District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 80/2021.
Date of Institution:08.02.2021.
Date of Order:12.5.2023.
Brij Bihari R/o Yamuna Enclave, Part 03, Dheeraj Nagar, Aitmadpur, Faridabad, Haryana – 121002.
…….Complainant……..
Versus
1. Raheja QBE Health Insurance, Ground Floor, P &G Plaza, Cardinal Gracious Road, Chakala, Andheri East, Mumbai – 400 099.
2. Medi Assist India Pvt. Ltd., IBC Knowledge Park, Tower-d, 4th floor, Bannerghatta Main Road, 4/1, Bengaluru, Karnatka – 560 029.
…Opposite parties
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Santosh Goswami , counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 2.3.2021.
ORDER:
The facts in brief of the complaint are that the Complainant holds a Family Floater Health Insurance Policy Bearing Policy No. RQBE01-101345-20-000 and at the time of the claim, the policy was active. Complainant's wife Mrs. Indu aged 27, the insured No. 2 in the above policy was admitted in Sattya Hospital, 376, IP Colony, Faridabad, Haryana 121003 on 13/06/2020 with the complaint of Fever, Burning Micturation, Body Pain. Vomiting etc. Upon diagnosis the Complainant was found to be suffering from UTI and Sepsis wherein against the treatment. the complainant paid a sum of INR 48544/- (Forty Eight) Thousands Five Hundreds Forty Four) only to the Hospital. The due intimation of the claim was given on 16/06/2020 to the respondent though the complainant did not receive the acknowledgement from the respondent. Subsequently, the complainant also sent the physical copy of the claim document along with claim form to the respondent No. 2 being the TPA of the Company on 30/06/2020 and was received by the respondent No. 2 on 03/07/2020 though the respondent No. 2 acknowledged the receiving of the physical copy on 11/09/2020 after a delay of 41 days. Status of claim was sought on 25th July, 29th July, 13th August, 15th August, 19th August, 31st August, 4th Sep 2020 and on numerous other dates and each time a ticket number was raised by the respondent No. 2 without any concrete information. It is noticeable that Hussain Shaikh, the Manager-client relation of the respondent says via mail dated 14/08/2020 that he did not receive any claim document. On 16/09/ 2020, the respondent raised certain query on the claim which was replied to by the complainant on 18/09/2020 and required documents were sent through mail. It was submitted that after having mailed so many times, the respondent was not able to locate the policy number and member id of the complainant which was reflected in this mail itself. The investigator of the respondent No. 2 visited the said Sattya Hospital in the month of October and went through the profile of the Hospital along with file of the patient, Mrs Indu. At the same time, the investigator visited the insured address and made an inquiry there as well. It was submitted that the investigator was not verifying the claim but was basically cross examining the insured. The investigator tried to make the insured hostile by questioning her in an irrational manner and also blamed her for filing a vexatious claim. Even after the physical verification, the respondent No. 2 kept on sending the same mail which was addressed to the complainant on 16/09/2020 and asking for the reply. Meanwhile, the complainant kept on mailing the respondent seeking the status of the claim. It was submitted that after numerous mails from the complainant, the respondent No. 2 asked for the Original cancelled cheque/passbook of the complainant through its mail dated 28.10.2020. At last, the complainant thought that he would get the money now and he re-despatched the passbook to the respondent No.2 on 02.01.2021. On 22.01.2021, the respondent No.2 sent a mail to the complainant informing that it was working on the case and would update the complainant on the next day. It was submitted that surprisingly, Policy Bazaar the facilitator which through policy was booked mailed the complainant on 22.01.2020 that the claim of the complainant had been denied and the denial letter was annexed to the mail. It was submitted that while the claim was rejected on 08.01.2021 as per the denial letter, the respondent No.2 was keep on mailing the complainant that it was working on his case. The mail dated 22.01.2021 testifies that the complainant was kept in dark, cheated and deliberately harassed by the respondents. As per the denial letter, the claim was rejected on two counts: i.e Sattya Hospital where the complainant got the treatment was only a 10 bedded hospital and that it is not registered. It was submitted that lots of reimbursement claims of the said Satya Hospital had been passed by the Insurance Companies. Had the registration and capacity of the hospital would be the basis for settlement of claims, these claims by different Insurance Companies would not have been settled. . The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) refund a sum of INR 48,544/- only alongwith 12% interest from the date of discharge of the complainant from the hospital to its actual realization.
b) pay Rs. 20,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 10,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that at the very threshold the present complaint, the present complaint was not maintainable, reason being, the complainant's wife Mrs. Indu was admitted at Sattya Hospital, I.P. Colony, Faridabad on 13/06/2020 and was diagnosed with Urinary Tract Infection & Sepsis and discharged on 18/06/2020 but from the relied upon documents, it was evident / established that the said hospital did not fulfill the criteria of a hospital as defined under clause No. 2 (XV) so incorporated in the insurance policy. Not only this. the complainant had violated the terms & conditions of the insurance policy by not supplying the requisite documents to the insurance company despite numerous correspondence so as to process the claim at the end of the insurance company. As such, the issue under the present complaint did not fall under the peri-pher of the provisions and more particularly the word "deficiency" as defined under section 2(11) & word "service" as defined section 2(42) and the word "unfair trade practice" as defined section 2(47) of the Consumer Protection Act, 2019. The complainant neither had any cause of action nor locus standi in lodging of the present complaint before this Hon'ble Commission, reason being, from the relied upon documents, it was evident / established that the complainant's wife Mrs. Indu was admitted at Sattya Hospital on 13.06.2020 and was diagnosed with Urinary Tract Infection & Sepsis and discharged on 18.06.2020 but the insurance company had not received any intimation till 18/06/2020. However, the O.P. No.2 on behalf of the insurance company have received documents vide claim form dated 28.06.2020 on 04.07.2020 but due to Covid 19 pandemic situation and limited staff of O.P. No.2 to handle hard copies along with incorrect policy details mentioned by the insured in the claim form there was some delay in registration of the claim and the claim was registered on 11.09.2020. After that, query was raised by the O.P. No.2 on 16.09.2020 to the complainant and in turn, the complainant had sent mail being query reply on 18.09.2020 at info@mediassistindia.com and to policy bazar on 26.11.2020 but nothing was received at the end of the insurance company. In the query letter, it was already mentioned the process for submission of query documents and also the O.P. No.2 has sent mail from email id - claims@mediassistindia.com to the complainant for supplying requisite documents but the complainant did not reply on the same email ID. Further, the complainant had violated the terms & conditions of the insurance policy by not. supplying the requisite documents to the insurance company so as to process the claim despite numerous correspondence at the end of the insurance company, hence, the insurance company, in compelling circumstance, have arrived at the decision in closing such claim vide Final Closure letter dated 08.01.2021 in continuation of previous letters & reminders thereto dated 16.09.2020, 06.10.2020, 14.10.2020, 05.12.2020,21.12.2020 & 26.12.2020.
At the same time, on 17.09.2020 the insurance company have deputed an independent investigator viz. Oracle Investigation Agency to investigate the matter so as to ascertain the genuineness of the claim, however, parallely the insurance company had received another claim of Mrs. Mousam from the same hospital with same diagnosis with same line of treatment but there was non-cooperation at the end of the treating hospital to share hospitalization details / records. On persistent follow-up the treating hospital confirmed that it was not registered. The insurance company have received letter from the treating hospital that the said hospital is being run under Private Limited Company. Not only this, the insurance company had received letter from treating doctor Dr. Chandra Mohan Goswami on 07.01.2021 that the hospital was 10 bedded hospital only. Whereas, as per clause No. 2(XV) of the insurance policy the Hospital criteria states the requirement of 15 beds for population above 10 lakhs. As per latest update the population of Faridabad population is 4.2 million (42 lakhs). As such, in view of the above, the insurance company have repudiated the case under not fulfilling the definition of the 'Hospital' as per the policy and non-submission of requisite claim documents vide repudiation letter dated 08.01.2021, which decision cannot be termed unconscionable at all. Investigation reports are signed by treating doctor Dr. C.M. Goswami and not certified by any registered pathologist. Registration certificate of Dr. C. M. Goswami allegedly issued from Haryana Medical Council (HMC) with registration No 6036, did not bear official stamp of
the authorised signatory. On all the claim documents submitted the Registration number of Dr. C. M. Goswami was 006030 but on the registration certificate of doctor submitted the registration number is 6036. As per NMC portal Registration No 6030 & 6036 were not registered with Dr. C.M. Goswami. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Registered notice sent to opposite party No.2 on 17.2.2021 not received back either served or unserved. Case called several times since morning but none had appeared on behalf of opposite party No.2. Learned counsel for the complainant filed the tracking report in which the item delivery confirmed on 19.2.2021. Therefore, opposite party No.2 was hereby proceeded ex-parte vide order dated 2.3.2021.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties–Raheja OBE Health Insurance with the prayer to: a) refund a sum of INR 48,544/- only alongwith 12% interest from the date of discharge of the complainant from the hospital to its actual realization. b) pay Rs. 20,000/- as compensation for causing mental agony and harassment .c) pay Rs. 10,000 /-as litigation expenses..
To establish his case the complainant has led in his evidence, EX.PW1/A – affidavit of Brij Bihari, PW1/1 – insurance policy, Ex.PW1/2 – discharge summary,, Ex.PW1/3 – Final bill,, Ex.PW1/4 – courier receipt, Ex.PW1/5 - letter dated 11.092020, Ex.PW1/6 – email regarding file status, Ex. PW1/7 – email dated 16.09.2020, Ex.PW1/8 – reply to query, Ex.PW1/9 – email dated 26.12.2020 regarding repudiation, Ex.PW1/10 – email, Ex. PW1/11 – email dated Jan.22,2021, Ex.PW1/12 – email, Ex.PW1/13 – letter dated 08.01.2021, Ex.PW1/14 – email dated Jan. 23,2021,, Ex.PW1/15 – email, Ex.PW1/16 – legal notice, Ex.PW1/17 – letter dated 03.02.2021,
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A – affidavit of Kiran S.NIkam, Manager (legal), M/s. Raheja QBE General Insurance Co. Ltd. Ground floor, Cardinal Gracious Road, Chakala, Andheri (East), Mumbai, Ex.R-1 – policy, Ex.R-2 – claim form, Ex. R-3 – Discharge summary, Ex.R-4 – Final bill, Ex.R-5 (Colly) – Visitation inputs, Ex.R-6 – letter dated 16.09.2020, Ex.R—7 – letter dated 06.10.2020, Ex.R-8 – letter dated 14.10.2020, Ex.R-9 – 05.12.2020, Ex.R-10 – letter dated 21.12.2020, Ex.R-11 – letter dated 26.12.202020.
7. As per email Ex.R-14 it looks that the complainant’s hospital as well as the counsel are the same in all 5 cases. It creates doubt. i.e. the complainant has obtained so many policies from different company. The details are as under:
Sl. No. Complaint No. Title
1. 343/2021 Nisha Rani Vs. Raheja QBE
Policy No. : RQBE01-101616-20-000
Valid from 11.06.2020 to 10.06.2021
Address of Hospital : Sattya Hospital Faridabad
Disease : Fever, Severe Pain Abdomen, burning
maturation, vomiting and loose motion.
Date of admission : 02.11.2020
Date of discharged : 06.11.2020
Claimed amount : INR 54,646/-
2. 235/2021 Nisha Rani Vs. ICICI Lombard
Policy No. : 4128i/H/1663255384/00/000
Valid upto 03.02.2021
Address of Hospital : Sattya Hospital Faridabad
Disease : Fever, Headache, Pain and Swelling in
Perennial area.
Date of Admission : 08.10.2020
Date of discharge : 10.10.2020
Claimed amount : INR 32,742/-
3. 237/2021 Mousam Vs. Raheja QBE Gen. Ins.
Policy No. : RQBE01-10613-20-000
Valid from 11.06.2020 to 10.06.2021.
Address of the hospital : Sattya Hospital Faridabad
Disease : Fever, Burning Mituration, Pain in lower
Abdomen
Date of admission : 07.09.2020
Date of discharge : 12.09.2020
Claimed amount : INR 48421/-
4. 90/2021 Natwar Thakur Vs. Max Bupa Health Ins.
Policy No. : 30262595
Address of the hospital : Sattya Hospital Faridabad
Disease : dehydration, ARF and Deranged LFT
Date of admission : 8.10.2020
Date of Discharge : 14.10.2020
Claimed amount : INR 48,325/-
5. 80/2021 Brij Bihari Vs. Raheja QBE GIC Ltd.
Policy No. : RQBE01-101345-20-000
Valid from 04.05.2021 to 03.05.2021
Address of the hospital : Sattya Hospital Faridabad
Disease : Fever, burning micturation, body pain,
vomitting
Date of admission : 13.06.2020
Date of Discharge : 18.06.2020
Claimed amount : INR 48,554/-
8. As per the counsel for the opposite party argued at length and stated at Bar that as per the investigation report of opposite party it seems that all the 5 cases mentioned above belongs to the same Advocate with the same hospital and same kind of disease and same amount of the bill. It creates suspicion of the merit of the cases and during the course of arguments of the counsel for the complainant in relations with the opposite party i.e owner of hospital etc.
9. Keeping in view of the above submissions, Commission is of the opinion that all the five cases comes of collusion. Hence, no deficiency on the behalf of the opposite party has been proved. Hence, the complaint is dismissed. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 12.05.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
