District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.366/2021.
Date of Institution: 29.07.2021.
Date of Order: 09.01.2023.
Umed Singh (Aadhar card No. 9068 7581 8138) s/o Sh. Hari Chand r/o H.No. MCF-2989, D-2, Sanjay Colony, Sector-23, Faridabad, Haryana – 121005.
…….Complainant……..
Versus
1. The Oriental Insurance Company Limited, 5-B/4, B.P. 2nd floor, Neealm Railway Road, NIT Faridabad – 121001.
2. Health Insurance TPA of India Ltd., 2nd floor, Majestic Omina Building, A-110, Sector-4, Noida (U.P) – 201301.
…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. Avinash Kumar, counsel for the complainant.
Sh. Jatinder Singh, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 19.10.2021.
ORDER:
The facts in brief of the complaint are that the complainant was holder of policy bearing NO. 272400/48/2019/11142 valid from 28.12.2018 to 27.12.2019. An incident happened place with of the complainant on 18.10.2019 in which the son of the complainant namely Yuvraj Dagar aged 21 years had got injury in his right forearm due to glass at his house around 7.30 p.m. upon which the complainant immediately had taken to his son at Metro Institute with Multispeciality Hospital, Sector-16A, Faridabad, where his son remained admitted since 18.10.2019 to 23.10.2019. On duty doctor namely Dr. Kaveshver Singh had informed to the police in this regard on the same date i.e. 18.10.2019. Upon which the police had registered a report with his daily diary on the same date i.e. 18.10.2019. At the time of admission of the son of the complainant with the said hospital, the complainant had disclosed to the said hospital about his mediclaim and provided all the necessary documents to the said hospital for cashless claim of his above said son. The said hospital had sent the documents to the opposite parties for cashless mediclaim and opposite parties had sent preapproval of the cashless treatment of the son of the complainant vide claim NO. 191400189369. Thereafter, the said hospital had started the treatment of the son of the complainant. The complainant got shocked and surprised when the opposite party No.2 had sent a pre-authorization denial letter on dated 21.10.2019 vide which the opposite party No.2 had denied the claim of the complainant by taking the plea that “as per the instructions of the Oriental Insurance Company Ltd., the claim was being denied. Upon the said letter of the opposite party NO.2 the complainant had paid the full bill amount of Rs.99,200/- out of his own pocket to the said hospital. Thereafter the complainant had sent the requisite documents to
the opposite parties for reimbursement of the claim after completing all the formalities. But the opposite parties did not reimburse the above said claim of the complainant till date after repeated requests and reminders of the complainant. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) Rs.99,200/- as treatment charges alongwith interest @ 24% p.a. from the date of making the payment i.e. 23.10.2019 till its actual final realization.
b) Expenses spent by the complainant for making several requests and reminders to the opposite party for releasing the treatment amount.
c) pay Rs. 4,00,000/- as compensation for causing mental agony and harassment .
d) 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 present complaint was not legally maintainable against the answering opposite party as the answering opposite party No.1 M/s. the Oriental Insurance Company Ltd. Had not rendered any deficient or short services to the complainant under insurance policy No. 272400/48/2019/11142 covering the insurance risk from 28.12.2018 to 27.12.2019 issued in the name of the complainant Umed Singh. As per available record, Mr. Yuvraj Dagar aged 21 years the son of the complainant Umed Singh, sustained Sharp Cut Injury on the Right Forearm on 18.10.2019 and was taken to Metro Hospital, SEcator-16A, Faridabad where the injured Yuvraj Dagar reached at 21:00 hours and was Medico Legally examined in emergency of the hospital, where the injured disclosed the injury sustained due to physical assault resulting in Sharp Cut Injury on the Right
Forearm at 7:30 Pm. The matter was reported to the policy authorities of police station, Sector-23, Faridabad, where the police authorities registered the DDR. The injured was got admitted for treatment on 18.10.2019 and was discharge don 23.10.2019. At the time of the admission of the patient Yuvraj Dagar in Metro Hospital, the hospital authorities sought pre-approval of the cashless treatment as the complainant was having the insurance policy for 4 members of his family under Happy Family Floater – 2015 policy, but the cashless treatment was declined vide denial letter dated 21.10.2019 wherein it was made clear that “Claim was denied as discrepancy in MLC and self declaration. In view of the submitted documents, the liability of the insurer cannot be ascertained at this juncture hence cashless facility cannot be accorded, please submit all his claim documents in reimbursement only” but the complainant had not approached the answering opposite party for reimbursement and thus the present complaint was pre-mature. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Registered notice issued to opposite party No.2 on dated 16.09.2021 not received back either served or unserved. Case called several times since morning but none had appeared on behalf of opposite party No.2. More than one month had been expired. Therefore, opposite party No.2 was proceeded against ex-parte vide order dated 19.10.2021.
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– Oriental Insurance Company Limited with the prayer to: a) Rs.99,200/- as treatment charges alongwith interest @ 24% p.a. from the date of making the payment i.e. 23.10.2019 till its actual final realization. b) Expenses spent by the complainant for making several requests and reminders to the opposite party for releasing the treatment amount. c) pay Rs. 4,00,000/- as compensation for causing mental agony and harassment . d) pay Rs. 21,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Umed Singh, Ex.CW1/1 – Pre-authorization Denial letter dated 21.10.2019, Ex.CW1/2 – insurance policy valid from 28.12.2018 to 27.12.2019, Ex.CW1/3 – Final Bill BreakUp, Ex.CW1/4 – Discharge summary, Ex.CW1/5 – Claim Form, Ex.CW1/6 – DDR, Ex. CW1/7 - certificate dated 08.02.2020, Ex.CW1/8 – Day wise event for discharge summary, Ex.CW1/9 – consent form, Ex.CW1/10 – aadhar card of Umed Singh, Ex.CW1/11 – Aadhar card,
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 , Annexure .R-1/1 – insurance policy valid from 28.12.2018 to 27.12.2019, Annexure R-1/2 – DDR,, Annexure R-1/3 – Consent Form, Annexure R-1/4 – Discharge summary, Ex.R-1/5 – Pre-authorization denial letter dated 21.10.2019.
7. In this complaint, the complaint was filed by the complainant with the prayer Rs.99,200/- as treatment charges alongwith interest @ 24% p.a. from the date of making the payment i.e. 23.10.2019 till its actual final realization.
8. After going through the evidence led by the both the parties and counsel for the opposite party No.1 has argued at length and stated at Bar the contents of the DDR and MLR are different. After going through the other
Annexure from R-1/3 to Annexure R-1/5, the Commission is of the opinion that this mediclaim does not cover under the assault. All the exhibits against the evidence of the complainant. Hence, no deficiency in service on the part of the opposite party has been proved. Resultantly, the complaint is dismissed. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 09.01.2023 (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.
