District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.607/2019.

 Date of Institution: 10.12.2019.

Date of Order: 15.07.2022.

Nanak Chand S/o Shri Tula Ram Singh, R/o House No.411, Sector-7B, Faridabad – 121006 (Haryana).

                                                                   …….Complainant……..

                                                Versus

1.                Oriental Insurance Company Ltd., (Mediclaim), Regd. & head office: Oriental House, A-25-27, Asaf Ali road, New Delhi.

2.                Oriental Insurance Company Ltd., Administrative Officer, SCO-D/5, Ist floor, (above Oriental Bank of Commerce, Sector 1 IMT, Manesar, Gurgaon – 122001 (Haryana).

3.                Medi Assist India, TPA Pvt. Ltd. (Medi Assist Insurance) 8B, Second floor, Tej Building, Bahadur Shah Zafar Marg, ITO, Near Times of India Building, New Delhi – 110 002.

4.                The Oriental Insurance Co. Ltd., 5-B/4 B.P.2^nd floor, Neelam Railway Road, NIT, Faridabad – Haryana – 121001.

                                                                    …Opposite parties……

Complaint under section-12 of Consumer Protection Act, 1986

Now  amended  Section 34 of Consumer protection Act 2019.

BEFORE:            Amit Arora……………..President

Mukesh Sharma…………Member.

PRESENT:                    Sh.  R.C.Khanna, counsel for the complainant.

                             Sh.  Anuj Gupta, counsel for opposite parties. Nos.1 to 4.

ORDER:  

                             The facts in brief of the complaint are that  the complainant was a registered customer of the opposite parties vide policy No. 215301/48/2018/19 for Rs.3,00,000/- and the complainant had got insured for his health from the above said opposite parties i.e the Insurance Company and TPA for the last so many years and the previous mediclaim policy to the present policy insured code No. 215301/48/2017/12 and applicant was allotted policy code No. 54971017.  The complainant was suffering from right hand fore arm without contrast intra muscular lesion in extensor Capri radialis – 5.6 x 4 x 12.7 cms (swelling on the fore arm of the complainant).  The complainant had spent Rs.2,31,999/- on the radiation treatment (including Rs.1,0 lac paid by opposite party No.3 to the hospital) and Rs.29,087/- on the medication as well as before and after hospitalization and the claimant cash less claim No. 14415303-1829249 and Med Claim Ma-id. No. 5009430593, thus the complainant deserves the payment of Rs.1,61,086/- being the hospitalization charges amount to Rs.1,31,999/- plus before and after hospitalization and effused to make payment of the amount claimed by the complainant which clearly proves that the opposite parties were not allowed to make payment of the legitimate due payment to the complainant amounting to Rs.1,61,086/-.  The complainant had filed earlier the complaint case No. 241/285-2018 which was decided on 10.07.2019 whereby the Hon’ble  President vide its order dated 10.07.2019 had directed the complainant to lodge claim within 2 weeks from the date of order i.e.10.07.2019 with the opposite party and the opposite parties was directed to settle the claim within 15 days from the date of receipt of claim from the complainant.  The claim was lodged on 29.07.2019 with the opposite party No.3 the main opposite party to make good the claim of the complainant.    The matter was already over delayed and when the complainant pursued the claim with opposite party No.3 the complainant was informed that the bills had been sent to the opposite parties Nos.1,2 & 4 and the matter was pending with them but neither the opposite party NO.3 nor the parties Nos.1,2 &4 make goods the claim of the complainant.  During the radiation treatment the Max Hospital gave a final bill of Rs.2,31,999/- whereas the opposite party No.3 paid Rs.1,00,000/- directly to the hospital and the balance was advised by the opposite party No.3 should refund Rs.1,31,999/- for which no claim had been paid till today inspite of the fact that the complainant had been having his balance payment of Rs.1,31,999/-  out of the hospitalization expenses from all the opposite parties liable to pay.   Opposite party No.3 after receiving the mail from the complainant against the opposite party No.3 vide mail dated 09.07.2017 and followed by 10.07.2017 informed the daughter of the complainant as under:

“full and final app. Already given for MGMT, of fibromatosis Si Restricted to Rs.1 lac patient having H/o of related ailment since 2015, “hence Claim Denied and as such the addressees in collusion with one another had not paid the balance amount of Rs.1,31,999/- plus medication and test in the hospital before and after the treatment amounting to Rs.29,087/- as such Rs.29,087/- had not been paid by the addressee No.3 in collusion with other addressees.  The addressees had taken the stand that their client had earlier detected the same disease in the year 2015 and if the disease was detected in 2015 then why the addressees increased the insured amount from Rs.2,00,000/- to Rs.3,00,000/-. Vide bill dated 23.06.2017 the opposite party No.3 sent a mail to Max Hospital, wherein it had been categorically written as under:-

i)                 Denial of cashless facility is in no way construed to be denial of treatment.  The patient may obtain the treatment as per his/her treating doctors advice and submit the full claim papers to them for possible reimbursement subject to admissibility of the claim as per terms and conditions of the policy”.  The aforesaid act of opposite party amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite parties to:

a)                 reimburse the amount of Rs.1,82,086/- to the complainant for all their acts of omission and commission against the complainant.

b)                 any other relief which the Hon’ble Forum  may deem fit and proper may kindly also be granted in favour of the complainant.

2.                Opposite parties  put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that  the complainant was admitted in Artemis Health Institute, Gurgaon on 09/06/2015 with chief complaint of swelling right hand for 2-3 months which was diagnosed as Benign Tumor of ECRL (Extension Capri Radials Lingus Muscle) and had undergone excision of tumor mass right forearm under General Anesthesia.  Thereafter had taken the enhancement of the sum insured every year in next two subsequent renewals of the insurance policy.  The complainant was admitted at Max Super Specialty Hospital Delhi on 4^th May 2017 for surgical management of right fore arm fibromatosis, this time he had taken treatment of the complication which was the outcome of surgery performed at Artemis Hospital Gurgaon on 09.06.2015. It was submitted that during the validity of insurance policy No. 215301/48/2016/6, complainant was admitted in Artemis Health Institute Gurgaon on 09.06.2015 with chief complaint of swelling right had for 2-3 months which was diagnosed as Benign Tumor of ECRL and had undergone excision of tumor mass right forearm under General Anesthesia.  Consequent upon discharge form hospital, complainant submitted claim for reimbursement of expenses incurred on treatment amounting Rs.1,07,965/-, which was received by the answering opposite party under reference No. 11321628.  On receipt of claim documents  it was processed by the team of doctors of answering opposite party as per policy terms and conditions for an amount of Rs.1,00,000/-, as per sum insured available under the policy.  The complainant during the validity of insurance policy No. 215301/48/2018/19 was again admitted in Max Super Specialty Hospital Delhi on 4^th May 2017 for surgical management of right fore arm fibroatosis.  Cashless request was eceived form hospital amounting to Rs.2,32,000/- under reference NO. 14415303, same was processed by the panel team of doctors of the answering opposite party No.3 as per policy terms and conditions and accorded approval of Rs.1,00,000/- keeping in view the sum insured available under the previous policy as the hospitalization of the complainant in Max Super Specialty  Hospital Delhi on 4^th May 2017 was for the treatment of complication which was the outcome of surgery performed at Artemis Hospital Gurgaon on 09.06.2015. The aforesaid decision to consider Rs.1,00,000/- the sum insured taken by the complainant in the insurance policy No.215301/48/2016/6 was taken by the answering opposite party in view of the terms and conditions and exclusion clause 4.1 of the policy in question.  The complainant submitted his claim form for reimbursement of balance bill of hospital as well as certain bills, since the hospitalization of the complainant in Max Super Speciality Hospital Delhi on 4^th May 2017 was for the treatment of complication which was the outcome of surgery performed at Artemis Hospital Gurgaon on 09.06.2015.  In view of the clause 4.1 of the insurance policy claim was processed on the basis of sum insured available during the previous 36 months as the ailment for which treatment under the policy year 2018 was taken existed in the year 2016 also i.e Rs.1,00,000/- the sum insured taken by the complainant in the insurance policy No. 215301/48/2016/6 was taken as sum insured while considering this claim.  The answering opposite party N.2 vide letter dated 14.10.2019 informed the complainant about the same and of disallowing the balance amount which was not found payable under the terms and conditions of the insurance policy was also explained herein. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                The parties led evidence in support of their respective versions.

4.                 We have heard learned counsel for the parties and have gone through the record on the file.

5.                In this case the complaint was filed by the complainant against opposite parties – Oriental Insurance Co. Ltd. with the prayer to : a)            reimburse the amount of Rs.1,82,086/- to the complainant for all their acts of omission and commission against the complainant. b)    any other relief which the Hon’ble Forum  may deem fit and proper may kindly also be granted in favour of the complainant.

                   To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Nanak Chand, Ex.C-1 – insurance  policy, Ex.C-2 – card,, Ex.C-3 – bill of supply bill (summary), Ex.C-4 – Bill of supply bill (Detailed), Ex.C-5 – Interim Pre Admission Bill (Summary), Ex.C-6 – letter dated 28.07.2019 regarding claim for reimbursement,, Ex.C-7 – Reimbursement claim form,, Ex.C-8 – order dated 10.07.2019 passed by DCDRF, Faridabad, Ex.C-9 – Adhaar card.

                   On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties, Ex.RW1/A – affidavit of Shri Ramesh Kumar,Sr. Div. Manager of Oriental Insurance Co. Ltd., NIT, Faridabad, Ex.R-1 – insurance policy, Ex.R-2 – OBC- Oriental royal Mediclaim Policy Schedule , Ex.R-3 – terms and conditions, Ex.R-4 – denial letter dated 14.10.2019.

6.                          In this case the complainant purchased OIC Oriental Bank Mediclaim Policy in April 2013 and the same was renewed further as detailed below:

It is evident from Bill of Supply Bill (summary) vide Ex.C-3 the complainant admitted in the hospital on 04.05.2017 and discharged from the hospital on 06.07.2017.  On the other hand, the counsel for the opposite parties argued that the hospitalization of the complainant in Max Super Specialty Hospital Delhi on 4^th May 2017 was for the treatment of complication which was the outcome of surgery performed at Artemis Hospital Gurgaon on 09.06.2015.  In view of the clause 4.1 of the Insurance policy claim was processed on the basis of sum insured available during the previous 36 months as the ailment for which treatment under the policy year 2018 was taken existed in the year 2016 also i.e. Rs.1,00,000/- the sum insured taken by the complainant in the insurance policy No.215301/48/2016/6 was taken as sum insured while considering this claim.

7.                If the above diseases are pre-existing at the time of inception of the policy, clause 4.1 for pre-existing disease shall  be applicable to such disease. If the continuity of the renewal is not maintained then subsequent cover will be treated as fresh policy and clauses 4.1. and 4.2 shall apply afresh (whether or bot a proposal is submitted afresh) unless agreed by the company and suitable endorsement passed on the policy, by the duly authorized official of the company.  Similarly, if the sum insured is enhanced subsequent to the inception of the first policy, clauses 4.1 and 4.2 shall apply afresh on the enhanced portion of the sum insured.

8.                After going through the evidence led by the parties, the Commission is of the opinion that  36 months from the date of the insurance policy i.e. 29.04.2013 and date of discharge in the hospital  is on 06.07.2017.  Hence, the complaint is allowed. Opposite parties are directed to pay the  lumsump amount of 50% of  the amount  to the complainant .

Details:

As per Ex.C-3,  the total amount of the bill :         Rs.2,32,000/-

Opposite parties already paid                       :         Rs.1,00,000/-

Balance                                                       :         Rs.1,32,000/-

The insured amount of the policy  bearing No. 215301/48/2017/12 amounting to Rs.2,00,000/-.  Opposite parties have already paid to the complainant  an amount o of  Rs.1,00,000/-.

9.                Opposite parties are directed to pay 50% of the remaining amount to the complainant.  There are no orders as to costs. Compliance of this order be made within 30 days from the date of receipt of the copy of order. Copy of this order be given to the parties  concerned free of costs and file be consigned to record room.

Announced on: 15.07.2022                                    (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.