Haryana

Bhiwani

CC/164/2022

Vikas Kumar - Complainant(s)

Versus

Paramount Health - Opp.Party(s)

Rajeev Kushik

12 Jun 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. : 164 of 2022

                                                        Date of Institution           : 17.08.2022

                                                                  Date of order                  : 12.06.2024

 

 

Vikash Kumar son of Sh. Vijay Kumar R/o 235 Chiranjiv Colony, BTM Road, Bhiwani, Previously posted as Branch Manager, IIFL Finance Limited, Bhiwani.

  

           ……Complainant.

 

Versus

 

1. Paramount Health Services Insurance TPA Pvt. Ltd., Plot NO.A/442 Road, No.28 MIDC Industrial Area, Ram Nagar, Wagle Estate, Thane(W), Mumbai-400604.

 

2. The Oriental Insurance Company Ltd., Bhiwani.

 

3. The Medical Superintendent, Manipal Hospitals Human Care Medical Charitable Trust, New Delhi Sector-6, Dwarka, New Delhi-95.

 

…… Opposite Parties.

 

COMPLAINT U/S 35 OF CONSUMER PROECTION ACT, 2019.

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-        Sh. Rajeev Kaushik, Advocate for complainant.

           Sh. Rajbir Singh, Advocate for OP No.2.

           OPs No.1 & 3 already exparte.

         

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant and his family members were covered under the Group Insurance Policy issued by OP No.2 vide policy No.112400/8/2022/55. It is stated that his mother Sneh Lata was diagnosed as Ca Gall Bladder with Omental deposits at Aadhar Hospital, Hisar on 26.01.2022 and was advised for surgical treatment. On 12.02.2022, complainant and his mother went to OP No.3 for medical treatment where surgical operation was done upon her and discharged on 14.02.2022. Complainant submitted claim of Rs.1,76,669/- on 26.02.2022 with OP No.1. It is stated that some correctness was required in the papers and complainant got it rectified from OP No.3 hospital and submitted with OP No.1. But despite that, OP No.1 rejected the claim of complainant.  Hence, the present complaint has been preferred alleging negligent conduct of OPs resulting into mental and physical harassment. In the end, prayer has been made to direct the OPs to pay claim amount of Rs.1,76,669/-. Further to pay compensation of Rs.2.00 lac for harassment and litigation expenses.

2.                 Notices were sent to the Ops. OPs No.1 & 3 did not bother to appear and were proceeded against exparte vide order dated 04.10.2022.

3.                 OP No.2 filed its written statement raising preliminary objections qua maintainability of complaint, locus standi, complaint bad for non-joinder of necessary parties and suppression of material facts. On merits, it is submitted that on receipt of clam from complainant, it was investigated by OP No.1, appointed by answering OP, to settle such type of claim and found that patient was admitted for Ca Gall Bladder with Omental Deposits for which she underwent diagnostic Leprotomy with Punch Biopsy.  This it was evident that hospitalization was primarily for investigation evaluation and diagnosis only and as per the terms and conditions no.4.10 of the policy, such expenses are out of scope of policy and intimation was given to complainant on 22.04.2022 by OP No.1 through e-mail. The clause 4.10 says that Expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalization period are out of scope of policy. As such, the OP denied for any deficiency in service on its part and prayed for dismissal of the complaint with costs.

4.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Annexure C-1 to Annexure C-7 were tendered and then closed the evidence on 07.06.2023.

5.                 In evidence of OP No.2, affidavit of incharge of Legal Hub of OP was filed as Ex. RW1/A alongwith documents Ex. R-1 & Ex. R-2 and closed the evidence on 28.03.2024.

6.                 We have heard learned counsels for both the sides and perused the record minutely.

7.                 It is not a dispute that during the treatment period, the patient was under insurance cover. From document Annexure C-2, it is evident that patient Sneh Lata on 29.01.2022 was advised to undergo a surgery for Ca Gall Bladder with Omental deposits. As per discharge summary Annexure C-3, the patient remained admitted as indoor patient at Human Care Medical Charitable Trust, Department of Surgical Oncology, New Delhi from 12.02.2022 to 14.02.2022 and course of treatment given in the hospital was for Carcinoma Gall Bladder as was diagnosed by the Aadhar Hospital, Hisar.  From bill details Annexure C-7 (bill dated 14.02.2022) issued by the treating hospital at Delhi reveals that Rs.1,40,000/- were taken by the hospital for the surgery as a package treatment for the ailment.  It is worthwhile to mention here that as per terms and conditions of the policy (Ex. R-2), pre-hospitalization charges are not admissible to the patient/complainant.  But in the present case, the OP insurance company has totally rejected the claim of complainant which shows negligent behavior of OPs No.1 & 2. In the present situation, the case law delivered by Hon’ble Punjab & Haryana High Court in CWP No.26178 of 2016 titled as National Insurance Co.Ltd. Vs. Sandeep & others reported in 2017 (1) RCR (Civil) Page 621 is of much significance wherein it has been  held that “Insurance companies give lucrative offers to attract customers-However, the moment any insured puts even the most genuine claim, seldom said claim would be accepted by any insurance company.”

8.                 After having heard learned counsels for the parties and going through the record, we have come to conclusion that the OP No.2 being insurer is negligent and deficient in providing proper services to the complainant which caused monetary loss as well as mental and physical harassment to him. As such, the complaint is allowed and OP No.2 insurance company is directed to comply with the following directions with 40 days from the date of passing of this order:-

(i)       To pay a sum of Rs.1,40,000/- (Rs. One lac forty thousand) to the complainant alongwith simple interest @ 9% per annum from the date of filing of this complaint till its actual realization. 

(ii)      To pay a sum of Rs.10,000/- (Rs. Ten thousand) on account of harassment caused to complainant.

(iii)     Also to pay a sum of Rs.5500/- towards litigation expenses.

                    In case of non-compliance with stipulated period, all the awarded amounts shall attract simple interest @ 12% per annum for the period of default. 

                    If this order is not complied with, then the complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party no.2 may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs, as per rules.  File be consigned to the record room after due compliance. 

Announced.

Dated:12.06.2024