Delhi

North East

RBT/CC/185/2022

ADITYA NASHIER - Complainant(s)

Versus

ORIENTAL INSURANCE COMPANY LTD. - Opp.Party(s)

05 Jul 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

RBT/Complaint Case No.185/22

 

 

In the matter of:

 

	Shri. AdityaNashier s/o Shri J.R Nashier, R/o: 44, SuvidhaKunj, PitamPura Delhi 110034	Complainant
	Versus
1.             2.           3.       4.	The Oriental Insurance Company Ltd., Through its Chair-cum Managing Director, Oriental House, A 25/27, Asaf Ali Road, New Delhi 110002   Branch Manager Oriental Insurance Company Ltd., Banking Ombudsman- Rohini, 215, Rama Market, PitamPura, New Delhi 110034   Max Super Speciality Hospital, FC-50, C & D Block, Shalimar Bagh, New Delhi 110088   Good Health Insurance TPA Ltd., 49, Nagarjuna Hills, Panjagutta, Hyderabad 500082	Opposite Parties

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:     DATE OF ORDER  :

11.09.2018 21.04.2023 05.07.2023

 

 

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986.

1. The case of the Complainant as revealed from the record is that the Complainant had purchased a Mediclaim Insurance Policy through online portal from the Opposite Party No. 1 & 2 for himself along with his family members. The policy was valid from 14.06.2017 to 13.06.2018. The Complainant had paid an annual premium of Rs. 20,202/-. Opposite Party No. 1 and 2 forcibly transferred its own responsibilities/liabilities by allotting a Third Party Administrator (TPA) i.e. Opposite Party No. 4 to the Complainant without obtaining his consent for the same. Complainant admitted his sonMr.AntrikshNashier to hospital ofOpposite Party No. 3 on 19.05.2018 at the advice of the treating doctor as the patient was diagnosed with “Acute Pancreatitis, Illeal Ulcer, InfectiveHyperuricemia”. It is further stated that once the patient was admitted to the hospital, Opposite Party No. 3 duly intimated the Opposite Party No. 4 about the admission and estimated the expenditure to be incurred during his stay in the hospital. All other necessary documentswere also submitted to the Opposite Party No. 4. It is further stated that Opposite Party No. 3 failed to remove the queries raised by the Opposite Party No. 4 till the date of discharge i.e. 22.05.2018. After that Opposite Party No. 3 raised a full and final bill for the complete hospitalization treatment taken from 19.05.2018 to 22.05.2018 of Rs. 58,828/-. On receipt of the final bill for approval on 22.05.2018, the Opposite Party No. 4 raised the query again and again just to kill the time so that the Complainant could pay all the dues at his own. After that at 08.17 p.m, Opposite Party No. 4 rejected the cashless approval of the Complainant after to do so till the time of discharge on 22.05.2018 which was against the conditions of the policy. Hence, the Opposite Party No. 4 failed to discharge his liabilities even on a valid insurance policy. After that Complainant paid the full amount to the hospital and got discharges his son at 09.00.p.m. After that at 10.03 p.m Opposite Party No. 4 sent an email for conforming the cashless approval of Rs. 20,914/-. The Complainant also filed a pre-hospitalization bill amounting to Rs. 46,776/- to the Opposite Party No. 4 but Opposite Party No. 4 made the short payment of Rs. 12,575/-. On 23.07.2018 a post hospitalization bill amounting toRs. 15,554/- along with the earlier short payment was submitted to Opposite Party No. 4 through the Opposite Party No. 2 but no payments against this bill has been made by Opposite Party No. 1 and 2 and Opposite Party No. 4. Complainant has prayed to direct the Opposite Party No. 1 and 2 and Opposite Party No. 4to pay an amount of Rs. 12,575/- i.e. illegally deducted from the total bill of Rs. 19,061, Rs. 52,637 i.e. illegally deducted from the totalbills of Rs. 58,828/-, Rs. 15,554/- claimed against post-hospitalization bill, Rs. 5,00,000/- against the compensation , interest of 18 % p.a to the applicant over all due payment and Rs. 25,000/- on account of litigation expense. The Complainant in support of his case filed his affidavit wherein he has supported the assertions made in the complaint.
2. Opposite Party No.1 and 2 contested the case and filed its written statement.It is sated that the Complainant and his family members were covered by the medical insurance policy which was affected form 16.06.2017 to 13.06.2018 Theinsurance was granted subject to Standard MediclaimInsurance policy (individual). It is stated that Mr.AntrikshNashier, son of the Complainant was covered for a sum of Rs. 1,50,000/-.It is stated that the said policy was to be governed with the terms and conditions. It is stated that as per the conditions the expenses incurred for the pre-existing ailment are not payable. As perthe policy terms the insured patient was entitled to 1 % of the sum insured towards the room rent i.e. Rs. 1,500/- per day. The claim has been paid after considering the relevant terms and condition of the policy. The allegationsof the Complainant had been denied and is prayed to dismissed the complaint.
3. Opposite Party No. 3 contested the case and filed its written statement.It is stated that there is no cause of action against the Opposite Party No. 3 i.e. Max Super Speciality Hospital. It is stated that Opposite Party No. 3 is not liable topay any compensation to the Complainant. To support its case Opposite Party No. 3 has filed affidavit of Shri. Indrajeet Kumar, working as General Manager, Hospital Operations of Opposite Party No. 3 wherein, he has supported the case of the Opposite Party No. 3 as mentioned in the written statement.
4. Opposite Party No. 4 was proceeded against ex-parte vide order dated 20.12.2018.
5. The Complainant filed separate rejoinder to the written statement of Opposite Party No. 1 and 2 and Opposite Party No. 4wherein the Complainant has denied the pleas raised by the Opposite Parties and has reiterated the assertions made in the complaint.
6. We have heard the Complainant and Ld. Counsels for the Opposite Party No. 1 and 2 and Opposite Party No. 3. We have also perused the file and written arguments filed by the Complainant and Opposite Party No. 1 and 2 and Opposite Party No. 3.The case of the Complainant is that he had purchased a  mdiclaim insurance policy from Opposite Party No. 1 and paid a premium of Rs. 20,202/-. The said policy was valid from 14.06.2017 to 13.06.2018. The Complainant, his wife Mrs. NeeraNashier, his son Mr. AntrikshNashier and daughter Ms. ShrishtiNashier were covered under the said policy. The case of the Complainant is that during the subsistence of the said policy his sonMr. AntrikshNashier was admitted in the hospital of Opposite Party No. 3 on 19.05.2018 and his son was discharge from the hospital on 22.05.2018.The Complainant himself paid the charges amounting to Rs. 58,829/- to the hospital and the cashless facility was not provided by Opposite Parties. After the discharge of his son from the hospital an email was sent by Opposite Party No. 4 at 10.03 p.m on 22.05.2018 stating therein that “Authorization letter to hospital for treatment and as a guarantee of payment of Rs. 20,914/-”. Thereafter the Complainant filed pre-hospitalization bill amounting toRs. 19,061/- along with short fall of Rs. 27,715/- “Total Rs. 46,776/-” on 05.06.2018. After reminders a payment of Rs. 12,575/- was released on 01.08.2018. The Opposite Party No. 1 and 2 and Opposite Party No. 4 have failed to make the balance payment of Rs. 34,201/-. Thereafter on 23.07.2018 post hospitalization bill amounting to Rs. 15,554/- along with earlier short payment was submitted to Opposite Party No. 4 but no payment was made to him. The case of the Opposite Party No. 1 and 2 is that there is no deficiency of service on their part. It is stated that the mediclaim insurance is governed by terms and conditions of the policy. However, it is admitted that the Complainant was having a valid insurancepolicy for the period during which his son was admitted in the hospital. It is the case of Opposite Party No. 1 and 2 that as per the conditions of the policy expenses inured for the pre-existing ailment are not payable. Only the expense which are reasonable and essential for the treatment are payable. As per the terms of the policy the patient was entitled to 1 % of the sum insuredtowards the room rent i.e. Rs. 1,500/- per day. The Complainant has opted for a room of higher categoryand on this account deductions were made. In the reply on merits it is submitted that there is no need to submit parawise reply of the complaint.
7. It is an admitted fact that Mr. AntrikshNashier was covered under the mediclaim insurance policy. It is also an admitted that cashless facility was denied while he was under treatment in hospital of Opposite Party No. 3. The Complainant as discussed above has submitted in his complaint that pre hospitalization medical expenses and post hospitalization medical expenses were not paid to him. The Opposite Party No. 1 and 2 did not mention about the reason or anything else as to why the said expenses was denied and not paid. As per the affidavit of the Complainant he paid Rs. 19,061/- along with short fall of Rs. 27,715/- totaling Rs. 46,776/- as pre hospitalization bill and Rs. 15,554/- as post hospitalization. The charges for the hospitalization period were also not paid fully and the same was deducted on the ground that Complainant had opted for the higher category room. Admittedlycashless facility was denied. In the totality of the facts and circumstances of the case,Opposite Party No. 1 and 2 are directed to pay jointly and severally an amount of Rs. 19,061/- along with short fall of Rs. 27,715/- totaling Rs. 46,776/- after deduction the amount i.e. Rs. 12,575/- which is already paid tothe Complainant along with interest @ 6 % p.a. from the date of filing the complaint till recovery. The Opposite Party No. 1 and 2 are also directed to pay jointly and severally the hospitalization expenses after deduction the amount already paid to the Complainant and also deducting the amount paid in excess by the Complainant for the room rent for which he was entitled along with interest @ 6 % p.a. from the date of filing the complaint till recovery. Opposite Party No. 1 and 2 shall also pay jointly and severally an amount of Rs. 15,554/- to the Complainant for post-hospitalization expenses after deduction the amount if any paid to the Complainant in this regard along with interest @ 6 % p.a. from the date of filing the complaint till recovery. Opposite Party No. 1 and 2 shall also pay jointly and severally an amount of Rs. 25,000/- on account of mental harassment and litigation expenses along with interest @ 6 % p.a. from the date of this order till recovery.
8. Order announced on 05.07.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)	(Adarsh Nain)	(Surinder Kumar Sharma)
(Member)	(Member)	(President)