Delhi

East Delhi

cc/514/2013

ITI GOEL - Complainant(s)

Versus

U.I.C - Opp.Party(s)

01 Oct 2013

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, SAINI ENCLAVE, DELHI-92

CC No.514/2013:

In the Matter of:

Smt. Iti Goel

House No.25/77, Gali No.15,

Vishwas Nagar, Shahdara,

Delhi-110 032

            Complainant

Vs

 

1. United India Insurance Co. Ltd.

Bancassurance Office : 68/1, Janpath,

New Delhi – 110 001

 

2. TPA

Medsave Health Care Ltd.

F-701A, Lado Sarai, Mehrauli,

New Delhi – 110 030

•  

     

                                                   Date of Admission - 22/07/2013        

Date of Order          - 06/02/2016

O R D E R

Poonam Malhotra, Member :

The brief facts of the present complaint are that the complainant, her husband and son were insured under a mediclaim policy for Rs.5,00,000/- with the Respondent No.I for the period of one year reckoning from 09/11/2012 vide Policy No.040500/48/12/14/00003392.  On 01/01/2013 the husband of the complainant felt indisposed &visited his doctor. On 03/01/2013 the husband of the complainant, Sh. Kamal Prakash Goel, got admitted to Taneja Hospital on the advice of his doctor for the treatment of LRTI with Septicemia and the Respondent No.II was duly intimated on 04/01/2013 and he was given the Medsave Reference No./File No. 20130116BOO1R4C2431 by the Respondent No.II.  The husband of the complainant was discharged from the hospital on 09/01/2013 and a bill of Rs.52,921/- was raised by the hospital.  A claim of Rs.53,380/- was lodged by the complainant and all the documents viz., original bills, Discharge Summary, Lab Testing Reports, etc. were submitted to the Respondent No.II.  The claim of the complainant was repudiated vide Letter dated 28/03/2013 on the ground that the purchase bill of a particular medicine had not been shown by the seller who sold the medicine to the hospital.  Objections to the repudiation were submitted to the respondents vide letter dated 29/04/2013 but in vain.  The complainant has prayed for directions to the respondents for reimbursement of his mediclaim of Rs.53,380/- which includes the hospital bill of Rs.52,921/- and pre – hospitalization bill of Rs.459/-.  He has also prayed for compensation of Rs.25,000/- for harassment & mental agony &Rs.10,000/- as the litigation cost.

 

In response to the notices issued to the respondents, reply filed by the Insurance Company, the Respondent No.I herein, only wherein while admitting the fact of issuance of Synd Arogya Group Mediclaim Insurance Policy bearing No.040500/48/12/14/00003392 for the period 14/11/2012 to 13/11/2013 to the complainant, it has challenged the discharge of the husband of the complainant from the Taneja Hospital on 09/01/2013 and has contended that the bills of Rs.52,291/- raised by the Taneja hospital and claimed by the complainant are false & fabricated.  It is submitted that the said claim has been thoroughly investigated by Respondent No.II, the TPA of Respondent No.I, and it has been found that the husband of the complainant was purportedly administered 17 injections of Eupen 500mg, cost of each injection being Rs.1,188/-. The said medicine was purchased by M/s. Altius Chemist, the pharmacy of the said hospital, from M/s. Adinath Medical Store, 330, Gyan Khand 1^st, Indirapuram, Ghaziabad – 201 010, U.P.   On investigation it was found that M/s. Adinath Medical Store refused to verify the said bill for want of record pertaining to it.  It was stated by them that they had purchased the said injections from Bhagirath Palace without any record.  It is also contended that the contents of the Discharge Summary & History Sheet of the patient are contradictory and in view of all the said facts it has repudiated the claim of the complainant as being hit by Condition No.5.7 of the Terms & Conditions of the said Insurance Policy as a fraudulent claim. Rest all of the allegations have been denied.

 

Rejoinder to the written statement of Respondent No.I to rebut the contentions raised by it and affidavit in evidence to reaffirm on oath the allegations made by her in her complaint filed by the complainant.  No affidavit in evidence filed by the respondents in support of their respective cases.       

 

Heard and perused the record.

The fact of issuance of a Mediclaim Policy of Rs.5,00,000/- by the Respondent No.I covering the complainant, her husband & her son under the policy for the period of one year from 14/11/2012 to 13/11/2013 vide Policy No.040500/48/12/14/00003392is not in dispute. Copy of the said policy has been filed on record as Annexure – I to the complaint.  She has also filed on record the documents relating to the pre-hospitalization treatment & with regard to the treatment of her husband at the Taneja Hospital from 03/01/2013 to 09/01/2013 for LRTI with Septicemia.  It is evident from the perusal of the Discharge Summary that on Sh. Kamal Prakash was admitted on 03/01/2013 to the Taneja Hospital for the treatment of LRTI with Septicemia and he was discharged from the hospital on 09/01/2013.  A total bill of Rs.52,921/- raised by the hospital was paid by the complainant and receipts were issued to her for the payments made by her.  Copies of the documents filed on record and the allegations made in the complaint have been verified on oath by the complainant.   The Respondent No.I in its written statement has controverted the allegations made in the complaint but it has not verified on oath the contentions made by it in its written statement.   In the present complaint the claim of the complainant  repudiated by the Respondent No.1 as being hit by condition 5.7, of the terms & conditions of the policy purchased by the complainant, as being fraudulent & supported by fraudulent means by the insured person or by any other person acting on his behalf. It is alleged by the Respondent No1 that on investigation of the claim lodged by complainant by its TPA, the Respondent No. II herein, they found that 17 injections of EUPEN 500 mg were administered to the husband of the Complainant during his period of hospitalization & the bill with regard to the purchase of the said injections by the in house hospital pharmacy from M/S. Adinath Medical Store Ghaziabad upon verification were found to be not genuine but is alleged to have been prepared fraudulently to claim undue benefit from the Insurance Company through claims as M/S Adinath Medical Store failed to produce the purchase records of the said medicine. In the light of the said observations made by the Respondents in their Repudiation Letter dt. 28/03/2013 there is not a scintilla of doubt that no element of fraud has been imputed to the Complainant, the insured person, or any other person acting on his behalf. On a plain reading of condition 5.7 it is abundantly clear that the fraud to be made a ground for the rejection of an insurance claim should be ascribable to the insured person or to any other person acting on his behalf. The fraud that can form the basis of repudiation of the claim has a very limited domain & its sphere cannot be extended arbitrarily by the Insurance Company Officials to include the frauds which are not imputable to the insured person or any other person acting on his behalf to repudiate the bonafide claim of the insured. In fact the Respondents have blatantly erred in rejecting the claim of the Complainant & their act of Repudiation of the claim of the Complainant on such arbitrary grounds is exhibitory of lack of interpretational ability of their officials entrusted with the responsibility to decide the claims of the insured persons. It is pertinent to mention here that by repudiating the genuine claims on such flimsy grounds or no ground at all the insurance companies would frustrate the very objective with which the people purchase the insurance policies.

We have observed in a number of cases that the Insurance Companies are rejecting the bonafide claims of the insured under the Policies of Insurance on arbitrary & flimsy grounds or no ground at all. Such rejections not only cause back-breaking & grave harassment of the consumer but it also affects the interest of the Insurance Companies who are burdened with extra payment by way of compensation, costs, interest, etc., due to the shirky approach adopted by the officials while deciding the insurance claims in the discharge of their duties. It is pertinent to mention here that if a bonafide claim is allowed, the insurance company can indubitably avoid the payment of compensation, litigation costs, interest, etc., which is thrust upon it due to the shirky approach adopted by its officials responsible for deciding the claims made by the insured persons under the insurance policies. Such rejections need to be taken seriously by the Insurance Companies & any official found indulging in such practice of earning the insurance company with financial liabilities which could be averted had he discharged his duties without avoiding the performance of his duties & the entire amount of compensation, costs, interest, etc with which the Insurance Company is burdened due to such uncalled for & arbitrary rejections. Such rejections besides burdening the insurance companies with unwarranted financial liabilities bring discredit to the companies. The instant case is glaring example of how the insurance company officials shirk from their responsibility of taking a decision for allowing a genuine claim & payment thereof to the insured/claimant & forcing them to take recourse to litigation for obtaining a judicial order to save themselves from the queries, if any that might be raised at a subsequent stage. On the contrary, if it was found by the Respondent Insurance Company upon investigation that the hospital was involved in some malpractice it was for the insurance company to depand it but it was certainly under an obligation to reimburse the claim of the Complainant.

We would like the Govt. Of India, the chairman of Insurance Regulatory & Development Authority of India & the Chairman of the Respondent Insurance Company to take definite curative measure to streamline the process of insurance claim settlement in order to achieve the objective behind taking an insurance policy in order to avoid the gruelling harassment of the consumers who lodge bonafide claims under the insurance policies taken by them.

            Taking into consideration the observations & discussion made supra, we allow this complaint & direct the Respondent No.I to reimburse the amount of Rs.53,230/- (i.e. Rs.52,921/- being the total bill raised by the hospital & Rs.309/- being the pre-hospitalization medicine bill filed on record as against Rs.459/- claimed by the Complainant) together with interest @ 10% p.a. Thereon from the date of payment made to the hospital till it is finally paid to the Respondent No.I. The Complaiannt of the present case has been put to gruelling harassment due to the uncalled for rejection of her bonafide claim and an unwanted litigation has been thrust upon her. We further award a compensation of Rs. 30,000/- & Rs.5,000/- as cost of litigation to the Complainant. The said amount of compensation & cost shall be recovered from the salary of the official of Respondent No.I who has repudiated the bonafide claim of the Complainant. The compliance of this order be made within 45 days from the date of this order.

            Copy of the order be supplied to the parties as per rules. Let the copy of this order be also served upon the secretary, Finance, Govt. Of India, the chairman of the Insurance Regulatory & Development Authority of India & the chairman of the Respondent Insurance Company for necessary action on their respective parts in the light of the observations made in the judgement.  

Copies of the order be supplied to the parties as per rules.

 

(Poonam Malhotra)                                                                                                (N.A.Zaidi)

        Member                                                                                                            President