CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/684/14

          Date of Institution:-    30.10.2014

          Order Reserved on:- 07.02.2024

                   Date of Decision:-      22.05.2024

IN THE MATTER OF:

Ms. Vijay Laxmi

S/o Sh. Mohan Nair,

R/o G-112, JulahBasti, LadhaChakki,

Mahipalpur Village, New Delhi - 110037

.….. Complainant

VERSUS

1. The Management of M/s Vidal Health TPA Pvt. Ltd.,

Office at B-25, 1^st Floor, Sector-1, Behind Indian Oil Building, NOIDA, Uttar Pradesh, NCR, Pin – 201301.

2. The Management of M/s Vidal Health TPA Pvt. Ltd.,

SJR iPark, First Floor, Tower No.2, EPIP Zone,

Whitefield, K. R. Puram, Bangalore – 560066.

.…..Opposite Party

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations thatshe has taken a health insurance and medical policy from the OPs vide her card no.DEL-NC-HO312-001-0000279-A valid from 14.01.2014 onwards. The clause 8 of guide book Vidal Health shows that policy holder is entitled for reimbursement in case of treatment of non-network hospital as well as for cashless facility. She is having spinal related sickness and taken treatment for Indian Spinal Injuries Hospital, VasantKunj but there was no relief. She has started taking treatment for Arya Vaidya Sala Kottackal Ayurvedic Hospital and Research Center, Karkardooma, delhi-92. The Doctors have advised admission for 14 days for further treatment which is essential for the improvement in her health. She had visited the network hospitals and found that they are not managed by qualified doctors and they were not having inpatient facilities so she opted for non-network hospital. Dr. Sujatha Nair of hospital has issued a certificate to this effect. The charges were Rs.48,000/- and requested for advance from OP which was not given. She has deposited a charges on 20.07.2014. She got admitted to hospital on 20.07.2014 and discharged on 02.08.2014 after the treatment. She approached the OP-1 and submitted the claim form with original bills of Rs.45209/- for reimbursement. She has written letter for reimbursement but in vain upon which notice dated 02.09.2014 was issued to the OP but in vain. Hence, this complaint.

2. The OPs have filed the joint reply with the averments that this Commission does not have jurisdiction to decide the complaint. The complaint has been pursued by AR without any authority. They are third party administrator and administer health insurance claim so they are not liable for payment of the claim to the complainant. The allegations of the complainant are false and denied.

3. The complainant has filed her rejoinder wherein she has denied the averments of written statement and reiterated the stand taken in the complaint.

4. The parties were directed to lead the evidence.
5. The complainant has filed her own affidavit in evidence wherein she has corroborated the version of complaint and placed reliance on the documents Ex.C1 to C18.

6. The OPs have filed the affidavit of Sh. Ajay Kumar Yadav, in evidence wherein he has corroborated the version of written statement.

7. We have heard the father of the complainant and manager of the OPs and perused the entire material on record.

8. The perusal of the material on record shows that complainant is a valid member of insurance/medical claim policy of the OPs as apparent from Health Card Ex.C1. Ex.C2 and C3 are the vidal health insurance guide book containing terms and conditions of the policy as well as list of the network hospital from where treatment can be taken. Ex.C4 is the certificate issued by the hospital in question to show that complainant has been advised to undergo 14 days AyurvedicPanchkarma Treatment as an inpatient as she is suffering from Kateegraham. The charges of Rs.48,000/-. The complainant has written a letter Ex.C5 to OP to provide the advance of Rs.48000/- for the treatment and even a reminder Ex.C7 was given to the complainant. The advance amount of Rs.48000/- was not given by OPs to the complainant.

9. The complainant has undergone treatment for 14 days in the hospital in question as apparent from certificate Ex.C8 and C10. The discharge summary Ex.C12 has been issued by the hospital. The payment of Rs.45209/- was made as apparent from Ex.C13. The payment of Rs.209/- was made on 02.08.2014 as apparent from receipt Ex.C9. Ex.C14 is the invoices issued by the hospital qua the medicines etc. used by the hospital. The complainant has lodged the claim Ex.C16 and C17 with the OPs but in vain and thereafter legal notice Ex.C18 was issued.

10. The network hospitals are shown at Sr. No.175, 176 and 177 of Ex.C3. The clause 8 of Ex.C2 shows that policy holder can take the treatment from non-network hospital and claim reimbursement.

11. The complainant has taken estimate from the concerned hospital and issued a request letter to OPs for the approval for treatment as well as to provide advance of the said amount but in vain. The complainant got admitted to hospital and took the treatment. The mediclaim was raised by the complainant which was rejected. The complainant/policy holder is entitled to take treatment from non-network hospital as per clause 8 of health insurance guide book. The treatment in the non-network Ayurvedichospital (the name of network Ayurvedic Hospital is at Sr. No.175-177) isin accordance with the terms and conditions of the medical policy so the question of rejection of the claim by OP does not arise at all. The rejection of claim is nothing but tantamount to unfair trade practice as well as deficiency in service.

12. In view of our aforesaid discussion, the complaint of the complainant is allowed to the effect that OP shall pay a sum of Rs.45,209/- along with an interest @7% from the date of filing the complaint i.e. 30.10.2014 till its realization to the complainant. The complainant is entitled for compensation of Rs.35,000/- for mental harassment and agony and Rs.20,000/- for litigation expenses. The OP is directed to comply with the order within 45 days from the receipt of the order failing which complainant will be entitled for interest @7% p.a. on the amount of mental harassment, agony and litigation charges i.e. from the date of order till its realization.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 22.05.2024.