Haryana

Karnal

324/2013

Vivek Kapur s/o R.P. Kapur - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

Sh. Naveen Khettarpal

10 Nov 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                              Complaint No.324 of 2013

                                                             Date of instt.  22.07.2013

                                                               Date of decision:10.11.2016

 

Vivek Kapur son of R.P.Kapur resident of Arpana Trust, Madhuban District Karnal.

 

                                                                         ……..Complainant.

                                                Versus

1. Oriental Insurance Company Limited, near Bus Stand, through its Divisional Manager Karnal.

2. Vipul Med Corp TPA Private Ltd., 515, Udyog Vihar, Phase-V, Gurgaon, Haryana, through its Administrative Officer.

                                                                                …………Opposite Parties.

 

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:-      Shri Naveen Khaterpal Advocate for complainant.

                    Shri Rohit Gupta Advocate for opposite party no.1.

                    None for opposite party no.2

 

 ORDER:

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer protection Act, 1986, on the averments that he was having Cashless Family Mediclaim Policy for Rs.5 lacs of opposite party no.1.He had been holding the policy since 1995-1996 without any break and the same was renewed for the period of 29.3.2012 to 28.3.2013. Under the said policy, he was insured for Rs.2,00,000/- and remaining two members of his family were insured for Rs.3,00,000/-. He felt uneasiness in August 2012. On 18.10.2012 he was admitted in Medenta, the Medicity Hospital Gurgaon, wherein he was diagnosed for heart problem. Coronary Angiogaphy followed by Radio Fire Ablation+Electrophysio STDY was performed and he was discharged on 20.10.2012. An amount of Rs.82,270/- was charged by the Hospital. Opposite party no.2 was having a tie up with the opposite party no.1 for settling the Mediclaim on behalf of opposite party no.1. Opposite party no.2 refused to cashless facility without any reason despite intimation given by Medenta Hospital on 18.10.2012, therefore, he had to pay the bill of the hospital. He was advised rest and he was entitled to expenses for a further period of 60 days after discharge, as per the policy conditions and guide book issued by opposite party no.2. He submitted the claim form alongwith original documents to opposite party no.1 on 10.11.2012, which were forwarded to opposite party no.2 for settling the claim. The opposite party no.2 sought some information, vide letters dated 14.12.2012 and 15.2.2013, from him and the said informations were supplied, vide registered post on 7.1.2013 and 1.3.2013 respectively, but no response was given by the opposite parties despite oral and written reminder dated 27.3.2013. He came to know that opposite party no.2 had closed his file on the ground that intimation was not sent within 48 hours and the claim was not submitted within 7 days. Medenta Hospital sent intimation to 18.10.2012 to seek the cashless facility and as per guide book issued by opposite party no.2 he was entitled to expenses for 60 days after discharge and the same was rightly submitted on 10.11.2012. The complainant had claimed an amount of Rs.92500/-. The acts of the opposite parties repudiating his claim amounted to deficiency in service and unfair trade practice, which caused him mental pain, agony and harassment apart from financial loss.

2.                Notice of the complaint was given to opposite parties. Opposite party no.1 put into appearance and filed written statement disputing the claim of the complainant. Objections have been raised that this Forum has got no territorial jurisdiction to entertain and decide the present complaint; that the complainant has no locus standi and cause of action to file the complaint; that the complaint is not maintainable in the present form; that the complicated questions of law and facts are involved, which cannot be decided by this Forum in summary jurisdiction and that there was no deficiency in service or unfair trade practice on the part of the opposite party.

                   On merits, it has been submitted that the documents sought by opposite party no.2 from complainant, vide letters dated 22.11.2012 and 14.12.2012, were mandatory to process the claim, but the complainant failed to supply the said documents. Therefore, the claim of the complainant was rightly closed by opposite party no.2.

3.                In evidence of the complainant, his affidavit EX.C1 and documents Ex.C2 to C10 have been tendered.

4.                On the other hand, in evidence of the opposite party affidavit of R.S.Bahlan, Senior Divisional Manager Ex.OP1/A and documents Ex.O2 and Ex.O3 have been tendered.

5.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.                Admittedly, the complainant had obtained Cashless Family Mediclaim Policy of Rs.5 lacs from opposite party no.1 and the same was renewed for the period of 29.3.2012 to 28.3.2013. Under the said policy he was insured for Rs.2 lacs and other two members of his family were insured for Rs.3 lacs. He was admitted in Medenta Hospital Gurgaon on 18.10.2012, where he was diagnosed for heart problem. . Coronary Angiogaphy followed by Radio Fire Ablation+Electrophysio STDY was performed and he was discharged on 20.10.2012. Medenta Hospital charged an amount of Rs.82,270/- from him. After discharge, he purchased the medicines and total amount of Rs.92,500/- was spent by him on his treatment. He submitted claim to opposite party no.1 on 10.11.2012, which was forwarded to opposite party no.2.

7.                Learned counsel for opposite party no.1 laid emphasis on the contention that letters dated 22.11.2012 and 14.12.2012 were issued by opposite party no.2 to the complainant seeking information, which was necessary for processing the claim, but the complainant did not supply the required documents, therefore, his claim was rightly made as ‘No Claim’. It has further been argued that intimation regarding admission of the complainant must have been given within 48 hours of admission as per policy condition, but no such intimation was given. Thus, the complainant violated the policy condition and on that ground also his claim was rightly repudiated.

8.                The arguments advanced by learned counsel for the opposite party no.1 cannot be accepted being devoid of force. The copy of the letter Ex.C4 is sufficient to prove that Medenta Hospital sent intimation to opposite party no.2 regarding admission of the complainant and for claiming cashless benefit on 18.12.2012 itself i.e. the date of admission of the complainant. Even the final bill  and discharge summary of the complainant were sent to opposite party no.2 on 30.10.2012, as is evident from Ex.C5. Thus, it stands established that due intimation regarding admission of the complainant in the hospital and discharge from the said hospital was given to opposite party no.2, within time as per policy condition.

9.                The copy of the document Ex.C8 shows that the complainant had sent the intimation sought by opposite party no.2, vide letters dated 15.11.2012 and 7.1.2013 through registered post. The address of opposite party no.2 was rightly mentioned, therefore, it is deemed to have been duly delivered. Under such circumstances, it cannot be said that the complainant had not submitted the required information to opposite party no.2.

10.              Admittedly, the complainant had submitted the claim on 10.11.2012 within a period of less than 60 days from discharge from the hospital. As per policy condition regarding reimbursement of pre/post hospital, medical expenses incurred 30days before admission and 60 days after discharge from the hospital will be reimbursement. The copy of the relevant portion of the policy is Ex.10. Thus, the complainant could very well submit bills and treatment record after 60 days of discharge from the hospital. Consequently, it stands established that the complainant had lodged claim regarding expenses incurred on his treatment in the hospital and after discharge from the hospital well within the time as per terms and conditions of the policy.

11.              In view of the aforediscussed facts and circumstances, we have no hesitation in concluding that the opposite parties were not justified in repudiating the genuine claim of the complainant.

12.              As a sequel to the foregoing discussion, we accept the present complaint and direct the opposite parties to pay Rs.92,500/- to the complainant  with interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the opposite parties to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The party concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 10.11.2016

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member