DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II U.T. CHANDIGARH [Complaint Case No:38 of 2011] Date of Institution : 24.01.2011 Date of Decision : 31.05.2012 ------------------------------------------ Mrs. Archana Malhotra wife of Sh. Arun Malhotra resident of House No.3050, Sector 40-C, Chandigarh. ---Complainant. V E R S U S 1. United India Insurance Co. Ltd., through its Senior Divisional Manager, SCO No.183-185, Sector 17-C, Chandigarh. 2. United India Insurance Co. Ltd., through its Chief Regional Manager, SCO No.123-124, Sector 17B, Chandigarh. 3. United India Insurance Co. Ltd., through its Chairman-cum-Managing Director, 24, Whites Road, Chennai. 4. MED. Save Health Care (TPA) Ltd., SCO No.121-123, Second Floor, Sector 34-A, Chandigarh. 5. MED. Save Health Care, F-701A Lado Sarai, Behind Gold Course, New Delhi – 110030 through Manager/M.D./C.M.D. 6. Dr. Renu Tayal through Abhilasha Hospital, 201, Sector 35-A, Chandigarh. 7. Abhilasha Hospital, through Dr. Renu Tayal, 201, Sector 35-A, Chandigarh. ---Opposite Parties. BEFORE: SHRI LAKSHMAN SHARMA PRESIDENT SMT. MADHU MUTNEJA MEMBER SH. JASWINDER SINDH SIDHU MEMBER Argued By: Sh. R. M. Dutta, Advocate for the complainant. Sh. Varun Chawla, Advocate proxy Sh. Rajneesh Malhotra, Advocate for OPs No.1, 2 and 3. None for OPs No.6 and 7. OPs No.4 and 5 already exparte. PER LAKSHMAN SHARMA, PRESIDENT 1. Mrs. Archana Malhotra has filed this complaint under Sections 12 and 13 of the Consumer Protection Act, 1986 praying therein for the following reliefs:- i) To reimburse a sum of Rs.32,500/- to indemnify the expenditure incurred by the complainant on her treatment. ii) To pay a sum of Rs.1,00,000/- as compensation for mental agony, harassment and inconvenience. iii) To pay a sum of Rs.7,000/- as costs of litigation. iv) To award any other relief, which the Forum deems fit. 2. In brief, the case of the complainant is that she got her health insured from United India Insurance Company Limited in the year 2003. Since then, she has been regularly getting the same renewed every year. On 15.03.2010, she got the said policy renewed up to 14.3.2011. The sum insured under the policy No.110200/48/09/978/00000300 was Rs.1,75,000/-. According to the complainant, she had to undergo surgery for Prolapsed Uterus Cystocelerectocele, Vaginal Prolapse. She accordingly approached OP No.1 for taking pre-authorisation for medical treatment. OP No.1 directed her to contact OP No.4 being the TPA i.e. Med Save Health Care. OP No.4 further advised her to contact IVY Hospital, Sector 71, Mohali and also issued pre-authorisation letter dated 3.09.2010 for a sum of Rs.30,000/-. The complainant contacted the said Hospital, who gave her an estimate of Rs.55,000/- for her medical treatment. She was also asked to deposit Rs.25,000/- in advance. As this amount seemed to be on the higher side, the complainant, contacted her family doctor namely Dr. Renu Tayal (OP No.6) of Abhilasha Hospital (OP No.7). It is averred that Dr. Renu Tayal told the complainant that the total costs of treatment would be approximately Rs.32,500/-. She further told that her hospital i.e. OP No.7 was fully equipped 15 bedded hospital and was having round the clock emergency and a resident doctor. Accordingly, the complainant got herself admitted in OP No.7 Hospital on 7.9.2010 and after surgery, she was discharged on 11.09.2010. It is averred that a sum of Rs.32,500/- was spent on her treatment. The complainant lodged the claim with OPs No.1 to 3 (Insurance Company) well in time. However, OP No.1 sent a rejection letter dated 22.09.2010 (Annexure C-5) issued by OP No.4 whereby her claim was rejected on the ground that the Hospital where the complainant got herself treated was only 8 bedded Hospital. According to the complainant, the rejection of the claim by the Insurance Company on this flimsly ground amounts to deficiency in service. In these circumstances, the present complaint has been filed by the complainant seeking the reliefs mentioned above. 3. In the written statement filed by OPs No.1 to 3, it has been admitted that the complainant was insured vide Mediclaim Insurance Policy No.110200/48/09/978/00000300 valid for the period 15.03.2010 to 14.03.2011. It has also been admitted that the sum insured under the policy was Rs.1,75,000/-. It has been pleaded that the contract of insurance is governed by the terms and conditions of the insurance policy. According to OPs No.1 to 3, the medical claim, if any, was to be assessed by Medsave Healthcare (TPA) Ltd., Chandigarh. It has been denied that the TPA asked the complainant to go to IVY Hospital for medical treatment. It has further been asserted that as per the investigation of the TPA, OP No.7 Hospital was not a 15 bedded hospital and therefore, was not to be considered as a hospital under the terms and conditions of the Insurance Policy. According to OPs No.1 to 3, the claim of the complainant has been rightly rejected keeping in view Clause No.2.1 of the Insurance Policy. So, there is no deficiency in service on their part. Therefore, it has been prayed by OPs No.1 to 3 that the complaint qua them be dismissed. 4. In the written statement filed by OPs No.6 and 7, it has been admitted that the complainant approached them for medical treatment and the total cost of treatment was estimated at Rs.32,500/-. It has been categorically averred that OP No.7 is 15 bedded Hospital with all latest facilities having round the clock emergency and a resident doctor. According to these OPs, the said Hospital is on the penal of various Health Care Companies (Certificate Annexure R-6/1). According to OPs No.6 and 7, they have no role to play in settlement of the claim and the complaint qua them deserves to be dismissed. 5. OP No.4 was duly served through Process Server. As none appeared on its behalf, so, it was ordered to be proceeded against exparte vide order dated 04.03.2011. Similarly, OP No.5 was also duly served through Registered A.D. Post. Since, none appeared on its behalf, so, OP No.5 was also proceeded against exparte vide order dated 29.08.2011. 6. We have heard the learned counsel for the parties and have gone through the documents on record. 7. It is admitted case of the parties that the complainant was insured for the period 15.03.2010 to 14.03.2011 vide Mediclaim Insurance Policy No.110200/48/09/978/00000300. It is also the admitted case of the parties that the complainant took treatment from Abhilasha Hospital (OP No.7) run by Dr. Renu Tayal (OP No.6). The complainant was operated upon for Prolapsed Uterus Cystocelerectocele, Vaginal Prolapse. Admittedly, the complainant incurred an expenditure of Rs.32,500/- on her medical treatment. 8. Clause 2.1 of the Mediclaim Policy reads as under: - “2.1 HOSPITAL/NURSING HOME MEANS ANY INSTITUTION IN INDIA ESTABLISHED FOR INDOOR CARE AND TREATMENT OF SICKNESS INJURIES AND WHICH EITHER (A) HAS BEEN REGISTERED AS A HOSPITAL OR NURSING HOME WITH THE LOCAL AUTHORITIES AND IS UNDER THE SUPERVISION OF REGISTERED AND QUALIFIED MEDICAL PRACTITIONER. OR (B) SHOULD COMPLY WITH MINIMUM CRITERIA AS UNDER: - I) IT SHOULD HAVE AT LEAST 15 INPATIENT BEDS. II) FULLY EQUIPPED OPERATION THEATRE OF ITS OWN WHENEVER SURGICAL OPERATIONS ARE CARRIED OUT. III) FULLY QUALIFIED NURSING STAFF UNDER ITS EMPLOYMENT ROUND THE CLOCK. IV) FULLY QUALIFIED DOCTOR(S) SHOULD BE INCHARGE ROUND THE CLOCK.” 9. Admittedly, the claim of the complainant has been rejected by OPs No.1 to 3 vide letter dated 22.09.2010 (Annexure C-5). The only ground on which the claim of the complainant for reimbursement of medical expenses has been rejected is that the Abhilasha Hospital (OP No.7) is only a 8 bedded Hospital. Apparently, the ground on which the claim has been rejected appears to be false and frivolous. Dr. Renu Tayal, who is the Proprietor of Abhilasha Hospital has filed her affidavit to the effect that Abhilasha Hospital is a 15 bedded hospital and is on the penal of various other Health Care Companies. She also issued a Certificate dated 11.09.2011 (Annexure C-4) to this effect. On the contrary, the case of OPs No.1 to 3 is that as per the report of TPA, Abhilasha Hospital is a 8 bedded Hospital. No affidavit of any person who visited the Abhilasha Hospital for verification of the claim has been placed on record. In the absence of such an affidavit, there is no material to rebut the affidavit filed by Dr. Renu Tayal. There is no other cogent evidence on record to prove that the Abhilasha Hospital is 8 bedded Hospital. As mentioned above, T.P.A was proceeded exparte and there is no written statement on its behalf. In the absence of its written statement, there is no other material on record to show as to on what basis the TPA reported that Abhilasha Hospital is a 8 bedded Hospital. In these circumstances, the affidavit of Dr. Renu Tayal (OP No.6) has to be relied upon and there is no material on record to disbelieve the said affidavit. 10. Furthermore, in the written statement, the OPs No.1 to 3 have failed to disclose about the material facts allegedly concealed by the complainant. So, it is to be presumed that no material facts were concealed. In the circumstances mentioned above, denial of the legitimate claim amounts to deficiency in service. 11. In these circumstances, OPs No.1 to 4 are liable to pay the amount, which the complainant spent on her medical treatment at OP No.7 Hospital. 12. In these circumstances, the complainant is entitled to a sum of Rs.32,500/-, which she spent on her treatment at OP No.7 Hospital. As the claim amount is to be paid by OPs No.1 to 4 only and as no specific relief has been sought against the remaining OPs No.5 to 7, the complaint qua OPs No.5 to 7 deserves to be dismissed. Accordingly, the complaint qua OPs No.5 to 7 is dismissed. 13. In view of the foregoing discussion, the present complaint is allowed qua OPs No.1 to 4 and they are directed as under:- (i) to pay a sum of Rs.32,500/- to the complainant with interest @9% p.a. from the date of rejection letter i.e.22.09.2010 till the actual payment; (ii) to pay a sum of Rs.7,000/- as costs of litigation. 14. This order be complied with by OPs No.1 to 4, jointly and severally, within 45 days from the date of receipt of its certified copy, failing which they shall be liable to pay the aforesaid amount of Rs.32,500/- along with penal interest @18% per annum from 22.09.2010 till the date of actual payment besides payment of Rs.7,000/- as costs of litigation. 15. Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. 16. Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. Announced 31st May, 2012. Sd/- (LAKSHMAN SHARMA) PRESIDENT Sd/- (MADHU MUTNEJA) MEMBER Sd/- (JASWINDER SINGH SIDHU) MEMBER Ad/-
DISTRICT CONSUMER FORUM-II C.C.No.38 of 2011 ORDER Present: None. --- The case was reserved on 29.05.2012. As per the detailed order of even date recorded separately, this complaint has been allowed qua OPs No.1 to 4 only and the same has been dismissed against OP No.5 to 7. After compliance file be consigned. Announced. 31.05.2012 Member President Member
| | MRS. MADHU MUTNEJA, MEMBER | HONABLE MR. LAKSHMAN SHARMA, PRESIDENT | MR. JASWINDER SINGH SIDHU, MEMBER | | 
