Delhi

North

CC/120/2018

NIKHIL CHANDRA GUPTA & ANR. - Complainant(s)

Versus

THE ORIENTAL INSURANCE CO. LTD. & ANR. - Opp.Party(s)

ANUJ JAIN

13 Oct 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Consumer Complaint No. 120/2018

In the matter of

1. Sh.Nikhil Chandra Gupta

S/o Sh. Rajender Prasad Gupta,

Address E-24, Netaji Subhash Marg,

Daryaganj, Delhi-110002

 

2. Sh. Rajender Prasad Gupta

S/o Sh. Baj Rang Lal Gupta,

Address E-24, Netaji Subhash Marg,

Daryaganj, Delhi-110002                                                                                                                  ...Complainants

Versus

1. The Oriental Insurance Co. Ltd.

          7678, Singh Sabha Road,

           Near Amba Cinema Road,

           Delhi -110007                                                                                                                       ...Opposite Party-1

2. E-Meditek (TPA) Services Ltd.

          577, Udyog Vihar, Phase-V

          Gurgaon -122016                                                                                                                  ...Opposite Party-2

 

                                                                                         ORDER

                                                                                       13/10/2023

Harpreet Kaur Charya, Member

1. Jurisdiction of this commission has been invoked by Sh. Nikhil Chandra Gupta, Complainant No. 1 and Sh. Rajendra Prasad Gupta, Complainant  No. 2 against, The Oriental Insurance Company Ltd., as O.P-1 (Insurer) and E-meditek Services Ltd. (TPA) as O.P-2, with the allegation of deficiency in service.
2. Briefly stated, the facts of the present complaint are, the complainants, were covered vide Medical Insurance Policy bearing no. 271500/48/2015/4696 for a period from 05/02/2015 to 04/02/2016 under ‘Happy Family Floater Policy’( herein after referred as Policy No.1).
3. Policy No.1 was renewed by paying a premium and a policy bearing number 271500/48/2016/5079 for a period from 05/02/2016 to  04/02/2017 under the name of ‘Family Floater Policy’ was issued( herein after referred as Policy No.2). It has been stated that the complainant No.2/Father of the complainant No. 1 was also insured to the sum of Rs. 10,00,000/- under the gold plan.
4. The complainant has alleged that at the time of issuance of policy, it was assured that all the treatments under the policy shall be cashless. On 31/01/2016, the complainant No. 2 had to undergo medical treatment in B.L. Kapoor Super Specialty Hospital, Karol Bagh, New Delhi for ‘CA Prostate’. O.P. was informed in advance vide claim no. 122011605401. A Pre-Approval Certificate bearing no. EMSL/PAC/OICL/340754/2016 dated 29/01/2016 was issued under Policy No. 1. On the basis of the said approval, the complainant No. 2 was admitted in the hospital on 30/01/2016 and was discharged on 31/01/2016 after treatment. The total cost of treatment was Rs.29,450/- (here in after referred as claim no. 1).
5. Despite approval, the payment was not released by the O.P., which is contrary to the terms and conditions of the policy i.e.cashless system for the payment of hospital bill, which was an inherent feature.
6. Complainant No. 2, in continuation to discharge from B.L. Kapoor Super Specialty Hospital on 31/01/2016, had to undergo diagnostic tests on 15/02/2016 and 18/02/2016 and had to purchase medicines on 16/02/2016 and 29/02/2016 for which Complainant No. 1 had to incur a total treatment cost of Rs. 2,15,312/- (here in after referred as claim no. 2).
7. Again, on 11/03/2016, the Complainant no. 2 had to purchase medicines  and had to undergo treatment in B.L. Kapoor Super Specialty Hospital on 21/03/2016 for which he had to incur total expenses of  Rs. 1,23,985/- (here in after referred as claim no. 3).
8. The complainants have stated that the total sum of 03 claims amounted to Rs. 3,68,746/- for which claim no. 1, claim no. 2 and claim no. 3 were lodged with O.P. on 05/02/2016; 15/03/2016 and 31/03/2016 respectively vide separate claim forms. Claim no. 1 was lodged under Policy no. 1; Claim no. 2 and Claim no. 3 were registered under Policy no. 2.
9. Claim no. 1 was firstly repudiated vide letter dated 17/02/2016 and with no specific response for Claim no. 2 and Claim no.3. It has been further alleged that it seems that Claim no. 2 and Claim no.3 were also rejected illegally with malafide motive in violation of policy terms and conditions.
10. A Legal notice dated 05/02/2018 was served upon O.P.s ,demanding reimbursement of the claim amount of Rs. 3,68,747/- at the rate of 18% p.a. from 15/03/2016 and the damages of Rs. 2,00,000/- till realization, which was neither replied not complied with.
11. Hence, the present complaint as O.P. did not settle the three claims. The complainant has prayed for directions to O.P.s to jointly and severally pay a sum of Rs. 3,68,747/- being the amount paid by complainant no. 1 for medical expenses; damages to the tune of Rs. 2,00,000/-; interest at the rate of 18 % p.a. from 15/03/2016 till realization; Rs. 11,000/- towards the legal notice charges and cost of litigation of the present complaint.
12. The complainant has annexed the copy of the policy no. 271500/48/2016/5079 as Annexure ‘A’ (colly); policy cover bearing no. 271500/48/2015/4696 (colly) as Annexure ‘B’; pre-approval certificate dated 29/01/2016 as Annexure ‘C’ (colly); discharge summary dated 31/01/2016 along with the advance receipts and bills as Annexure ‘D’ (colly); Claim form for Rs. 29.450/- as Annexure ‘E’, letter dated 15/03/2016 addressed to O.P.2 as Annexure ‘F’ and ‘G’ (colly); letter dated 17/02/2016 rejecting the claim as Annexure ‘H’ and Legal notice along with speed postal receipts as Annexure ‘I’ (colly) and the treatment records from Max Healthcare have been annexed as Annexure ‘J’ (colly).
13. Notice of the present complaint was served upon OP.  Despite, service neither any reply was filed on behalf of OP nor anyone appeared.  Hence, they were proceeded ex-parte vide order dated 10/08/2018. 
14. Ex-parte evidence by way of affidavit was filed by the complainant.  Sh.Nikhil Chandra Gupta (CW-1) has repeated the contents of the complaint and has got exhibited the medical insurance policy bearing No.271500/48/2015/4697 as Ex.-CW1/1; copy of medical Insurance policy bearing No.271500/48/2016/5079 has been exhibited as Ex-CW-1/2; internet generated copy of email sent by OP-2 to OP-1 to B.L.Kapoor Memorial Hospital certifying pre-approval for the treatment as Ex.-CW1/3.  Copy of discharge summary along with bills, final bill summary, payment receipts have been exhibited as Ex.-CW1/4 to Ex.-CW1/9. Claim No.1 lodged with OPs on 05/02/2016 is exhibited as Ex.-CW1/10.  Claim No.2 and Claim No.3 are Ex.-CW1/11 (colly) and Ex.-CW1/12 (colly). Copy of repudiation letter dated 17/02/2016 with respect to claim No.1 is Ex.-CW1/13. The complainant has also got exhibited the Legal notice along with postal receipts as Ex.-CW1/14 and Ex.-CW1/15.
15. We have heard the arguments of Ld. Counsel for the complainant and Ld. Counsel for the OP. 
16. We have also perused the written arguments filed by the parties and the material placed on record. Though, OPs were proceeded ex-parte vide order dated 10/08/2018, due to non appearance despite service of summon,  Ld. Counsel of OP appeared at the time of arguments. During the course of arguments, the Ld. Counsel for OP was requested to produce original file of the claim of the complainant vide order dated 06/07/2022.  Despite several opportunities, the same was not produced before this Commission and finally on 17/02/2023, Ld. Counsel for OP filed supplementary written argument along with fresh Investigation Report dated 16/02/2023.  It was further stated by Ld. Counsel for OP that the original claim File is not available with the OP Company and the photocopy, which were filed earlier are only the scanned copy of the original, which were available with the OP Insurance company. 
17. The details of policies purchased by the complainants are hereunder:

S.No.	Policy No.	Period
	271500/48/2015/4696	05/02/2015 to 04/02/2016
	271500/48/2016/5079	05/02/2016 to 04/02/2017

 

18. Claim no. 1 was rejected by OP-1 vide repudiation letter dated 17/02/2016 (Ex.CW1/13) wherein the claim has been rejected on the ground that as per policy terms and conditions it’s an OPD procedure and no hospitalization is required.  Hence claim is not payable.  They have also stated in the said letter that as per Section 2. Definition 2.3 (c) - other than treatment mentioned under 2.3 (A), the condition of minimum hospitalization SHALL also not treatment is as such that it necessitates hospitalization and the procedure involves infrastructural facilities available only in hospital, OR iii) surgical to be done under general anesthesia BUT    II) due to technological advances hospitalization in either of the case is required for less than 24 (twenty four) hour.
19. If we look at the pre-approval certificate dated 29/01/2016 (Ex.CW1/3) wherein the maximum  duration of stay bears ‘1’ and the estimated expenses as well as authorized limit of Rs.18,000/- and the date of hospitalization of complainant No.2 is 13/01/2016 with date of discharge as 31/01/2016. Complainant has also filed the policy terms and conditions and “Happy Family Floater Policy” as per clause 2.3 :-

HOSPITALIZATION PERIOD: expenses on hospitalization are admissible only if hospitalization is for a minimum period of 24 (Twenty four) hours.  However,

1.  This time SHALL not apply to the following specific treatment taken in the Network Hospital/Nursing Home where the insured is discharged on the same day.  Such treatment SHALL be consider to be taken under Hospitalization Benefit,
1.  
2.  
3.  
4.  
5.  

xv Surgery of Prostrate

•  
•  
•  
• 26.  
  27.  
  3.  

1. The treatment is such that it necessitates  hospitalization and the procedure involves specialized infrastructure facility available only in hospital,
   382.  
2. Surgical procedure involved has to be done under general anesthesia
   1216.  
3. Due to technological advances hospitalization in either of the case is required for less than 24 (Twenty Four) hours.

 

20. It is interesting to note that the Pre-Approval Certificate (hereinafter to referred as ‘PAC’) dated 29/01/2016; 8.43 p.m. has been issued by              E-Meditek (TPA Service Ltd.), OP-2, has been sent through an email dated 29/01/2016 at 08.45 p.m., wherein the proposed date of hospitalization is “Jan 29 2016 12:00 PM- Jan 29 2016 12:00 PM” .  As per the said ‘PAC’ the E-Meditek (TPA), OP-2 has written that the B.L.Kapoor Memorial Hospital has been authorized to admit Rajender Prasad Gupta, Complainant No.-2 with authorization specifications.  When the said ‘PAC’ is being issued at 8.43 p.m. with the proposed date of hospitalization as 29/01/2016 from 12:00 p.m. to 12:00 p.m., thus, the hospitalization cannot be “zero” minutes. When the PAC is being issued at 8.43 pm, it is expected that the complainant will get hospitalized on the next day,  the date of hospitalization in the present case is 30/01//2016.
21. Thus, combined reading of clause 2.3 (A) (xxvi) and  the Pre-Approval Certificate with subject “PAC Approved “was issued by E-meditek (OP-2) on 29/01/2016, wherein, the expenses for treatment of CA Prostate have been allowed to the extent of Rs.18,000/-.  Further, the estimated cost of hospitalization corresponding to number of days bears ‘1’, i.e One day. Once, the Pre-Approval Certificate has been issued by TPA, the claim No.1 is well covered under the above-mentioned clause 2.3 (A) (xxvi) of policy terms and conditions.
22. ‘PAC’ dated 29/01/2016 has neither been withdrawn not modified. Thus, it remains valid. When the OP-2 has issued the ‘PAC’ for Rs. 18,000/- and relying upon the pre authorization the complainant got hospitalized, the complainant is entitled to receive the same. From the above discussion, we come to the conclusion that the complainants are entitled to receive claim No.1 as it is admissible and as a corollary claim No.2 and claim No.3 also stand admissible. 
23. Therefore, in the fact and circumstances of the present complaint, we direct OPs to settle the claims of the complainants of Rs. 3,68,747/- along with interest @7% p.a. from the date of filing of the complaint till realization.  We further award compensation of Rs.15,000/- on account of mental agony and harassment, inclusive of litigation expenses.   
24. The order be complied within 30 days of receipt of this order, in case of non-compliance the complainant shall be entitled to interest @9% p.a. on          Rs. 3,68,747/- from the date of order till realization.
25. Office is directed to supply the copy of this order to the parties as per rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

 

(Harpreet Kaur Charya) Member	(Ashwani Kumar Mehta)              Member             (Divya Jyoti Jaipuriar)        President