DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

Rakesh Jaspal r/o House No.1102/2, Sector 39-B, Chandigarh.

                                      ---Complainant.

Versus

1.            National Insurance Company Ltd., Regional Office-II, SCO No. 337-340, Sector 35-B, Chandigarh through its Regional Manager

2.            National Insurance Company Ltd., SCO No.4-5, 2^nd Floor, Sector   9-D, Chandigarh through its Branch Manager.

3.            Vipul Medicorp T.P.A. Ltd., 515, Udyog Vihar, Phase 5, Gurgaon (Haryana), through its Director.

---Opposite Parties.

BEFORE:  SHRI LAKSHMAN SHARMA                 PRESIDENT

                   SMT. MADHU MUTNEJA                       MEMBER

                   SHRI JASWINDER SINGH SIDHU       MEMBER

Argued by:  Sh. Sanjay Judge, Adv. for the complainant

                   Sh. J.P. Nahar, Adv. for the OPs.

PER MADHU MUTNEJA, MEMBER.

1.                      The Complainant was the holder of a continuing medi-claim policy, which was issued to him on 25.1.2011, effective till 24.1.2012.  He had paid Rs.9,495/- as premium for the same.  On 29.1.2011 the complainant fell ill and was admitted at the Fortis Hospital, Sector 62, Mohali on account of coronary syndrome where necessary tests, treatment and investigations were conducted.   At the time of admission, the complainant provided a copy of the cashless policy to Fortis Hospital. During the treatment the said hospital sought confirmation from opposite party No.3 about the cashless policy. The complainant was diagnosed as suffering from coronary artery disease and was put on the requisite medical management.  He was discharged in the evening, but was compelled to pay Rs.11,300/- towards various charges of medication and treatment due to denial of cashless facility by opposite party No.3. Thereafter, the complainant approached the Insurance Ombudsman vide letter dated 5.1.2012 and vide letter dated 19.4.2012. He was told to submit the claim with the National Insurance Company directly.  It has been pleaded by the Complainant that despite the fact that he held a cashless policy, he was made to pay Rs.11,300/- to the hospital. This according to him amounts to deficiency in service on the part of the opposite parties.   Hence this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the Act only). The Complainant has prayed for payment of cost of treatment, compensation, cost of litigation as well as refund of premium paid towards cashless facility.

2.                      As none appeared on behalf of opposite party No.3 despite service, therefore, it was proceeded against exparte on 24 July, 2012.

3.                      In their written statement opposite party No.1 & 2 have admitted the issuance of the policy in question and treatment in the Hospital; also that he was diagnosed to be suffering from coronary artery disease.  It has also been admitted that opposite party No.3 received a Pre-Authorization Request Form from Fortis Hospital for Rs.11,250/- as package rate.   However, it has been submitted that mere obtaining cashless insurance policy does not mean that every claim would be paid to the insured.   It has been denied that the queries raised by opposite party No.3 were vague and superfluous.  It has been pleaded that according to the policy it was a second renewal of Policy. Also, Coronary Artery Disease would be covered only after four continuous claim free years.  It has hence been pleaded that though the Complainant has paid the amount to Fortis Hospital, he has never submitted any bills and documents to the TPA for processing the claim.  Opposite Party has stated that the original papers are still in possession of the complainant and so the claim has not been processed or paid. Thus, pleading that there is no deficiency in service on their part, Opposite Parties No.1 and 2 have prayed for dismissal of the complaint.

4.                      We have heard the learned counsel for the contesting parties and have gone through the documents on record and the written arguments advanced by the learned counsel for the Complainant.

5.                      The grievance of the Complainant is that despite being a holder of a cashless medi-claim policy, the Opposite Parties have not made payment to him, when he was admitted to Fortis Hospital for Coronary Syndrome. The Opposite Parties No. 1 and 2 in reply have stated that even though the Complainant was entitled to a cashless policy, however, the said disease was covered only after four continuous claim free years. As per records of TPA this was the second year of policy of the Complainant and hence, as per the terms and conditions, the amount was not payable.  The payment of the claim is always subject to the terms, conditions and exclusions of the insurance policy.  The Opposite Parties No.1 and 2 have further contended that the Complainant never submitted any bills and documents for processing of the claim to the TPA, due to which, his papers have never been submitted and hence, not processed.  The policy at Annexure C-1 has been issued based on the proposal form and declaration dated 20.01.2009, signed by the Complainant. The TPA did not have any previous policy details regarding the Complainant and as per their record, it was only a second renewal and a third year policy, due to which the claim had been denied.

6.                      On examination of record by the Opposite Parties No.1 and 2, it has been found that the Complainant had taken the first policy from 24.01.2005 to 24.01.2006. Later, the policy was regularly renewed each year  till 24.01.2012. At present, the sum insured in the policy is Rs.3,00,000/-, against which the claim has been lodged.  The payment of claim had been denied as the TPA did not have the details regarding the renewals of policies by the Complainant and according to them it was only a second renewal. It has already been stated that the Complainant had not submitted any papers for reimbursement of claim to the TPA. Hence, as per the Opposite Parties No.1 and 2 due to non-submission of papers, the Complainant was not entitled to any amount or even refund of the premium for cashless facility.

7.                      The denial of claim by the Opposite Parties is unjustified when the policy has been in continuation without break for 07 years. However, Opposite Parties No.1 and 2 have pleaded that the Complainant has not yet submitted any claim papers with them for processing of the claim.  The Complainant insists that the bill/claim should have been paid without demur to the hospital itself as it was a cashless policy.  The cashless facility has been denied by the TPA (Opposite Party No.3) due to a misunderstanding about the year/ period of  continuation of policy. The deficiency in service by the Opposite Parties especially T.P.A. (Opposite Party No.3) is apparent and the harassment caused to the Policy Holder is very very genuine.  As the claim has been denied due to communication gap in working between the Opposite Parties. The Complainant accordingly needs to be suitably compensated.       

8.                      We hence allow this complaint. The counsel for the Complainant has already submitted the required bills/ papers to the learned counsel for the Opposite Parties in Forum on 01.10.2012 for processing of claim. The Opposite Parties will pay the claim amount as per the terms & conditions of the policy, as per the bills submitted to them by the Complainant, within 45 days of receipt of this order. In addition, the Opposite Parties are directed to pay a compensation of Rs.10,000/- to the Complainant for deficiency in service and mental harassment, for denial of cashless facility. The Opposite Parties will also pay Rs.5,000/- as cost of litigation.

9.                      The Opposite Parties are directed to comply with the above order within the stipulated time, failing which the Opposite Parties shall be liable to pay the claimed amount of Rs.11,300/-  as also the compensation of Rs.10,000/- along with interest @9% per annum, from the date of this order, till it is paid, besides paying Rs.5,000/- as cost of litigation.

10.                   Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced.

12/10/2012

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER

“Dutt”