District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 137/2022.
Date of Institution:09.03.2022.
Date of Order:21.04.2023.
Rahul Kaushik S/o Subhash Sharma R/o H.No. G-252, DLF, Sector-10, Faridabad, Haryana Age 35 years. M.9313386595.
…….Complainant……..
Versus
1. The New India Assurance Co. Ltd., Micro Office: Shop No. 137, Main HUDA Market, Near Pristine Mall, Sector-31, Faridabad – 121003 (Haryana).
2. The New India Assurance Co. Ltd., Registered office: Bldg., 87, M.G.Road, Fort, Mumbai – 400 001.
…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. D.C.Dhankar , counsel for the complainant.
Sh. Sanjeev Bansal , counsel for opposite party.
ORDER:
The facts in brief of the complaint are that at the inducement and instigation by the agent of opposite parties, complainant took medical claim insurance police vide policy N\o. 31270534192800000109 for the period from 1412.2018 to 13.12.2019 in his name as well as in the name of his family members. and prior to issuing the medical policy, opposite parties got completed entire formalities and also opposite parties got medically examined complainant and his other family members and after having full satisfaction by their side, opposite parties issued the policy in favour of the complainant as complainant was having continue mediclaim policy since the year 2018. And complainant also renewed mediclaim policy vide policy No. 31270534202800000128 valid from 14.12.2020 to 13.122021. The complainant suffered from complaint of pyrexia/repeated vomiting/UTI and hepatitis etc. and weakness on 6.12.2021 and he was got admitted in Ghai Hospital, Sector-9, Faridabad and remain admitted as indoor patient in the above Hospital since 6-12-2021 to 10.12.2021 and various investigations were conducted and complainant were given various medicines and treatment as per requirements. The above said hospital sent the details of complainant in respect of his admission, disease and treatment given to him alongwith all the investigation reports and other related documents to opposite parties on 06.12.2021 but opposite parties had not disbursed the amount for cashless facility of billing to the said hospital and had issued a simple denial letter dated 10.12.2021 by taking the false and baseless plea that on the basis of information provided to them, liability cannot be ascertained at this juncture. Hence, pre-authorisation cannot be extended in this case they also confirm that he consumed alcohol. Previous authorization null and void. After their denial complainant anyhow or the other had managed the amount of billing of the hospital and had paid an amount of Rs.43152/- on 10.12.2021 and after that also paid an amount of Rs.6000/- for his treatment to the said hospital thus the complainant had paid total amount for Rs.49.152/- for his treatment. Opposite parties without considering the claim of the complainant and without appreciating the medical records, treatment given to the complainant and other relevant things as well, opposite parties had repudiated the claim of the complainant on the flimsy grounds only on the basis of any third party information, rather in the discharge summary it was clearly mentioned that the history of alcoholism and tobacco or substance abuse if any allergy were Nil but opposite parties without considering the medical treatment documents and history of the patient had repudiated the cashless facility of the claim of the complainant which was absolutely against the terms and conditions of the policy and same was against the principal of natural justice and without considering the fact of medical history of complainant. The complainant sent legal notice dated 30.12.2021 to the opposite parties 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 parties to:
a) make the payment of claim amount of Rs.49,152/- alongwith interest @ 24% from the date of bill till the realization of that amount to the complainant.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties Nos. 1 & 2 put in appearance through counsel and filed written statement wherein Opposite partiesNos.1 & 2 refuted claim of the complainant and submitted that the claim of the complainant w snot tenable as per clause and terms and conditions of the policy of insurance and the claim of the complainant had been duly considered and after observation of the documents, the TPA of the complaint i.e. HITPA given opinion that “on the basis of information provided to them (HITPA), liability could not be ascertained at this juncture. Hence, pe-authorization facility could not be extended in this case. He also confirmed that he consumed alcohol. Previous authorization null and void”, as such the complaint of the complainant was liable to be dismissed on this score alone. It was worth mentioning that after denial of the claim of the complainant by the TPA of the complainant, the complainant never lodged any claim with answering opposite parties for reimbursement of his claim, Hence at this stage the complainant of the complainant was pre-mature. Earlier pre-authorization approval letter dated 06.12.2021 of Rs.14,000/- vide reference No. 211200306705010201 subject to initial/provisional authorization approved subject to active line of surgical/medical management. Kindly revert with final bill with discharge summary. The said approval letter dated 06.12.2021 had been declined vide letter dated 10.12.2021. Opposite parties Nos.1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– The New India Assurance co. Ltd. & Ors. with the prayer to: a) make the payment of claim amount of Rs.49,152/- alongwith interest @ 24% from the date of bill till the realization of that amount to the complainant. 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.CW1/A - affidavit of Rahul Kaushik, Ex.C-1 – policy schedule, Ex.C-2 – Discharge summary, Ex.C-3 – Bill, Ex.C-4 – Pre-authorization denial letter, Ex.C-5 – legal notice.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.R/A – affidavit of Shesh Bhisla, The New India Assurance Company Limited, Faridabad, Ex.R-1 – policy schedule, Ex.R-2 – Pre-authorization approval letter, Ex.R-3 – pre-authorization denial letter dated10.12.2021.
6. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order, subject to submission of documents and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 21.04.2023 (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.
