District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.36/2021.
Date of Institution: 21.01.2021.
Date of Order: 28.09.2022.
Ajay Kumar aged 40 years S/o Sh. Damodar Dass Goyal R/o 129/27-A, Jawahar Colony, A-Block, Near Press colony, Faridabad -121001.
…….Complainant……..
Versus
1. Sarvodaya Hospital & Research centre, Sector-8, Faridabad – 121007 through owner/A.R./Auth. Signatory/MD/MO etc.
2. Care health Insurance Limited, (Formerly known as Religare Heath Insurance co. ltd. ) Regd. Office: 5th floor, 19-Chawla House, Nehru Place, New Delhi – 110 019 through RM/A.R./Auth. Signatory/MD/Manager/BM etc.
2nd. Add.: Unit No. 604-607, 6th floor, Tower-C, Unitech Cyber Park, Sec-39, Gurugram-122001 (Hr.).
…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. Dharmandra Sharma, counsel for the complainant.
Sh. Shekhar Anand Gupta, counsel for opposite party No.1.
Sh. N.K.Garg, counsel for opposite party No.2.
ORDER:
The facts in brief of the complaint are that the complainant and his family mediclaim with opposite party No. cover from 26.09.2020 to 25.9.2021. His son (client ID-57128640 and hospital IP No. IP220649) admitted with opposite party No.1 with complaint of fever which was high grade 102-103f intermitted since 7 days associated with chills, riggors and cough cold non productive. Patient had 2-3 episodes of non bloody vomiting since 1 day and generalized weakness no history of loose motions from period 3.11.2020 to 7.11.2020. The hospital raised a bill of Rs.51,948/- for the treated of Master Divyansh the son of the complainant by opposite party No.1 out of which the opposite party No.2 approved a sum of Rs.41,696/- and balance amount after discount ie. Rs.9150/- was illegally, un justified, without and policy, pressuriselly charged by opposite party No.1 in collusion with opposite party NHo.2. Both the parties were negligent towards their professional act and conduct and illegally charged Rs.9150/- as copy amount out of the advance amount deposited by the complainant at the time of admission of his son with opposite party No.1 circumstantially. The complainant several times requested the opposite parties to return illegally, unjustified, without any policy, pressuriselly charged amount Rs.9150/- at the time of discharge on dated 07.11.2020 through personal presentation as well as various email but till date no satisfactory reply was given or no disputed amount was refunded. The complainant sent legal notice dated 04.12.2020 to the opposite party but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) return back Rs.9150/- alongwith the interest @ 24% P.A. to the applicant from 07.11.2020 till realization.
b) pay Rs. 51,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-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 answering opposite party had performed its part of duty diligently and had provided all the necessary support to the complainant for the cashless mediclaim by providing all the documentation to the opposite prty No.2 in timely manner. The answering opposite party No.2 in timely manner. The answering opposite party had sent the request for cashless hospitalization/treatment of the patient alongwith the estimate expenses summary and other required documents to insurance company/TPA on 3.11.2020 when the son of the complainant was admitted with the answering opposite party. The insurance company i.e opposite party No.2 upon the intimation/request of the answering opposite party, given the approval with 20% co-payment clause due to the terms of the policy taken by the complainant. The answering opposite party had no role to play in the approval/denial of the insurance claim of the complainant as it’s a matter between the complainant and the opposite party No.2, however answering opposite party had provided all the necessary documentation in this regard in timely manner. The present complaint was liable to be dismissed against the answering opposite party as otherwise also the answering opposite party had provided the best of the medical services to the complainant as the son of the complainant namely Divyansh was admitted with the answering opposite party on 3.11.2020 and got discharge don 7.11.2020 from the answering opposite party hospital after recovering from his ailment completely and as far as the responsibility to reimburse the expenses of the treatment under the mediclaim policy was the concern of the opposite party No.2 and the answering opposite party had also provided all the necessary support in this regard which he could provide to the complainant. The answering opposite party raised a bill of Rs.51,948/- for the treatment of the son of the complainant, out of which opposite party No.2 approved a bill of Rs.41,696/- and the answering opposite party only charged the balance amount of Rs.9150/- from the complainant. 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 opposite party company issued a health insurance policy under the product namely “Care” under Floater cover bearing NO. 14903531 in favour of the complainant namely Ajay Kumar his spouse Mamta and his two sons namely Davis and Divyansh for a sum insured of Rs.5,00,000/- with effect from 26.09.2019 to 25.09.2020 and further renewed from 26.09.2020 to 25.09.2021. The complainant approached the opposite party company with a cashless claim request through the treating hospital i.e. Sarvodaya Hospital & Research Centre, Faridabad with respect to insured’s hospitalization w.e.f 3.11.2020 with complaints of high grade fever and chills (as per the pre auth form) The said policy so procured by the complainant was having various types of plan and out of which one was Smart Select Plan. As per the policy certificate, the below clause was mentioned as well
Optional Cover
S.No. | Particulars | Details |
1. | No claim Bonus-Super | Applicable |
2. | Smart Select | Additional 20% Co-payment applicable for all claims made in Non Smart Select net work hospitals |
Sarvodaya Hospital had not been mentioned in the Annexure IV i.e. list of hospitals where co-payment of 20% was not applicable under Optional Cover “Smart Select”.
Hence 20% of co pay i.e R.9,002/- was deducted out of the total payable amount i.e. Rs.45,010/-. As per the proposal form filed by the complainant, the complainant had chosen smart select plan in the proposal form. The complainant had also signed the following declarations in the proposal form and had signed the proposal form himself. Thus in view of plan adopted by the complainant read with terms and conditions of this plan, the claim was processed and approved for Rs.36008/- out of total payable amount i.e. Rs.45,010/-. The total invoice amount was Rs.51949/- and post deducting the hospital discount of Rs.5688/- and nonpayables (non medical items) of Rs.1250, the total payable amount came out to be Rs.45010/-. As the complainant had selected smart select and the trating hospital i.e. SArvodaya was not in the Annexue IV, hence the complainant had to pay 20% of the payable amount as co-pay. Hence Rs.9002/- was deducted as co-pay out of the payable amount of Rs.45010/-. The claim was processed in consonance with the policy terms and conditions. Thus the claim of the complainant that answering opposite party had deducted Rs.9150/- illegally, unjustified without any policy was totally, misleading and was wrong. The opposite parties had rightly and legally deducted this amount as per terms of the policy and same were duly in the knowledge of the complainant. The claim in question was totally based on technical facts. It requires the leading of positive evidence and cannot be tried and decided by summary way and in such like cases the disputes in question can only be decided by the Civil courts as such the Hon’ble Forum on this count also had no jurisdiction to entertain ad try the present complaint. Opposite party No. 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
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–Sarvodaya Hospital & Research Centre & Ors. with the prayer to: a) return back Rs.9150/- alongwith the interest @ 24% P.A. to the applicant from 07.11.2020 till realization. b) pay Rs. 51,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Ajay Kumar, Ex.C-1 –Discharge summary, Ex,C-2 – Bill of supply, Ex.C-3 – letter dated 18.09.2020, Ex.C-4 – legal notice, Ex/.C-5 & 6 – Postal receipts, Ex.C-7 – reply to legal notice dated 29.12.2020. Ex.C-8 – email dated 02.12.2020.
On the other hand counsel for the opposite party No.1 strongly
agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Saurabh Gahlote, duty authorized representative of Sarvodaya Hospital & research centre (A Unit of Anshu Hospitals Ltd.), YMCA Road, sEctor-8, Faridabad, Ex.OP-1/A – Resolution, Ex.OP-1/A- Bill of Supply (
Duplicate copy),, Ex.OP/1/B – Discharge summary, Annx.D-1/B – Discharge summary.
Opposite party No.2 led in his evidence Ex.RW-2/A – affidavit of Ravi Boolchandani of Religare Health Insurance Company (now Care Health Insurance Ltd.), Ex.R-1 – insurance policy, Ex.R-2 – Terms and conditions, Ex.R-3 – Pre-Authorization Form, Ex.R-4 – Proposal form, Ex.R-5 (colly), Ex.R-6 – letter dated 18.11.2020 regarding claim approval & settlement letter,, Ex.R-7 – legal notice.
7. The complainant has prayed in his prayer clause to return back Rs.9150/- alongwith the interest @ 24% P.A. to the applicant from 07.11.2020 till realization.
During the course of arguments counsel for the complainant has placed on record Smart Select Network Locator vide Annx. X in which it has been mentioned that List of hospitals i.e Sarvodaya Hospital And Research centre as per their requirements.
On the other hand, counsel for the opposite party N0.2 argued that Sarvodaya Hospital has not been mentioned that list of hospital where co payment of 20% is not applicable under optional cover “Smart Select”. Hence, 20% of co pay i.e Rs.9,002/- was deducted out of the total claimed amount i.e. Rs.45,010/-.
8. After going through the evidence led by the parties, the Commission is of the opinion that as per Smart Select Network Locator Vide Annx.X, the name of Sarvodaya Hospital And Research Centre comes under the list of the hospital. In the interest of justice, the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the T&C of the policy 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 alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 28.09.2022 (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.
