Haryana

Yamunanagar

CC/301/2013

Anil Kumar S/o Ramesh Kumar - Complainant(s)

Versus

Oriental Insurance Co.Ltd. - Opp.Party(s)

D.S.Khurana

29 Aug 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR.

 

                                                                          

Complaint No.301 of 30.04.2013.

Date of institution: 30.04.2013/08.04.2013

Date of decision: 29.08.2017.

 

Anil Kumar son of Shri Ramesh Kumar, aged about 40 years resident of House No.70, Sector 17 HUDA, Jagadhri, Tehsil Jagadhir, District Yamuna Nagar.

                                                                                                            …Complainant.

                                    Versus

1. Oriental Insurance Co. Ltd. through its Branch Manager, Old Court Road, Jagadhri, District Yamuna Nagar.

 

2. Vipul Medi Corp. TPA Pvt. Ltd, 515 Udyog Vihar, Phase V, Gurgaon (Haryana).

 

 

         ….Respondents.

     

BEFORE        SH. SATPAL, PRESIDENT

                        SH. S.C.SHARMA, MEMBER.

                        SMT. VEENA RANI SHEOKAND, MEMBER.   

 

 

Present:           Sh. DS Khurana, Advocate, for complainant.   

                        Shri Parmod Gupta, Advocate for OP No.1

                        OP No.2 already ex parte.

 

 

ORDER (SATPAL, PRESIDENT)

 

 

1.                     The complainant Anil Kumar has filed this complaint under section 12 of the Consumer Protection Act 1986 as amended up to date (hereinafter respondent will be referred as OPs). 

2.                     Brief facts of the complaint, as alleged by the complainant, are that complainant was insured with the OP No.1 for the last 11 years under the medi claim policy and last time policy was renewed on 15.06.2012 and valid upto 14.06.2013 on payment of premium which was duly accepted by the OP No.1 and at the time of taking of the medi claim policy, OP no.1 had assured that the complainant shall  be entitled to re imbursement to the tune of Rs.5 lac regarding any sort of medical assistance and compensation for which the complainant will have to take the treatment. It is pertinent to mention here that the complainant had taken a Joint Policy along with his wife Smt. Kiran Bansal wherein Shri Kiran Bansal was also insured to an additional sum of Rs.5 lacs.

3.                     The complainant  fell ill on 13.08.2012 and thereafter he was taken to Medanta Institute at Gurgaon, the medi city Global Health Pvt. Ltd. where he remained admitted and under treatment till 18.08.2012.  It will not be out of place to mention here that the complainant was discharged on 17.08.2012 and for that purpose the final bill of the complainant, forwarded by the Hospital authorities to the OP no.1 and 2 for approval and despite repeated requests and reminders and repeated calls, the approval was not given in time on 17.08.2012 and as a result of the same, the complainant was forced to stay back in the hospital on the said day. The approval was supposed to be given within 2-3 hours, but the complainant kept on waiting till 9.30 pm for the approval but as the bills were not approved and therefore the discharge from the hospital was cancelled on that day. The complainant was forced to stay in the hospital in the night and none of the doctors came to attend the complainant as his treatment had already been completed and due to non providing of approval in time, the complainant was forced to face the harassment and agony for over staying in the hospital. Number of calls were made from the mobile No.9354524195, 9355224195, 9466878578 as well as from land line numbers 01732-320955, 320455 and 320655, but no response was received from the OPs. The family of the complainant remained in tension due to non discharge of the complainant from the hospital and they also made numerous and repeated calls to the OPs. The complainant was required to attend the court on 18.08.2012 as one of his case was fixed in the court and the counsel of the complainant  also had to face problem due to the same. The hospital authorities has drawn out bill of Rs.1,19,286/- whereas only a sum of Rs.81048/-  was reimbursed and the complainant was forced to deposit a sum of Rs.38238/- from his own pocket. Further sum of Rs.11606/- were also incurred in addition to the aforesaid charges. Further a sum of Rs.7000/- were spent on the medicines due to over stay in the hospital. Hence, this complaint.

4.                     Upon notice OP No.1appeared and filed its written statement taking some preliminary objections such as complainant has not come to the Forum with clean hands and has concealed the true and material facts from this Hon’ble court and has filed the false and frivolous complaint on misrepresentation of facts and as such the complaint is not maintainable. The complainant has very cleverly concealed the fact that he has already taken a claim on the policy mentioned in this petition and total limit of the policy exceeds in this claim and the complainant has not disclosed the fact that he has got enhanced the limit of Insurance policy from Rs.3 lac intentionally and deliberately and has not disclosed the fact while getting the policy amount enhanced that he is ill and having multiple diseases and he was bound to disclose this fact and has intentionally, deliberately and knowingly to put a wrongful gain to himself, got enhanced the policy amount from Rs.3 lac to Rs. 5 lac and as such the complainant is liable to be dismissed and on merit it is stated that complainant be directed to disclose the policy particulars etc. or produce all the policies for the last 11 years . However, it is made clear that the policy was cashless and it is very much clear and told to the hospital by the TPA that TPA is paying cashless amount to the hospital vide letter dated 18.08.2012 and was also told to the complainant that cashless facility does not mean denial of treatment to the patient. However, it means that the patient will have to pay charges at the hospital and send the bills and all the releated documents in original and lodged a reimbursement claim with the TPA but no reimbursement claim is ever lodged by the complainant with the TPA of excess amount, if paid any, to the hospital. It is also submitted that a cash less request was received by the TPA from the concerned hospital and as per the estimate submitted by hospital it was Rs.84500/- and as per terms and conditions of the policy a sum Rs.81048/- was released to the hospital as per terms and conditions of the policy and the said amount was upto the discharge from the hospital. It is incorrect to say that the complainant was forced to stay back in the hospital from 17.08.2012 to 18.08.2012 as alleged. It was the sweet will of the complainant to stay more in the hospital or at any place for which the answering OP is not liable because as per terms and conditions of the policy, the TPA is bound to release the amount from the date of admission to the date of discharge and the said amount stands released to the hospital well in time by the TPA as per terms and conditions of the policy and nothing is payable by the answering OP to the complainant because whatever was permissible as per terms and conditions of the policy, the same stands released and no illegal deduction are ever made by the TPA. It is a question of common sense that a person who is under going a treatment for a continuous 5/6 days as indoor patient and stands discharged on 17.08.2012 cannot attend the court on 18.08.2012 and this may be the reason that he should get an exemption from the Court by showing that he is in the hospital might have not shifted from the hospital though he was discharged on 17.08.2012 which shows the malafide intention of the complainant. Rests contents of the complaint were denied being wrong and incorrect and lastly prayed for dismissal of the complaint qua the OP No.1.

                        OP No.2 did not appear before this Forum and he was proceeded ex parte vide order dated 10.09.2014.

5.                     In support of his case, learned counsel for the complainant tendered into evidence the affidavit of complainant as Annexure CW/A and documents as Annexure C1 to C13 and closed the evidence on behalf of complainant.
6.                     On the other hand learned counsel for the OP No.1 tendered into evidence the affidavit of Shri Sanjeev Madan Branch Manager as Annexure RW/A and documents Annexure R1 to R5 and closed the evidence on behalf of OP No.1.

7.                     We have heard learned counsel for the parties and have also perused the record available on the file.

8.                     Learned counsel for the complainant argued that the complainant was having medical claim policy for reimbursment to the tune of Rs.500000/- and the said policy bearing No.0261701/48/2013/262 was valid from 16.6.2012 to 15.6.2013.  The complainant fell ill and had admitted in Medanta Institute at Gurgaon on 13.8.2012 and discharged on 18.8.2012. The treatment of the complainant was  completed on 17.8.2012 but due to non approval of the cashless bill, the complainant was forced to stay at hospital on 17.8.2012 and discharged on 18.8.2012.  The hosptial raised a bill of Rs.119286/-  and the OP company only paid Rs.81048/-.  The complainant was forced to deposit Rs.38,238/- from his own pocket which is illegal.  Besides this the complainant spent Rs.11606/- as well as Rs.7000/- as medical charges and prayed for acceptance of complaint.

9.                     On the other hand learned counsel for Op No.1 argued that as per terms and conditions of the policy at point no.4.1, when the cover incept for the first time are excluded up to four years and then the complainant is only entitled for the sum assured of Rs.400000/-.  The amount was reimbursed to the complainant vide terms and condition no.4.16, term no.1.2 (a) of the policy.  Sum claimed was not payable so the same was rightly not reimbursed as the parties are bound with terms and conditions of the policy and prayed for dismissal of complaint.

10.                   After hearing the learned counsel for the parties and after going through the records, it is admitted fact that the complainant was admitted in hospital on 13.8.2012 and discharged on 18.8.2012 and at that time the policy was in force.  It is also admitted that an amount of Rs.81048/- was paid by the Ops to the hospital. The case of the complainant is that the hospital authorities had drawn out the bill of Rs.1,19,2865/- but the Ops had reimbursed only Rs.81048/- to the hospital and the complainant was forced to deposit a sum of Rs.38238/- from his own pocket.  Besides this, the complainant spent Rs.7000/- on medicine after discharge as well as Rs.11606/- on other expenses.  The foremost question which arises before us for consideration is whether the complainant is entitled for reimbursement of remaining amount of Rs.49944/- or not? The version of the Op-Insurance company is that as per annexure R.4 the OP company has paid Rs.81048/- to the complainant rightly and remaining amount is disallowed as the sum assured was enhanced from Rs.400000/- to Rs.500000/- in 2011-2012 and maximum liability is limited to a sum insured of Rs.400000/- as per policy of 2010-2011 as disease falls under clause 4.3.  Rs.12,500/- was disallowed towards room rent expenses as room rent is payable @ of Rs.4000/- per day, while patient stayed in room of @ Rs.6500/- per day and Rs.3399/- disallowed due to non payable items i.e. HIV, anti HVC, HBSAG, Urobag, Thermometer, Tegaderm charges etc. as well as Rs.22339/- was disallowed due to the fact that the patient was discharged on 17.8.2012 while the company had given the approval on 17.8.2012 on receipt of final bill and discharge summary as such the company is not liable to make the remaining payment. 

11.                   We have gone through the terms and condition no.1.2(a) which is reproduced as under:-

“Room Boarding and Nursing Expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured or Rs.5000/- per day whichever is less”.

As per this terms and conditions of the policy, the complainant is entitled to only 1% of the sum insured or Rs.5000/- per day whichever is less.  The sum insured in policy in question is Rs.400000/- (as per 4.1 terms and condtion  of the policy) and the OP company has rightly reimbursed Rs.4000/- per day room rent to the complainant and the complainant is not entitled for an amount of Rs.12,500/- the difference of room rent paid by him to the hospital @Rs.6500/- per day.

                        The terms no.4.16 of the policy is reproduced as under:-

“External and or durable medical/non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc. Ambulatory devices i.e. walker, crutches, Belts, Collars, Caps, Splints, Slings, braces, Stockings etc. of any kind.  Diabetic foot wear, Glucometer/Thermometer and similar related items etc and also any medical equipment which is subsequently used at home etc”.

As per terms and conditions 4.16 of the policy the complainant is not entitled for reimbursement of external and or durable medical/non medical equipment.  The Op company disallowed Rs.3399/- due to non payable items i.e. HIV, anti HVC Urobag Thermometer etc.

As per the version of the complainant, he was discharged on 17.8.2012 but the OP company has not approved/paid the bill to the hospital whereas the OP company stated that approval was given to the hospital on 17.8.2012 on receipt of final bill and discharge summary and as such the company is not liable to make the payment after 17.8.2012.  So, the complainant is liable to pay the remaining amount of Rs.22,339/- to the hospital as he remained in the hospital after discharge.

                        In view of the facts, discussed above, we are of the considered that  the complainant is not entitled to reimbursement of any remaining amount of Rs.49,944/- and the OP company rightly paid/reimbursed the medical claim as per the terms and condition of the policy.  The parties are bound by the terms and conditions of the policy, hence, there is no merit in the complaint of the complainant and the same is hereby dismissed with no order as to costs.  The parties are directed to bear their own costs.  Copies of this order be sent to the parties free of costs.  File be consigned to the record-room after due compliance.

 

Announced in open court.                        (SATPAL)

Dated: 29.08.2017                                       PRESIDENT

                                                                D.C.D.R.F.YAMUNA NAGAR

                                                                AT JAGADHRI

 

 

(VEENA RANI SHEOKAND)                    (S.C.SHARMA)

MEMBER                                                      MEMBER