DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.137/2011
Sh. Ram Singh Bisht
60/B, Shakti Khand-I
Indirapuram, Ghazibad (UP) ….Complainant
Versus
1. Reliance General Insurance Co. Ltd.
A-1/172, 1st Floor, Janakpuri,
New Delhi-110058
2. Medi Assist India Pvt. Ltd.
F-2, Kailash Plaza, 2nd Floor,
H-352, Sant Nagar,
New Delhi-110065 ….Opposite Parties
Date of Institution : 08.04.11 Date of Order : 07.09.17
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
The case of the complainant, in nutshell, is that the complainant, his wife and 13 years old son were beneficiary by holding a ‘Reliance Health wise Policy’ bearing No.1303702825000921 of OP No.1 for the period 08.09.2010 to 07.09.2011 and the insured amount was Rs.2 lacs for which the complainant paid requisite premium of Rs.8,248/-. It is stated that on 13.01.2011 the complainant’s wife Smt. Devi Bisht was admitted in Chandra Laxmi Hospital, Vaishali, Ghaziabad due to gastro problem and stomach pain and she was diagnosed as a case of viral hepatitis and thereafter his wife was discharged on 18.01.11. It is stated that before admission in the hospital, the complainant had telephonically informed to the OP No.1 and OP No.2 regarding his wife’s hospitalization. The complainant submitted a claim of Rs.36,962/- on 03.02.11 to OP No.1 vide claim No.5698967. It is stated that the complainant and his family members were insured for Rs.2,00,000/- and the OPs are legally bound to pay Rs.36,392/- on account of expenditure incurred on his wife’s treatment/hospitalization. Hence, the complainant has filed the present complaint for issuing the following directions to the OPs:-
- to pay Rs.36,392/- as mediclaim (insurance) amount of Rs.36,392/- to the complainant alongwith interest @ 18% from 03.02.11 till its payment,
- to pay Rs.50,000/- to the complainant as compensation for harassment, inconvenience, frustration and mental agony suffered by the complainant and Rs.10,000/- towards costs and other expenses.
OPs in the written statement have inter-alia stated that before honouring the claim of the complainant certain clauses and definitions as per policy are required to be represented. For the sake of convenience the relevant portion is reproduced as under:-
Definition 13 Medical charges mean reasonable charges unavoidably incurred by the Insured/Insured Person for the medical treatment of disease, illness of injury the subject matter of the claim as an In- patient in a Hospital/Nursing Home, and includes the costs of a bed, treatment and care by medical staff, medical procedures, medical practitioners/Consultants/specialist fees, medicines and consumables including cost of pacemaker, cost of organs, artificial limbs etc. as long as these are recommended by the attending Medical Practitioner.
Condition No.2 Duly of Disclosure -The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statement, misrepresentation, mis-description or non-disclosure of any material particulars in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld, of a claim being fraudulent of any fraudulent means or device being used by the Insured/Insured Person or any on acting on his/their behalf to obtain a benefit under this policy.
Condition No.15: Fraudulent Claims –If any claim is in any respect fraudulent, or if any false statement, or declaration is mace or used in support thereof, of if any fraudulent means or devices are used by the Insured/Insured Person or any one acting on his/her behalf to obtain any benefit under this Policy, or if a claim is made and rejected and no Court action or suit is Commenced within twelve months after such rejection or, in case of arbitration taking place as provided therein, within twelve (12) calendar months after the Arbitrator or Arbitrators have made their award, all benefits under this Policy shall be forfeited.
It is submitted that on scrutiny of claim documents of the complainant it was found that the patient was admitted at Chandra Laxmi Hospital on 13.01.11 with complaints of yellowish discoloration of urine and sclera, repeated vomiting, loss of appetite and pain abdomen diagnosed as case of acute viral hepatitis and discharged on 18.01.2011. The claim was got verified and various irregularities and discrepancies in claim documents were noted. As per papers of the hospital, the patient was admitted on 13.01.2011 at 12:00 p.m. and discharged on 18.01.2011 at 7.00 p.m. However, as per statement of insured, patient was admitted on 12.01.11 at 9:00 am and discharged on 18.01.11 at 12 p.m. and during stay the patient was advised injection Hepamerz on twice a day basis and 12 injections could be administered during hospitalization but, however, medicine bills are prepared for 22 injections. It was also observed that as per indoor record patient was presented in emergency/casualty prior to admission on 13.01.2011, but the claimant submitted OPD prescription dated 13.01.2011 before admission. It is stated that “though the patient was diagnosed as a case of Acute viral hepatitis all viral markers are negative, further since the day of admission till all vital signs of patient found to be normal, there was no complaint of fever but patient was also treated with and administered tablet calpol. Thus, no justified indications warranting Hospitalization of insured.” There The complainant made payment of Rs.36,000/- against the hospital bill on 18.01.2011 but as per receipts enclosed it was noted that the payment was made in two parts one of Rs.10,000/- on 13.01.11 and second of Rs.24,600/- on 18.01.11. Facts are manipulated and exaggerated and documents are made artificially with ulterior motive to make the claim payable. Hence, they regretted to pay the claim. Therefore, the claim of complainant regarding hospitalization of his wife was repudiated vide letters dated 09.03.11 and 24.03.11 as there were two claims reported for the treatment. Hence, the repudiation was totally justified and in accordance with the observations and the reports of the appointed surveyor and investigators There was no deficiency in service or unfair trade practice on the part of the OPs. OPs have prayed for dismissal of the complaint.
Complainant has filed a written arguments/rejoinder to the written statement of OP.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. Satyan Kapur, Dy. Manager (legal) has been filed in evidence on behalf of the OP No.1.
Written arguments have been filed on behalf of the parties.
We have heard the arguments on behalf of the parties and have also carefully gone through the file.
It is not in dispute that the complainant had obtained a ‘Reliance Health wise Policy’ bearing No.1303702825000921 of OPs for the period 08.09.2010 to 07.09.2011 and the insured amount was Rs.2 lacs for which the complainant paid requisite premium. The complainant’s wife Smt. Devi Bisht was admitted in the Chandra Laxmi Hospital, Vaishali, Ghaziabad on 13.01.11 and she was diagnosed as viral hepatitis and thereafter his wife was discharged on 18.01.11 as per discharge card Annexure-A. The complainant has filed the OPD prescription dated 13.01.11 (copy annexure-C). The OPs have filed surveyor report dated 01.03.2011 (copy annexure-D). The OPs vide letter dated 09.03.11 repudiated the claim ( Annexure-E).
OPs repudiated the claim of the complainant for minor changes as per the discharge card and as per the statement of the insured patient i.e. as per records the complainant’s wife was admitted on 13.01.2011 at 1 p.m. and discharged on 18.1.11 at 7 p.m. but as per the statement of the insured patient she was admitted on 12.01.11 at 9 p.m. and discharged on 18.01.11 at 12 p.m. Documents have to be given preference over oral statement. Secondly, the complainant made the payment twice i.e. at the time of admission of Rs.10,000/- on 13.01.11 and of Rs.24600/- on 18.01.11 totaling to Rs.34,600/-. The OPs rejected the claim on these above two grounds which was not at all justified as it is a practice in all the hospitals that at the time of admission they ask the patient to deposit some amount. It is quite apparent that instead of dealing with the claim of the complainant legally, the OPs made efforts to find out the holes in the documents and ultimately succeeded in repudiating his claim by finding totally insignificant holes therein. Hence, it is a clear cut case of deficiency in service on the part of the OPs by not paying the amount to the complainant.
In view of the above discussion, we hold that the OPs Company committed deficiency in service while rejecting the claim in question of the complainant. We, therefore, allow the complaint and direct the OP No.1 Company to pay Rs. 36,392/-along with interest @ 6% p.a. from the date of filing of the complaint till realization towards the claim in question and Rs.10,000/- in lumpsum towards compensation for mental agony and harassment and cost of litigation to the complainant within one month from the date of receipt of copy of this order failing which the OP No.1 Company shall become liable to pay the above stated amount of Rs. 36,392/- along with interest @ 9% p.a. from the date of filing of the complaint till realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 07.09.17.
