the proceedings of the case, the complainant Sh. Mohan Madaan died on 27.09.2016 and an application for substitution of LR has been filed alongwith copy of death certificate of Sh. Mohan Madaan and vide order dated 09.01.2018 the application was allowed and Sh. JatinMadaan being the LR has been substituted in place of deceased complainant as Smt. Sudesh Madaan widow of deceased Sh. Mohan Madaan has given NOC in favour of her son namely Sh. JatinMadaan and amended memo of parties has been filed.
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7. In order to prove his case, the complainant Sh. JatinMadaanfiled his affidavit in evidence and also filed written arguments. The complainant also placed on record copy of Mediclaim Policy schedule, copy of patient bill IP15-16/6411 dated 10.08.2015 of Rs.72,746/- issued by Jaipur Golden Hospital, Delhi, copy of receipt no.1173 dated 03.08.2015 of Rs.10,500/- issued by NASA MR Imaging Centre, Delhi, copy of medical prescription dated 03.08.2015 issued by Dr. Anil Handa, Ear, Nose & Throat Clinic, Rohini, Delhi, copy of discharge summary dated 13.08.2015 issued by Jaipur Golden Hospital showing that the patient was admitted in the hospital in a state of facial diphgis and was in danger of aspiration and nurtilatory, copy of repudiation of claim, copy of legal notice dated nil sent by the complainant through his Counsel to OPs by Speed Post/Courier alongwith postal receipts and copy of SPA.
8. On the other hand, Dr. Nishith Mittal, Medical Superintendent of OP-3 filed his affidavit in evidence. OP-3 has also filed written arguments.
9. This forum has considered the case of the complainant as well as OP in the light of evidence and documents placed on record by the complainant. The documents and evidence of the parties shows that the complainant Sh. JatinMadaanwas admitted in Jaipur Golden Hospital, Delhi on 04.08.2015 and was discharged on 10.08.2015
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from the hospital for treatment of his illness which was danger to his life.
10. Moreover, despite receiving notices of this case from the Forum, OP-1 & OP-2 have kept mum and have not bothered to answer the case of the complainant. The complainant has also placed on record copy of Mediclaim insurance policy and OP-1 & OP-2 have failed to contest the case and prove the defence if any. Accordingly, we are of opinion that there is no merit in the defence of OP and OP ought not to have repudiated the claim of the complainant. Since OP-1 has not released the said amount to the complainant, so, while refusing the claim, OP-1 has indulged in unfair trade practice and deficiency in service. Thus, OP-1 is held guilty accordingly.
11. Thus, holding guilty for the same, we direct the OP-1 as under:
i) To pay to the complainant an amount of Rs.83,246/- being the amount for hospitalization and medical treatment expenses paid by the complainant.
ii) To pay to the complainant an amount of Rs.25,000/- as compensation for harassment and mental agony suffered.
iii) To pay to the complainant an amount of Rs.8,000/- towards cost of litigation.
12. The above amount shall be paid by OP-1 to the complainant within 30 days from the date of receiving copy of this order failing which OP-1 shall be liable to pay interest on the entire awarded amount @ 10%per annum from the date of receiving copy of this order till the
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date of payment. If OP-1 fails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.
13. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 14th day of November, 2019.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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