Haryana

Karnal

CC/279/2018

Harinder Singh - Complainant(s)

Versus

Tata AIG Insurance Company Limited - Opp.Party(s)

Ravi Mehta

02 Dec 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 279 of 2018

                                                          Date of instt.18.10.2018

                                                          Date of Decision 02.12.2019

 

Harinder Singh, aged 32 years, son of Shri Balbir Singh, resident of Quarter no.102, Old LIG, near MIG, Police Complex, Madhuban, District Karnal.

 

                                                 …….Complainant.

                                              Versus

 

1. TATA AIG Insurance Company Limited, through its General Manager, Area Office, SCO 254, 1^st floor, Sector 12, Karnal.

2. TATA AIG Insurance Company Limited, through its General Manager, Head Office, SCO 6, 7, Cabin no.21-22, 2^nd floor, Ranjan Plaza, Ambala Chandigarh, Highway, Zirkpur, Mohali.

3. Family Health Plan (TPA Limited), Cyber Spazio, Suite no.101, 102, 109, Ground Gloor, Road no.2, Nanjara Hills, Hyderbad.

4. Shri Ram Chand Memorial Hospital Pvt. Ltd. 12, Ashoka Colony, Opp. Virk Hospital, Karnal.

                                                                         …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present Shri Ravi Mehra Advocate for complainant.

                Shri Naveen Khatterpal Advocate for OPs no.1 and 2.

                OPs no.3 and 4 exparte.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant has taken the Medi-Claim Insurance Family Policy from OP no.1, vide policy no.0200127153 dated 05.01.2018 to 04.01.2019, this policy continue last 6 years and the complainant paid a sum of Rs.9717/- per annum as premium. The said policy was cashless policy. On 19.07.2018 the complainant has suffered from some disease and he was got admitted in Ram Chand Memorial Hospital, Karnal for four days i.e. 19.07.2018 to 23.07.2018. Complainant spent Rs.68,897/- on his treatment. Prior to this complainant checked himself from the said hospital on 15.07.2018 and paid an amount of Rs.1640/- to said hospital and again checked on 26.07.2018 and on 31.07.2018 and paid Rs.184/- and Rs.1500/- respectively.  After the treatment the complainant submitted the necessary documents i.e. bills etc. for settlement of the claim to OP no.1. The OP no.1 has received all the documents and told to the complaint to wait for some days. Thereafter, complainant requested the OPs so many times for settlement of the claim but OPs did not settle the claim and lastly repudiated the claim of the complainant, vide letter dated 17.09.2018 on the false ground. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, OPs no.1 and 2 appeared and filed their written statement raising preliminary objections with regard to maintainability; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the insured had availed mediclaim policies, vide policy no.0235842219 from 01.01.2013 to 12.02.2016. Further, complainant extended his mediclaim for every year under policy no.0200127153. The present claim falls under the policy no.0200127153 which was availed from 01.05.2018 to 01.04.2019. He has lodged claim of Rs.69697/- on 24.07.2018 by sending duly filled and signed claim form to OP on 07.08.2018 claiming reimbursement of expenses in respect of treatment taken by him for Recurrent UTI for which he was admitted in Shri Ram Chand Memorial Hospital from 19.07.2018 to 23.07.2018. It is further pleaded that after receiving claim intimation and some documents, OPs no.1 and 2 sent the claim to concerned department for processing the same. During processing, it was found that complainant has not provided entire requisite documents as well as information to the OPs no.1 and 2 and in the absence of said documents and information, the claim cannot be processed. OPs no.1 and 2 sent letter dated 09.08.2018 to the complainant while requesting him to provide following additional information(s) document(s).

1. Kindly send consultant papers, doctor’s fee receipt, lab reports, lab bills, Chemist bills post hospitalization.

2. Kindly send consultation papers, doctor’s fee receipt, lab reports, lab bills, Chemist Bills prior to hospitalization.

3. Please assist our verifier to cross check the hospital records from the hospital authority in presence of the member-patient.

Simultaneously, the OPs no.1 and 2 appointed an independent investigator, M/s Proclaim surveyor and Loss Adjusters to investigate the claim and ascertain its genuineness. The investigator sent the reminder letters dated 19.08.2018, 29.08.2018 and 31.08.2018 through which investigator demanded the documents but complainant failed to submit the documents. The investigator submits his report to the insurance company with the following observations:

a) The complainant/the hospital did not provide pre and post hospitalization medical bills/reports.

b) Irregularities observed in IPD records-patient with IPD no.61 was admitted on 19.07.2018 whereas patient with IPD no.64 was admitted on 17.07.2018, IPD 66 admitted on 15.07.2018, 67 on 20.07.2018, 68 on 17.07.2018.

c) Medicine purchased by the chemist in Aug, 2018 whereas the same medicine with same batch number was administered to the patient in July, 2018.

d) Although, hospital was in house, no pathologist, no lab technician was found at hospital.

e) NO OPD allowed to patient before hospitalization even though he had taken consultation from same hospital.

f) No tariff list provided by hospital, registration certificate of doctor and pathologist not provided.

g) Daily injection, Diclogenac, (Diclogesic) & Inj. Paracetamol (Neomol) was given and still during the entire day i.e. on 19 July 2018 temperature never came to normal.

h) As per statement of insured, Symptoms started from 15 July, 2018 i.e. 4 days before hospitalization but as per hospital indoor case papers, symptoms started from 7-10 days before the said hospitalization.

i) As per the statement of insured he asserts that he was never prescribed discharge medicines by hospital, but as per hospital checklist bill dated 23.07.2018, discharge medicines are prescribed which are capsule Acera D, Tab. Paracip 650 mg and Calpol, inj. Inem 1gm.

j) As per the statement of insured he states that he does not remember attending Doctor’s name, which is quite surprising.

k) In recurrent UTI (Urinary Tract Infection) case, Urine Culture and Sensitivity test not done. Generally, this test is done to find out exact microorganism causing.

l) A cursory look at the Hospital Indoor case papers, TPR/BP Chart, Medication Chart shows that they were written by one person at a stretch. When a person is admitted for 4-6 days it is unluckily that the same treating doctor/nurse was on duty during the course of admission.

m) Generally in ICP, before writing daily notes all Physicians write “S/B Dr. EYZ”. But such comments are missing from the comment section.

The claim of the complainant was finally denied, vide repudiation letter dated 17.09.2018 with the reasons that “if any claim is in any manner dishonest or fraudulent, or in supported by any dishonest or fraudulent means or devices, whether by you or any insured person or anyone acting on behalf of you or an insured person, then this policy shall be void and all benefits paid under it shall be forfeited.” There is no deficiency in service on the part of the OPs no.1 and 2. All other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OPs no.3 and 4 did not appear and proceeded against exparte, vide order dated 28.03.2019 and 14.06.2019 respectively.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C6 and closed the evidence on 03.09.2019.

5.             On the other hand, OPs no.1 and 2 tendered into evidence affidavit of Amit Chawla Ex.RW1/A and documents Ex.R1 to Ex.R7 and closed the evidence on 15.11.2019.

6.             We have heard the learned counsel of both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             The case of the complainant, in brief, that he has taken the Medi-Claim Insurance Family Policy from OP no.1, vide policy no.0200127153 dated 05.01.2018 to 04.01.2019, this policy had been continued for last 6 years. On 19.07.2018 the complainant has suffered from some disease and he was got admitted in Ram Chand Memorial Hospital, Karnal for four days i.e. 19.07.2018 to 23.07.2018. Complainant spent Rs.68,897/- on his treatment. Prior to this complainant checked himself from the said hospital  and spent Rs.3324/-. After the treatment the complainant submitted the necessary documents i.e. bills etc. for settlement of the claim but OPs did not settle the claim and lastly repudiated the claim of the complainant, vide letter dated 17.09.2018 on the false ground.

8.             The case of the OPs no.1 and 2 is that the insured had availed mediclaim policies; vide policy no.0235842219 from 01.01.2013 to 12.02.2016. Further, complainant extended his mediclaim for every year under policy no.0200127153. The present claim falls under the policy no.0200127153 which was availed from 01.05.2018 to 01.04.2019. He has lodged claim of Rs.69697/- on 24.07.2018 by sending duly filled and signed claim form to OP on 07.08.2018 claiming reimbursement of expenses in respect of treatment taken by him for Recurrent UTI for which he was admitted in Shri Ram Chand Memorial Hospital from 19.07.2018 to 23.07.2018. After receiving claim intimation and some documents, OPs no.1 and 2 sent the claim to concerned department for processing the same. During processing, it was found that complainant has not provided entire requisite documents as well as information to the OPs no.1 and 2 and in the absence of said documents and information, the claim cannot be processed. OPs no.1 and 2 sent letter dated 09.08.2018 to the complainant while requesting him to provide the documents but complainant failed to do so. Hence, the claim of the complainant was finally denied, vide repudiation letter dated 17.09.2018.

9.             Admittedly, the complainant purchased the medical claim insurance policy from OP no.1 and during the subsistence of the policy he has got admitted and taken treatment from Ram Chander Memorial Hospital Karnal. The claim of the complainant has been repudiated by the OPs, vide letter Ex.R7 with the observation that the claim of the complainant is based upon dishonest and fraudulent manner.

10.            As per the version of the OP, the complainant has not provided entire requisite documents and information. The OP had demanded pre and post hospitalization medical bills/reports. No lab technician was found in the hospital, no tariff list provided by hospital. The case of the OPs is relied upon the baseless allegations once it is admitted by OPs that complainant had provided the bills of Rs.69697/-, why the complainant had not provided other informations as desired by the OPs. Thus, we are of the considered view that the claim of the complainant has been repudiated by the OPs on the baseless ground. The act of the OPs no.1 and 2 amounts to deficiency in service and unfair trade practice.

11.            The complainant has spent Rs.72,221/- for his treatment which is proved from the medical bill Ex.C5. Thus, the complainant is entitled for the same alongwith compensation and litigation expenses.

12.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs no.1 and 2 to pay Rs.72,221/-to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs no.1 and  2 to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:02.12.2019                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member