DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 1297/2016
D.No._________________________ Dated: _________________
IN THE MATTER OF:
AMIT GUPTA S/o SH. JAI BHAGWAN GUPTA,
R/o AM/170, GROUND FLOOR,
SHALIMAR BAGH, DELHI-110088.… COMPLAINANT
Versus
1. THE ORIENTAL INSURANCE CO. LTD.,
(THROUGH ITS MANAGER),
DIVISIONAL OFFICE-XI, 30/26, 1ST PARK,
NAGIA PARK, SHAKTI NAGAR, DELHI-110007.
2. THE MEDICAL SUPERINTENDENT,
FORTIS HOSPITAL,
A-BLOCK, SHALIMAR BAGH,
NEW DELHI-110088. … OPPOSITE PARTY (IES)
CORAM:SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 16.12.2016
Date of decision: 08.11.2019
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against OPs under Section 12 of the Consumer Protection Act, 1986 thereby alleging that the complainant has taken a Mediclaim Insurance policy from OP-1 bearing no. 271400/48/2015/5023 and the sum insured of Rs.6,00,000/- for the period from 15.01.2015 to 14.01.2016 (mid-night) and the insured persons against the said policy are Self, his
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wife namely Smt. Mithilesh Gupta, his daughter Mihika Gupta, his son Mehul Gupta and his mother Smt. Saroj Gupta alias Smt. Saroj Rani. The complainant further alleged that the mother of the complainant Smt. Saroj Gupta unfortunately fell ill in April-2015 and was admitted in many hospitals but was not cured and lastly died on 29.11.2015 and the complainant’s mother was admitted in Fortis Hospital i.e. OP-2 on 22.04.2015 and the treatment was done in OP-2 and was discharged on 25.04.2015 and the expenditure paid by the complainant on treatment in Fortis Hospital was Rs.83,961/-. Thereafter, the complainant was compelled by OP-1 to get the treatment by arranging the money/amount from different sources with great difficulty and the complainant paid Rs.83,961/- to OP-2 and OP-1 only released Rs.80,771/- to the complainant and still balance amount of Rs.3,190/- is due on OP-1 and the complainant is entitled for balance amount of Rs.3,190/-. The complainant further alleged that the complainant’s mother illness was not cured completely and this time she was admitted in Saroj Hospital, Madhuban Chowk, Rohini, Delhi on 09.06.2015 and was discharged on 12.06.2015 and the expenditure paid by the complainant on treatment in Saroj Hospital was Rs.56,732/- and the complainant was compelled by OP-1 to get the treatment by arranging the money from different sources with great difficulty and the complainant paid Rs.56,732/- to the said Hospital and OP-1 only released Rs.45,625/- to the complainant and still balance
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amount Rs.11,107/- is due on OP-1 and the complainant was entitled for balance amount of Rs.11,107/-. The complainant further alleged that the illness of the complainant’s mother was not cured completely and many Pre & Post hospitalization bills were raised and the complainant applied for Pre & Post hospitalization bill/claim amounting Rs.73,675/- and OP-1 did not release a single penny against the claim amount of Rs.73,675/-. Thereafter, the complainant paid Rs.73,675/- on Pre & Post hospitalization. The complainant further alleged that the illness of the complainant’s mother was not cured completely and this time admitted in Action Cancer Hospital, A-4, Paschim Vihar, New Delhi on 29.09.2015 and was discharged on 01.10.2015 and the expenditure paid by the complainant on treatment in the said hospital of Rs.94,191/- and the complainant was compelled by OP-1 to get the treatment by arranging the money from different sources with great difficulty and the complainant paid an amount of Rs.94,191/- on treatment and OP-1 did not release a single penny against the claim amount of Rs.94,191/-. The complainant further alleged that the illness of the complainant’s mother was not cured completely and this time again admitted in Fortis Hospital, A-Block, Shalimar Bagh, New Delhi on 27.11.2015 and died on 29.11.2015 and the expenditure paid by the complainant on treatment in Fortis Hospital of Rs.60,938/- and the complainant was compelled by OP-1 to get the treatment by arranging the money from different sources with great difficulty and
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the complainant paid Rs.60,938/- to the hospital and the OP-1 only released Rs.38,798/- to the complainant and still balance amount Rs.22,140/- is due on OP-1. The complainant further alleged that the complainant applied/requested OP-1 for releasing the claim but OP-1 did not release the total claim amount on one pretext and other and the complainant supplied all the relevant documents to the officials of OP-1 as demanded by OP-1 but the officials of OP-1 was not giving proper response in this matter and not releasing the total claim and lastly OP-1 repudiated the claims of the complainant and OP-1 has failed to release the claim despite repeated requests of the complainant and approach of OP-1 amounts to deficiency in services and unfair trade practice.
2. On these allegations the complainant has filed the present complaint praying for direction to OP-1 to give/release the total claim/balance claim amounting Rs.2,04,303/- alongwith interest @ 24% p.a. till its realization as well as compensation of Rs.2,00,000/- for causing damages for mental pain, agony, harassment and has also sought Rs.25,000/- towards cost of litigation.
3. OPs have been contesting the complaint and have filed their separate written statements. In its written statement, OP-1 submitted that the complaint is not maintainable and is liable to be dismissed and there is no deficiency in service on the part of OP-1. OP-1 further submitted that the Happy Family Floater policy
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obtained by the complainant from OP-1 for the year 2014-2015 first time and it was renewed vide policy no. 271400/48/2015/5023 (for 2015-2016 i.e. Second year policy) for the period of one-year w.e.f. 15.01.2015 to 14.01.2016 and the patient (deceased Saroj Gupta) aged about 60 years was hospitalized various occasions in different hospitals and primarily diagnosed “CHF-CAD, Severe LV Dysfunction EF 20% Dilutional Hyponatremia, Congestive Hepatopathy Hypothyroidism, diffuse brain Dysfunction on her first hospitalization in Fortis Hospital and DM/DCMP/Severe LV Dysfunction EF 25% - 30%, altered Sensorium/Hypothyroidism /Anorexia/Redaledema/Retroperitoneal Lymphadenopathy on her second hospitalization in Saroj Hospital and Carcinoma Cervix, Post OP/RT in June-2015 on her third hospitalization in Action Cancer Hospital and again she was diagnosed with Recurrent Episode of Syncope and Cardiac Arrest on her fourth hospitalization in Fortis Hospital with the history of so many diseases vide respective discharge summaries issued by the hospital concerned on various occasions, whereas, during the scrutiny of in-patient records, it has been found recorded that the patient is suffering from diabetes/CAD/Caner and other associated illness for several years and further it has been found recorded that while close scrutiny of the treatment records by the TPA (not impleaded) of OP-1 process the claim and found that the patient contracted the present ailment/diseases within 2nd year of insurance cover, whereas, the
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above treatments are covered only after 02 to 04 years, which falls within the scope of exclusion clause of the policy. OP-1 further submitted that the policy in question was in 2nd year of the policy period which comes under the exclusion clause 4.1 as well as clause 4.2 of the policy terms, conditions and exclusions the complainant/patient was considered for re-imbursement of the claimed amount in part and admittedly the same was credited into the account of the complainant and the claim amount for cancer treatment and other allied treatment was denied under the above exclusion clauses and the claim of the complainant held not admissible by OP-1 vide letter dated 24.02.2016.
4. In its written statement, OP-2 submitted that the complaint is not maintainable and is liable to be dismissed and there is no deficiency in service on the part of OP-2. OP-2 further submitted that the mother of the complainant was admitted in OP-2’s hospital firstly on 22.04.2015 and was discharged on 25.04.2015 and the mother of the complainant was admitted after having problems pertaining to CHF-CAD, Severe LV Dysfunction EF 20%, Dilutional Hyponatremia, Congestive Hepatopathy, Hypothyrodism and diffuse brain dysfunction etc. and the complainant’s mother was diagnosis for the aforesaid complaints and after treatment was discharged in stable condition on 25.04.2015 and OP-2 raised a bill of Rs.83,961/- and same was paid by the complainant. OP-2 further submitted that after a few months, the mother of the complainant
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was again admitted on 27.11.2015, despite best efforts made by the team of the best doctors of OP-2 considering the illness of the complainant’s mother she died on 29.11.2015 and OP-2 has raised a bill of Rs.60,938/- for 2nd time admission and same was paid by the complainant and between the first and next visit as above mentioned the complainant’s mother did not visit OP-2’s hospital and OP-2 has provided best treatment to the complainant’s mother and same is proved as per assertion made by the complainant in complaint itself and the complainant has not alleged any single allegation of negligence in the treatment provided by OP-2.
5. Complainant filed separate rejoinders and denied the contentions of OPs which has been taken in their written statements.
6. In order to prove his case, the complainant filed his affidavit in evidence and also filed written arguments. The complainant also placed on record copy of Happy Family Floater Policy for the period from 15.01.2015 to 14.01.2016 (mid-night), copy of receipt no.51-01/2300009915 dated 12.01.2015, copy of discharge summary dated 25.04.2015 issued by Fortis Hospital, Shalimar Bagh, Delhi, copy of bill no. 1107/15/I/Cs/0000490 dated 25.04.2015 for a sum of Rs.83,961/- issued by Fortis Hospital, copy of discharge summary dated 12.06.2015 issued by Saroj Hospital, copy of final bill no. IHL/15-16/00004649 dated 12.06.2015 for a sum of Rs.56,732/- issued by Saroj Hospital, copy of Claim Form, copy of bill dated 12.06.2015 for a sum of Rs.23,900/- issued by Ganesh
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Diagnostic & Imaging Centre Pvt. Ltd., copy of Whole Body PET-CT Scan dated 12.06.2015 (2) issued by Ganesh Diagnostic & Imaging Centre Pvt. Ltd., copy of report dated 12.06.2015 issued by Ganesh Diagnostic & Imaging Centre Pvt. Ltd., copy of Haematology, Complete Blood Count, Hepatic Profile (LFT) Without GGT, Bio-Chemistry, copy of investigation report, Immunoassay (2) issued by Sri Balaji Action Medical Institute, Paschim Vihar, Delhi, copies of receipt no.196115/1601900 dated 15.06.2015 of Rs.2,040/-, receipt no.196102/1601842 dated 15.06.2015 of Rs.11,970/- issued by Action Cancer Hospital, copy of Prescription dated 15.06.2015 issued by Action Cancer Hospital, copies of cash receipt dated 15.06.2015 of Rs.700/- & Rs.650/-, receipt dated 16.06.2015 of Rs.1,000/-, receipt dated 17.06.2015 of Rs.450/- issued by Action Cancer Hospital, copy of Prescription dated 17.06.2015 issued by Action Cancer Hospital, copy of Invoice-Cum-Receipt no. SBCS260042 dated 19.06.2015 for a sum of Rs.1,230/-, no.SBCS 260096 dated 19.06.2015 for a sum of Rs.540/-, no.SBCS260111 for a sum of Rs.720/- issued by Max Super Speciality Hospital, copy of Medical Oncology OPD Note dated 19.06.2015 issued by Max Super Speciality Hospital, copies of Invoice-Cum-Receipt no. 145123 dated 24.06.2015 for a sum of Rs.752.4, no.145827 dated 27.06.2015 for a sum of Rs.819.6, no.HBCS777944 dated 29.06.2015 for a sum of Rs.720/-, no.HBT0658746 dated 29.06.2015 of Rs.41.79, no.146807 dated 02.07.2015 of
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Rs.1,548.5, no.148133 dated 09.07.2015 of Rs.748.3, no.SBCS268437 dated 10.07.2015 of Rs.4,338/-, no.SBCS268554 dated 10.07.2015 of Rs.1,935/-, no.148354 dated 10.07.2015 of Rs.730/-, no.SBCS268466 dated 10.07.2015 of Rs.954/-, no.148592 dated 11.07.2015 of Rs.3,260/-, no.150445 dated 21.07.2015 of Rs.4,890/-, no.SBCS272906 dated 22.07.2015 of Rs.720/-, no.153196 dated 03.08.2015 of Rs.6,520/-, no.SBCS277955 of Rs.720/- issued by Max Super Speciality Hospital, copies of prescription dated 10.07.2015 & 12.07.2015 issued by Max Super Speciality Hospital, copy of bill-cum-receipt no.1003/15/O/Cs/ 0027726 dated 10.07.2015 of Rs.2,600/- issued by Fortis Hospital, copies of cash/bill no.6298 dated 13.07.2015 of Rs.674/-, no.6388 dated 22.07.2015 of Rs.576.40, no.6398 dated 23.07.2015 of Rs.494/-, no.6407 dated 25.07.2015 of Rs.416/-, no. 6441 dated 28.07.2015 of Rs.1049/-, no.6499 dated 02.08.2015 of Rs.534.56, no.6516 dated 03.08.2015 of Rs.971.50, no.6586 dated 10.08.2015 of Rs.1016.56, no.7207 dated 17.10.2015 of Rs.191/-, no.7276 dated 26.10.2015 of Rs.234/-, no.7267 dated 25.10.2015 of Rs.512.37, no.7272 dated 26.10.2015 of Rs.188/-, no.7279 dated 27.10.2015 of Rs.137.62, copy of bill dated 28.10.2015 of Rs.150/-, copy of cash bill dated 28.10.2015 of Rs.200/-, bill dated 06.11.2015 of Rs.622.76, copy of cash bill dated 13.11.2015 of Rs.200/-, copy of letter dated 22.11.2015 sent by the complainant to Medical Superintendent, Action Cancer Hospital, Delhi for
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verification of Hospital record, copy of courier receipt dated 04.12.2015 issued by Trackon Couriers Pvt. Ltd., copies of letters dated 25.11.2015 & 11.12.2015 sent by Park Mediclaim TPA Pvt. Ltd. to the complainant asking for documents, copy of reply dated 22.12.2015 sent by the complainant to Park Mediclaim TPA Pvt. Ltd. alongwith courier receipt dated 26.12.2015 issued by DTDC Express Ltd., copy of Special Final Reminder Cum Closure Letter dated 09.01.2016 sent by Park Mediclaim TPA Pvt. Ltd. to the complainant, copy of reply dated on 22.01.2016 sent by the complainant to Park Mediclaim TPA Pvt. Ltd., copy of medical prescriptiondated 05.01.2015 issued by Dr. A.K. Malhotra in the name of Smt. Saroj Rani, copy of bill dated 06.01.2015 of Rs.3,300/- issued by Dr. Mittal’s Diagnostic Centre, copy of Ultrasound Examination-Whole Abdomen, X-Ray Abdomen, Hormone Assay Report issued by Dr. Mittal’s Diagnostic Center, copy of death summary issued by Department of Cardiology, Fortis Hospital, Shalimar Bagh, Delhi, copy of Adhoc Bill dated 29.11.2015 of Rs.60,938/- issued by Fortis Hospital, Shalimar Bagh, Delhi, copies of receipts dated 27.11.2015 & 29.11.2015 of Rs.10,000/- & Rs.50,938/- about advance payment issued by Fortis Hospital, Shalimar Bagh, Delhi, copy of Prescription dated 06.05.2016 issued by Action Cancer Hospital to the effect that Ms. Saroj Rani underwent surgery for Carcinoma Cervix in May-2006 and received Radio Therapy which finished in July-2006 and Ms.
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Saroj Rani remained disease free approx. for 9 years and in June-2015 she developed generalized weakness and pain for which she was investigated and showed some mass near pancreas and this disease was probably not related to previous Carcinoma Cervix, and copy of repudiation letter dated 24.02.2016 issued by OP-1.
7. On the other hand, Sh. Chhotu Ram, Senior Divisional Manager of OP-1 and Sh. Mahipal Singh Bhanot, AR on behalf of OP-2 filed their separate affidavits in evidence. OPs have also filed written arguments.
8. This forum has considered the case of the complainant as well as OPs in the light of evidence and documents placed on record by the complainant. The case of the complainant has remained consistent and there is nothing on record to disbelieve his case. The documents and evidence of the parties shows that the mother of the complainant was admitted in various Hospital for treatment of her illness on various dates and ultimately she died on 29.11.2015. The certificate dated 06.05.2016 issued by Dr. Shruti Bhatia, M.D., DNB of Action Cancer Hospital, Paschim Vihar, Delhi clearly shows that the diseases treatment for which the mother of the complainant was hospitalized were not related to previous Carcinoma Cervix which she had in 2006. In this certificate, Dr. Shruti Bhatia has stated that the mother of the complainant remained disease free for approx. 9 years. It clearly shows that the defence taken by OP-1 is not plausible and cannot be believed in
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the absence of any evidence to the contrary on the part of OP-1. Accordingly, we are of opinion that there is no merit in the defence of OP-1 and OP-1 ought not to have repudiated the claim of the complainant. Since OP-1 has not released the claim to the complainant, so, while refusing the claim, OP-1 has indulged in unfair trade practice and deficiency in service. Thus, OP-1 is held guilty accordingly.
9. Thus, holding guilty for the same, we direct OP-1 as under:
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ii) To pay to the complainant an amount of Rs.40,000/- as compensation for harassment and mental agony suffered.
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10. The above amount shall be paid by OP-1 to the complainant within 30 days from the date of receiving copy of this order failing which OP-1 shall be liable to pay interest on the entire awarded amount @ 10%per annum from the date of receiving copy of this order till the date of payment. If OP-1 fails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.
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11. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 8th day of November, 2019.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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