CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.610/2010
SH. YOGESH MISHRA
C/O HOTEL SIDDARTH
JAYPEE HOTELS
3, RAJENDRA PLACE, NEW DELHI
…………. COMPLAINANT
VS.
- PARAMOUNT HEALTH SERVICES (TPA) PVT. LTD.,
D-39, OKHLA INDUSTRIAL AREA, PH-I,
NEAR D.D. MOTORS, NEW DELHI-110020
- RELIANCE GENRAL INSURANCE CO. LTD.,
2ND FLOOR, MERCANTILE HOUSE,
15 KASTURBA GANDHI MARG, NEW DELHI-110001
…………..RESPONDENTS
Date of Order: 08.03.2016
O R D E R
A.S. Yadav – President
Initially the complaint was filed against OP-1. Thereafter complaint was amended and OP-2 was impleaded vide order dated 27.5.11. It is not in dispute that complaint took the Reliance Group Mediclaim Floater Policy for the period 17.6.2009 to 16.6.2010 from OP-2.
The case of the complainant is that on 27.4.2009 at and around 11 at night complainant experienced sudden and acute pain in his chest along irritation in throat, headache, uneasiness and discomfort. The complainant was immediately rushed to Max Hospital. Complainant was examined in the emergency wing of the said hospital. The doctor taking note/diagnosing the precarious condition of complainant referred him for admission in the hospital. Thereafter complainant was kept under observation and the ECG and UGI Endoscopy tests were taken in the hospital and since the condition of the complainant stabilized he was discharged on 30.4.2010. Complainant submitted his claim alongwith all the necessary documents on 14.5.10 to OP for reimbursement of hospitalization expenses for Rs.25,972/- for his treatment form 27.6.10 to 30.6.10.
It is further stated that OP vide its letter dated 26.5.10 rejected the claim of complainant for reimbursement of hospitalization expense stating that complainant was investigated during the hospitalization and treatment which could be done on OPD basis as such the claim of complaint stands repudiated as per clause 4.9 of the policy. It is stated that it was for the doctor and not the insurer to decide whether a case requires emergency medical attention or not. It is stated that complainant was admitted as per the advice of the doctor and was treated in the hospital. Repudiation of his claim amounts to deficiency in service on the part of OP. It is prayed that OP be directed to refund Rs.25,972/- and Rs.1 lakh for mental torture.
OP-1 in the reply took the plea that there is no privity of contract between complainant and OP-1. OP-1 is only a Third Party Administrator(TPA) to OP-2 for processing and settlement of cases of medical policy holders on behalf of insurance company as per policy terms.
OP-2 in the reply has not disputed about the admission of complainant in the hospital but has taken the plea that the claim was repudiated on the ground that as per medical opinion, the present hospitalization was for the investigation and evaluation of the ailment and no active management(only oral medication) which could have been done as out-patient.
The discharge summary shows diagnosis – panic attach with HTN with APD with Erosive Gastritis H. Pylori Positive During admission ECG was done within normal limits. Patient was managed conservatively with Inj. Pantocid., Tab Crocin, Tab. Amlopress, Tab Alprax, Tab. Zolfresh and Tab. Larpose. Gastroenterologist consultation sought and UGI Endoscopy was done, report suggestive of GERD Grade. Gastric Erosions with H.Pylori Positive. Patient was started on HP Kit. Psychiatric consultation sought in view of low mood with decreased sleep.
The admission of the complainant in hospital was as per advice of the doctor. He was treated in the hospital. Medicines were given and the tests were undertaken. Nobody admits himself in the hospital on his own. The general tendency of a person is to get the treatment without admission. When there is no alternative a person gets himself admitted only on medical advice. In this case complainant was admitted in the hospital on medical advice and the tests were done which were required in view of his health condition. The repudiation of the claim in terms of clause 4.9 was just unjustified.
OP is directed to pay Rs.25,972/- to complainant alongwith interest @ 9% p.a. from the date of filing of the complaint. OP is also directed to pay Rs.10,000/- towards compensation and Rs.5,000/- towards litigation expenses.
Let the order be complied with within one month of the receipt thereof. The complaint stands disposed of accordingly.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(D.R. TAMTA) (A.S. YADAV)
MEMBER PRESIDENT
