District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.279/2020.

 Date of Institution: 28.08.2020.

Date of Order: 08.07.2022.

1.                Deepak Kohli, S/o Shri V.K.Kohli, R/o House No. 610, Sector-28, Faridabad.

2.                Poonam Kohli W/o Shri Deepak Kohili, R/o House No. 610, Sector-28, Faridabad.

                                                                   …….Complainants……..

                                                Versus

1.                Raksha Health Insurance TPA Pvt. Ltd., through its Manager, First floor, 14/3, Mathura Road, Faridabad.

2.                Oriental Insurance Company ltd., through its Divisional Manager, Office at G-8, New Delhi, south Extension – Part-I, New Delhi.

Service may also be affected at: Divisional Manager, Oriental Insurance Company ltd., NH5, NIT, Railway Road, Near Bankey Bihari Mandir, Faridabad.

3.                Fortis Flt. Lt. Rajam Dhall Hospital through its Chief Medical Officer, Sector-B, Pocket – I, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi – 110070. Service may also be affected at: Fortis Escorts Hospital, Neelam Bata Road, NIT, Faridabad.

                                                                    …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.

PRESENT:          Sh. Deepak Kohli complainant in person with counsel Shri Manoj Arora.

Sh. Rajesh Singh, AR on behalf of Opposite party No.1.

Sh. Neeraj Kumar Gupta, counsel for opposite party N.2

Sh. Rajesh Khanna, counsel for opposite party No.3.

ORDER:  

                             The facts in brief of the complaint are that  in the year 2005, the complainant No.1 had taken a mediclaim policy form opposite party No.2 for the complainants and since then he was getting the policy renewed now  its new policy No. was 212700/48/2018/2005 for the policy period 29.11.2017 to 28.11.2018 and also include his son in the mediclaim policy after his birth in 2007.  Since 2005, the complainants had not taken any claim from the opposite parties Nos.1 & 2 except a claim of around Rs.16,000/- for the ailment of their son.  On 28.05.2018, the  complainant No.2 approached to opposite party No.2 with pain in lower abdomen, which she was suffering from last one month.  Dr. Pradeep Muley, after seeing the Ultra sound of the complainant No.2 observed that she was having multiple uterine fibroids with bulky uterus and advised for Uterine Artery Embolization surgery for Uterine Fibroids and gave appointment for surgery on 05.06.2018. The concerned officials of opposite party No.3 asked about  the mediclaim policy of the complainant No.2, and asked the requisite documents.  The complainant No.2 had submitted the Identity Card issued by opposite parties Nos.1 & 2 alongwith the aadhar card of the complainant No.2 and the mediclaim policy.  Accordingly on 04.06.2018, the officials of opposite party No.3 had sent a request for cashless hospitalization for mediclaim insurance policy in the requisite format alongwith the estimate for treatment to the tune of Rs.1,19,020/-  to

opposite party No.1, wherein, the officials of opposite party No.3 had duly mentioned the procedure/treatment i.e. Angiographic Mapping (specific artery + Body Part) + Guided Uterine Artery Embolization (UAE) – Uterine Fibroid, required for the complainant NO.2.  On 04.06.2018, the officials of opposite party No.1 after seeking the request and estimate had given an initial approval of Rs.60,000/- with the  condition that for further enhancement final bill alongwith the discharge summary may required to be deposited.  After receiving the initial approval and with the assurance that the approval would enhance after submitting the final bill, the complainant No.2 got admitted on 05.06.2018 at 7:52 a.m. and after getting treatment from the opposite party No.3 got discharge on 06.06.2018.  The final bill raised by the opposite  party No.3 was Rs.1,17,676/-.  The official of the opposite party No.3  then asked for depositing the entire amount of Rs.1,17,676/-.  The complainants got shocked as there was an initial approval for Rs.60,000/-.  The concerned officials of opposite party No.l3 then informed that the opposite parties Nos.1 & 2 refused to make the payment for a single penny with the reason “Uterine Embolisation not payable as per the policy”.  The concerned staff of opposite party No.3 had also given the letter of refusal to the complainant No.1  The complainant No.1 raised his query that under what clause Uterine Embolisation was not payable and what was the treatment for Uterine Fibroids.  The query was duly replied by the concerned doctor of the opposite party No.3 but the complainants were not having copy of the reply.  The concerned staff of the opposite party No.3 then again raised the issue with the opposite parties Nos.1 & 2 and also raised the issue that the patient was already had approval for Uterine Embolisation for the sum of Rs.60,000/- but the opposite parties Nos.1 & 2 refused to make any payment.  The complainant No.1 then raised the issue with the officials of opposite parties Nos.1 & 2 but they did not make any satisfactory reply and advised the complainants to pay the bill and file for reimbursement of the

 same.  The complainants were not having that much money available with them and had to make immediate arrangements for making the payment.  Vide his letter dated 20.06.2018, the complainant No.1 made request to the opposite party No.2 for the reimbursement of medical bill alongwith the original documents with claim form.  Opposite party No.1 had replied the said letter of the complainant No.1 vide letter dated 20.08.2018, whereby they demanded certain more document sin specific format.  The complainants had supplied the said documents to the opposite party No. 1on 30.11.2018.  Opposite party No.2 then replied to the complainants vide letter dated 11.10.2018 which was received by the complainants on 18.10.2018 informing that the opposite party No.1 i.e. TPA had recommended the claim of the complainants as No Claim as per clause 3.11 and vide the said letter given an opportunity to the complainants to substantiate their claim within 2 weeks from the date of receipt of the said letter.  In the meantime the mother of the complainant No.1 got brain hemorrhage on 30.10.2018 and he could not give timely reply but had replied the letter of 11.10.2018 vide his letter dated 09.11.2018.  To the surprise of the complainants, the opposite party No.2 has rejected the claim of the complainants one the same ground of clause 3.11 of the policy and did not consider the representation of the complainant No.1. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite parties to:

a)                 pay all the bills for treatment etc. submitted by the complainant amounting to Rs.1,11,676/- with interest @ 18% p.a. from the date of submission and further with pendentlite interest till its realization.

b)                 pay Rs.1,00,000/- as compensation for causing mental agony and harassment .

c)                 pay Rs.21,000/ - as litigation expenses .

2.                Opposite party No.1  put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that   the insurance contract was between the insured and the insurer i.e. The Oriental Insurance Co. Ltd. (Opposite Party no.2) As per the privity of the contract, the insurance company by itself or its TPA (Opposite party No.1) was obliged to process the claim as per the terms and conditions of the policy.  By the virtue of the memorandum of the understanding, signed with the Oriental Insurance Company Ltd.,  Opposite party No.1 was nominated as the Third Party Administrator for arranging to process the claims of the insurance company as per the terms and conditions laid down by opposite party No.2. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                Opposite party No.2  put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that    the complainants  had no locus standi to file the present complaint.  After repeated request, the complainants could not complete the formalities and not submit the documents to the office of answering opposite party.  When the complainants could not fulfill the conditions of the policy then there was no question of acceptance or denial did not arise hence the complaint of the complainants was premature and not maintainable.  The complainants were admitted that the complainants were residing at Delhi, but in the title of the complaint they  mentioned their address at Faridabad and the policy issuing office also at New Delhi and the complainant No.2 also take her treatment at Delhi, so the Hon’ble Commission had no competent territorial jurisdiction to entertain  and decide the same. The claim of the complainant was not maintainable and opposite

party had rightly repudiated  the claim of the complainant as per clause No.3.11 of insurance policy because the said  disease interamural fibroid not covered under the said policy. Opposite party No.2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

4.                Opposite party No.3  put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that   the complainant No.2 was admitted by the complainant No.1 at his own free will and she was admitted in hospital from 05.6.2018 to 06.06.2018 after adhering to the requisite procedure and all consent documents were duly signed.  It was submitted that after filing up of the registration form the patient undertakes to be liable to pay bill raised by the hospital for the treatment provided to them and therefore, the complainants were liable to pay the bills against the treatment rendered by opposite party No.3.  After treatment, the bill was raised by the hospital and same was duly paid by the complainants.  The present disputed pertains only between the complainants and opposite parties Nos.1 & 2, as the opposite party No.1 had rejected the claim of complainants of Rs.1,17,676/- as per rules and guidelines of their company.  Hence, no case whatsoever had been made by the complainants against the answering opposite party.  Therefore, name of answering opposite party was liable to be deleted from the array of  parties.  The complainants had included the name of hospital as a party in the memo of parties without any cause of action against the opposite party No.3.  It was mentioned that no deficiency of service was alleged against the hospital and therefore the complaint against the hospital was liable to be rejected at the very outset. Opposite party No.3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint..

5.                The parties led evidence in support of their respective versions.

6.                 We have heard learned counsel for the parties and have gone through the record on the file.

7.                In this case the complaint was filed by the complainant against opposite parties – Raksha Health Insurance TPA Pvt. Ltd. with the prayer to : a)  pay all the bills for treatment etc. submitted by the complainant amounting to Rs.1,11,676/- with interest @ 18% p.a. from the date of submission and further with pendentlite interest till its realization. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .  c)  pay Rs.21,000/ - as litigation expenses .

                   To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Shri Deepak Kohli,, Ex. C-1 – OPD Consultation, Ex.C-2 & 3 – Identity card,  Ex.C-4 request form alongwith estimate of treatment, Ex.C-5 – Initial approval given by opposite party No.1 vide letter dated 04.06.2018, Ex.C-6 -  letter dated 06.06.2018, Ex.C-7(colly) – Certificate, Ex.C-8  - Discharge summary, Ex.C-9 – Inpatient bill, Ex.C-10(colly) – receipt,, Ex.C-11 – letter dated 20.08.2018,, Ex. C-12 – letter dated 20.08.2018 – final reminder for claim, Ex.C-13 – letter dated 11.10.2018,, Ex.C-14 – letter dated 09.11.2018, Ex.C-15 – letter dated 20.11.2018.

                   On the other hand counsel for the opposite party  No.2 strongly agitated and opposed. As per the evidence of the opposite party No.2,  affidavit of Shri Ramesh Kumar, Senior Divisional Manager, The Oriental Insurance Co. Ltd., Faridabad,

                   Shri Rajesh Khanna, counsel for opposite party No.3 has made a

statement that written statement already filed on behalf of opposite party No.3 be read as evidence on behalf of opposite party No.3 and closed the same.

8.                After going through the evidence led by parties, the Commission is of the opinion  that  the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days  of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint  till its realization.  The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment and Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties free of costs and file be consigned to record room.

Announced on: 08.07.2022                                  (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.