District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 443/2020.
Date of Institution:26.11.2020.
Date of Order:26.04.2023.
Anoop Kumar S/o Sh. Radhey Shyam Age 36 Years R/o Village Panhera Kalan, Post Office Fatehpur Billoch, Tehsil Ballabgarh, District Faridabad Mobile No. 9891614370
....Complainant
Versus
1. The New India Assurance Company Ltd., 1-2, B.K.Chowk, Bank Lane, NIT Faridabad Through its Sr. Divisional Manager
2. Raksha Health Insurance TPA Pvt. Ltd., C/o Escorts Corporate center, 15/5, Mathura Road, Faridabad Haryana-121003 Through its Managing Director/Directors/ Principal Officer.
…Opposite party
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. Rajender Mittal , counsel for the complainant.
Sh. Sanjeev Bansal , counsel for opposite party No.1.
Opposite party No..2 exparte vide order dated 11.02.2022.
ORDER:
The facts in brief of the complaint are that the complainant got himself insured against personal Mediclaim policy vide Policy No. 31180034120400000007 Member ID No.N9074632, (Unique Policy No. 93000034170400000037) valid from 29.06.2017 to 28-06-2018 from the opposite party No.1. The complainant was suffering from the grave decease with periodic paralysis with pain and weakness in bilateral lower limbs with inability to walk, hence he was got admitted in Metro Heart Institute with Multispecialty Sector-16 Faridabad on 27-01-2018, where various test was done by the concerned doctors and treatment was given to the complainant and he was discharged on 28-01-2018. The said hospital authorities have charged Rs. 14,611/- from the complainant for his treatment and further the complainant has spent an amount of Rs.6,557/- for purchasing of medicines as prescribed by the doctors thus the complainant has spent an amount of Rs.21,168/- in total on his treatment. The complainant during the period when he was admitted in the hospital, the cashless facility was denied by the respondents No.1 & 2 and they had assured that the complainant has to deposit the Medi-claim bill in the hospital and the complainant can be reimbursed later on after submission of his claim to the respondents. The complainant submitted his Medi-claim forms for reimbursement of the medical bills through respondent No.2 vide claim No. 90221718402568 and 90221819000889 on 05-03-2018 and 02-04-2018 and the original documents as required by the opposite parties were submitted by the complainant along with the claim forms but the opposite parties
despite the repeated request of the complainant did not reimbursed the amount in question for which they were legally bound to do so. Ultimately the complainant has moved an application on 27-04-2018 in the name of the opposite party No.2 for return of the original papers pertaining to his treatment, final bill and bills for purchasing of medicines and other relevant documents which were submitted by the complainant along with the claim forms. The opposite parties did not returned the original bills rather the respondent No.2 has issued a letter dated 15-03-2018 received on 29-04-2018 claiming therein for submission of a receipt of Rs.1,336/- dated 05-01-2018 and accordingly the complainant submitted the said receipt with the opposite party No.2, but to the utter surprise of the complainant they have not released the payment till date with the plea that your claim has been repudiated and when the complainant asked the opposite party No.2 to give this fact in writing then the respondent No.2 had refused to do so. The complainant was also got admitted for the same decease in Sarvodaya Hospital Faridabad on 12-07-2017 and was discharged on 14-07- 2017 and accordingly the respondents have paid the entire amount of bills without any hindrance and obstacle. The complainant sent legal notice to the opposite party through registered post but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) to release the amount of medi-claim bills of Rs. 21,168/- alongwith interest @ 24% p.a to the complainant from the date of due till actual payment against medi-claim Policy No. 31180034120400000007 Member ID No. N9074632 FTD, (Unique Policy No. 93000034170400000037) valid from 29.06.2017 to 28-06- 2018.
b) pay Rs. 50,000/- 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 in terms of order dated 13.12.2019 passed by this Hon'ble court. the complainant had lodged his claim which had been registered vide claim no, TP015930000179131657 and the claim of the complainant was not tenable as per clause 4.4.11 of the terms and conditions of the policy of insurance and the claim of the complainant has been duly considered and after observation of the documents the opposite party no 2 given opinion that "33 year old male who was known case of Grave's Disease with periodic paralysis and hyperthyroidism present with complaints of pain and weakness in Bilateral Lower Limbs. Patient was admitted for investigation and evaluation. Radiological and Pathological Tests done during course of hospitalization highlighted the following findings. Nerve conduction velocity test was negative for all 4 limbs, Free T3 levels, Free T4 levels were elevated in view of the Grave's Disease and hyperthyroidism, all system and general physical examination were within normal limits. On scrutiny of the documents related to hospitalization, it was observed that the patient was admitted for investigation and evolution purpose. only and could have managed on O.P.D. basis. Claim is repudiated under Exclusion Clause No. 4.4.11- Hospitalization and course of management only for the purpose of evolution and diagnosis is Not Covered under the scope of merits of the policy. Clause No. 4.4.11- Clause No. 4.4.11- Charges incurred at Hospital primarily for diagnosis, X-ray laboratory or examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a Hospital" hence the claim of the complainant is rightly repudiated by the company of the answering respondent vide
letter dated 07.09.2020,. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Case had been called several times since morning but none had appeared on behalf of opposite party No.2. therefore, opposite party No.2 was proceeded against ex-parte vide order dated 11.2.2022.
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–The New India Assurance Co. Ltd. with the prayer to: a) to release the amount of medi-claim bills of Rs. 21,168/- alongwith interest @ 24% p.a to the complainant from the date of due till actual payment against medi-claim Policy No. 31180034120400000007 Member ID No. N9074632 FTD, (Unique Policy No. 93000034170400000037) valid from 29.06.2017 to 28-06- 2018. b) pay Rs. 50,000/- 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.CW-1/A – affidavit of Anoop Kumar, Ex.C-1 – OPD consultation, Ex.C-2 – GST invoice, Ex.C-3 – Bill of supply, Ex.C-4 to 7 – GST invoice, Ex.C-8 – Final Bill break up, Ex.C-9 – Discharge summary, ex.C-10 – copy of order dated 13.12.2019 passed by DCDRF, FBD, Ex.C-11 – repudiation letter, datd 07.09.2020.
On the other hand counsel for the opposite party No.1 strongly
agitated and opposed. As per the evidence of the opposite party No.1 Ex.R/A- affidavit of Sshashi Bhola, New India Assurance co. Ltd., Faridabad, ex.R-1 – repudiation letter, Ex.R-2 – insurance policy, Ex.r-3 – order dated13.12.2019 passed by DCDRF, FBD.
7. The opposite parties Nos. 1 & 2, jointly & servally, are directed to process the claim within 30 days of receiving the documents from the complainant as per the terms and conditions of the policy and pay the due amount to the complainant alongwith interest @ 6% p.a from the date of filing of complaint till its realization. The opposite parties Nos.1 & 2 are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment and Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on: 26.04.2023 (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.
