District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.521/2019.
Date of Institution: 30.10.2019.
Date of Order: 07.06.2022.
Rameshwar Bansal son of Shri Shivji Ram Bansal, resident of house NO. 169, Sector-17, Faridabad.
…….Complainant……..
Versus
1. The New India Insurance Co. Ltd., Branch Ist & 2nd floor, NIT Chowk, Rangoli Silk Emporium, Faridabad through its Branch Manager.
2. Raksha Health Insurance TPA Pvt. Ltd., C/o Escorts Corporate Center, 15/5, Mathura Road, Faridabad – 12003.
…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.
PRESENT: Sh. Amit Kumar , counsel for the complainant.
Sh. Sanjeev Bansal, counsel for opposite party No.1
Opposite party No.2 exparte vide order dated 31.05.2022.
ORDER:
The facts in brief of the complaint are that the complainant had obtained a mediclaim policy from opposite party No.1 vide policy No. 31270234192800000661 valid from 18.06.2019 to 17.06.2019 and paid the amount of the insurance policy vide cheque No. 491340 dated 17.06.2019 amounting to Rs. 52,626/- drawn on IDBI Bank Ltd. Which was encashed. The sum insured in the said policy was Rs.10,00,000/-. The complainant was suddenly suffering from pain in calf/heel, difficulty in standing, backache, loose stools as well as SLR right-70, left-80. The complainant went to Sarvodaya Hospital & Research Centre, YMCA Road, Sector-8, Faridabad. On examination he was admitted in the said hospital on 18.6.2019 with above said complaints and patients diagnosis CBC-15.30, LFT-WNL, RFT-WNL, HbA1c-5.70, Vit B12-152.40, FT3/FT4/TSH-2.83/1.25/3.20 x Ray Ls Spine AP/Lat View-F/s /o Degenerative changes in LS spine. Patient was started on alalgesics, PPI, antibiotics and other supportive measures. X-ray showed-Degenerative changes in LS spine. MRI was done which showed – Findings reveals partial disc. Desiccating changes with:- posterior disc osteophyte complex at L4-L5 level causing severe bilaterial lateral recess, neural foraminal and bony canal stenosis with impingement of bilateral exiting and traversing cauda equine nerve roots. Grade I retrolisthesis of L5 over S1 with annular tear and superimposed lef paracentral and foraminal disc protrusion causing severe bilateral (LR) lateral recesses and neural foraminal senosis with impringement of bilateral exiting and traversing cauda equine nerve roots. NCV was done in view of above findings which showed-normal nerve conduction study. Physiotheraphy LS spacewas done. Inj. Optineuron was added to treatment. Patient responded well to the treatment hence being discharge with advise on 20.06.2019. The complainant had spent a sum of Rs.44,458/- on his treatment including hospitalization etc. The complainant had paid Rs.44,500/- to the hospital and submitted his cashless claim to the opposite party No.2. On 09.07.2019 opposite party No.2 demanded copy of complete set of Indoor case papers and vital charting, prescriptions and investigation report of any supporting treatment taken, for present ailment prior to admission, if any, MRI, X ray films dated 19.06.2019 and original pre numbered preprinted duly signed and stamped receipt against the final hospital bill. On 05.08.2019 opposite party No.2 wrote a letter to the complainant stated that on scrutiny of document sit was observed that patient could be managed on OPD basis & admission was primarily for investigation/evaluation purpose. Hence the claim recommended for repudiation as per policy clause as per policy clause 4.4.11. As per clause 4.4.11 : Charges incurred at Hospital, primarily for diagnosis, x-ray or laboratory examination or other diagnostic studies not consistent with or incidental to the diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or inquiry for which confinement was required at a hospital. It was pertinent to mention that the complainant was admitted with advice of concerned doctor in the hospital which was authorized to cashless/claim facilities on behalf of opposite parties. The complainant was paying the amount of policy regularly since 2007 to till date and the policy was valid from 18.06.2019 to 17.6.2020. There was no default of payment on behalf of complainant for making the payment. Thereafter the complainant had approached the opposite parties several times and demanded the above said amount of Rs.44,500/- but the opposite parties were not paying any heed to the legitimate request of the complainant and on 11.10.2019 the opposite parties flatly refused to the request of the complainant. 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) pay an amount of Rs.44,500/- as medical expenses/treatment charges incurred of the complainant.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs.21,000/- -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 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 observation of the documents, the opposite party No.2 given opinion that “patient was admitted with diagnosed case of PIVD L4-L5/L5/S1 with Facetopathy, Severe V B12 Deficiency, investigated & managed conservatively, as per ICP’s patient had c/o pain & weakness in leg since 1 week, loose stools with no abdominal pain since 3-4 days but in diagnosis No Gastroenteritis mentions, on scrutiny of documents it was observed that patient could be managed on OPD basis & admission was primarily for investigation/evaluation purpose, hence the claim recommended for repudiation as per policy clause 4.4.11” which are as under:- “Charges incurred at hospital primarily for diagnosis, X-ray or laboratory examination 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 hospital, hence the claim of the complainant was rightly repudiated. 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 by the virtue of the memorandum of the understanding signed with the New India Assurance company Ltd, opposite party No.2 was nominated as the Third Party Administrator for arranging to process the claim filed by the insured as per the terms and conditions laid down by opposite party No.1. Opposite party No.2 would like to apprise that complainant was covered under the mediclaim policy No. 31270234192800000661 period of 18.06.2019 to 17.06.2020 issued by the New India Assurance Company Ltd. Opposite party No.1 further the claim in respect of Mr. Rameshwar Bansal hospitalized in Sarvodaya Hospital and Research Centre – Faridabad for the treatment of PIVD L4-L5/L5-81 with facetopathy, severe V B12 deficiency, during 18.06.2019 to 20.06.2019. On perusal of claim documents it was found that pt admitted with c/o pain & weakness in leg since 1 week, loose stool with no abdominal pain since 3-4 days. But in diagnosis no Gastroenteritis Mentioned. During hospitalization, only investigation were done, which could have been managed on OPD basis. Hence, claim was recommended for repudiation to opposite party No.1, as per policy clause No.4.4.11 in accordance with the policy terms and conditions laid by the opposite party No.1. Opposite party No.2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. Case called several times since morning but none appeared on behalf of opposite party No.2. It was already 3.30p.m. Therefore, opposite party No.2 was hereby proceeded against ex-parte vide order dated 31.05.2022.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
7. In this case the complaint was filed by the complainant against opposite parties – New India Insurance Co. Ltd., with the prayer to: ) pay an amount of Rs.44,500/- as medical expenses/treatment charges incurred of the complainant. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs.21,000/- -as litigation expenses.
To establish his case the complainant has led in his evidence affidavit of Shri Rameshwar Bansal,, Annx.-A – Insurance policy, Annx.A-2 – Discharge summary, Annx.A-3 – Repudiation letter dated 29.08.2019, Final Bill.
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.
R1 – affidavit of Shri Niranjan Abrol, , Ex.R-1(1 to 34) – policy with terms and conditions.
8. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite parties, jointly & severally. are directed to process the claim of the complainant 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. 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: 07.06.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
