Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-206/18.08.2017
Sh. Digember Singh Chauhan
s/o Sh. Kailash Singh Chauhan
r/o B-5/29, Ground Floor, Sector-17,
Rohini, Delhi-110085 ...Complainant
Versus
OP1: The United India Insurance Company Ltd.
D.O. No. VII 10203, Jamuna House 3rd Floor
Padam Singh Road, Karol Bagh,
New Delhi-110005
OP2: The MD India Healthcare Services (TPA) Pvt. Ltd.
18/13, WEA, Ground Floor, Ganga Plaza,
Pusa Lane, Karol Bagh, New Delhi-110005 ...Opposite Party
Order Reserved on: 25.01.2023
Date of Order: 09.05.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Vyas Muni Rai
ORDER
1.1. The present complaint has been filed by Sh. Digember Singh Chauhan ( in short the complaint) under Section 12 of the Consumer Protection Act, 1986 against the United India Insurance Co. Ltd. (in short OP1) and the MD India Health Care Services (TPA) Pvt. Ltd. [in short OP2]. In brief, the complainant took the mediclaim policy [individual health policy] from OP1 vide policy no. 0407002816P110098027 which was valid from 29.10.2016 to 28.10.2017; OP2 is the TPA of the OP1. On 24.02.2017, the complainant visited at Ekansh Nursing Home in emergency with the complaints of severe pain left lower abdomen and difficulty in passing urine, dysuria and vomiting several times and treating doctors of the said nursing home advised him for hospitalization, accordingly he got admitted on same time/day and diagnosed as a case of UTI with left Ureteric Colic.
1.2. After the hospitalization, the complainant sent email dated 24.02.2017 to the OP2, on their email address intimating about the said hospitalization; complainant got discharged on 02.03.2017, thereafter, he submitted his claim form for Rs. 58,401/- [ Rs. fifty eight thousand four hundred one rupees] along with all the original medical documents to the OP2 on 09.03.2017 vide receipt no. ED546602456IN; on doing so, no response came from the OPs; complainant checked his claim status on the website of OP2 and it was found a query letter dated 11.04.2017 which was duly replied vide letter dated 12.04.2017 under acknowledgement along with required documents through speed post under acknowledgement on 12.04.2017 itself [ query letter dated 11.04.2017 and reply of the same dated 12.04.2017 are kept at page no. 39-40 of the paper-book].
1.3. Thereafter, one official of OP2 visited at the house of complainant for investigation of verification without prior intimation; where he met with the mother of the complainant as the complainant was not present at the home and the official took written statement of his mother regarding the illness of the complainant [statement of his mother is at page no 60 of the paper-book]. On 27.04.2017, complainant called on customer care number of OP2 and one official, namely, Sh. Jasbeer told the complainant that his claim is under process; on 29.05.2017, again the complainant called to customer care number of OP2 and this time one official namely Ms. Roshni told the complainant that his claim is still under process and he was provided the request no. 716637; complainant neither received any response from both the OPs nor the claim of the complainant was paid.
1.4. In the facts and circumstances of the case outlined above, the complainant has alleged deficiency in services, and unfair trade practices against OPs for acting dishonestly to the disadvantage of the complainant by causing harassment, mental tension etc. to the complainant.
1.5. Being feeling aggrieved from the acts/ omissions of OPs, complainant has filed this complaint with request to issue directions to OPs to pay an amount of Rs. 58,401/- under mediclaim insurance policy with interest at the rate of 18% pa and also, to pay compensation of Rs. 50,000/- for causing mental harassment and tension etc., apart from Rs. 25,000/- towards litigation costs.
2.1. OP1 has filed reply under the signature of Sh. Rajeev K. Gupta, AM, under the head i.e. ‘Preliminary Objections’ and ‘Reply On Merits’; in the Preliminary Objections; OP1 has taken the stand that complaint is not maintainable under the law as TPA, after scrutiny of documents submitted by the complainant, repudiated the claim as there is misrepresentation of facts in the claim documents; as such the claim is not maintainable under the law and complaint is liable to be dismissed. The patient was treated for UTI with left Ureteric Colic from 24.02.2017 to 02.03.2017; and claim is not admissible as per clause 5.7 of the policy, company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured or by any other person acting on his behalf. OP1 has also pleaded that Ekansh Hospital is the same hospital where patients were treated, whose complaint cases are pending before CDRF-Janakpuri, New Delhi, Vipin Taneja vs UIIC and Sunil Gupta vs UIIC cases are pending before the Hon’ble Forum; earlier number of false cases against the OP were filed and some have been challenged before Hon’ble State Commission, New Delhi. Therefore, in these circumstances, the present complaint is not maintainable under the law, the complainant has not come with clean hands and has concealed and suppressed material facts. In reply on merits, the contents of paras of the complaint have been denied being wrong and false while referring Preliminary Objections; OP has also pleaded that complainant is not consumer within definition of CP Act. However, deposit of premium has been admitted.
2.2. OP2(TPA) was served on 21.10.2017 with notice of complaint; Sh. Pradeep Chauhan, AR of OP2 appeared on 15.12.2017 and submitted that reply is ready and the same will be filed during the course of the day with an advance copy to the complainant, AR of OP2 again appeared on 06.02.2018, 23.03.2018 and 03.05.2018 but none appeared thereafter; nor any reply, affidavit etc. were filed on behalf of OP2.
3. The complainant has filed affidavit of evidence under his signature, while Sh. Rajeev K. Gupta, AM has filed the affidavit of evidence on behalf of OP1. In the affidavit file by the complainant document have also been referred which will be discussed at appropriate stage; Contents of affidavits of evidence of both the parties are narration of the facts given in their pleadings; both the parties have filed their written arguments and perusal of the same reveals that the contents of the written arguments are repetition and narration of facts given in their pleadings; no new facts/ features have been submitted.
4. We have considered and analysed the rival contentions of the parties & perused the documents on record. We have also considered the oral submissions of Mr. Tanuj Sharma, Counsel for the complainant but no oral submissions has been addressed on behalf of OP1 and OP2. The complainant’s mediclaim policy which was for the period of 29.10.2016 to 28.10.2017 in his name which is admitted facts by the parties [individual health policy at page no. 11 of the complaint]. In the said health policy schedule, it is mentioned that inception date of the first policy was 29.10.2011 for sum assured of Rs. 4,00,000/- having net premium of Rs. 3,438/-; intimation of email dated 24.02.2017 from the complainant regarding his hospitalization at Ekansh Nursing Home addressed to OP2(TPA) followed by submissions of necessary documents is also on record [page no. 10 and page no. 9 of complaint] and are admitted facts. It is also admitted by OP2(TPA) of receipt of claim document vide letter dated 03.02.2017 [page no. 39 of the complaint]; however, some additional information/ documents/ clarifications was sought from the complainant and the complainant vide letter dated 09.03.2017 [ page no. 9 of the complaint] submitted all the required documents [containing 30 pages] and requested to settle the claim at the earliest.
5. Vide letter dated 12.04.2017 addressed to OP2(TPA)[ at page no. 40]; which was in response to the queries raised by OP2; the complainant, inter alia, has submitted that what has been asked through this query letter; have already been submitted with original claim papers with a covering letter dated 09.03.2017; complainant in the letter dated 12.04.2017 has also opinioned; claim submitted by him has been scrutinized by an incompetent doctor/ quack etc., he further submitted complete IPD papers as asked for and the same has been mentioned in the letter of the complainant dated 12.04.2017, the complainant also submitted the claim with bill of total expenses amounting to Rs. 58,401/- incurred during his hospitalization [page no. 14-15 of the complaint], we also find on record discharge summary from the Ekansh Nursing Home [page no. 21 of the complaint] wherein details of the physical findings and the course provided during the hospitalization are mentioned; in the said discharge summary under the head “past history” consulting surgeon has mentioned that “no fever, loose motion or similar complaints in the past.”
6. In the reply & evidence filed by the OP1, there are allegations of adoption of fraudulent means or device on the part of the complainant but there is no description of fraudulent means adopted by complainant nor OP1 has proved the same. OP1 in its reply, affidavit of evidence and written submissions has also taken the stand that the claim is not admissible as per clause 5.7 of the policy; though, copy of the policy document having terms and conditions and the referred clause 5.7; on the basis of which the claim of the complainant has been denied, has not been filed on record; however, in the pleadings, affidavit of evidence, OP1 has deciphered clause 5.7 of the policy as under:-
“The company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his behalf.”
However, what was the fraudulent means and device adopted by the complainant in claiming his claim has not been mentioned and not proved by OP against the complainant; mere narration to the effect that Ekansh Hospital/ Nursing Home is the same hospital where patients were treated; whose claim cases are pending before CDRF- Janakpuri, New Delhi against UIIC are not sufficient reason to suffice the stand of OP1, unless there are specific findings in favour of OP1; nor any record of such order and finality of judgment has been submitted by OP1 in support of its stand.
7. OPs stand to the effect that complainant has not come with clean hands and has concealed and suppressed the material facts have also no legs to stand of its own in absence of any documentary proof; this stands has not been substantiated in any manner; allegations of OP1 against the Ekansh Nursing Home about pending of bogus claims by other claimants in different Commissions have also not been proved or any such final order has been submitted on record; mere allegations without document cannot stand to the scrutiny of law. Complainant has also filed on record a registration certificate dated 24.09.2014 certifying that registration of Ekansh Nursing Home, 122-123, Sahabad, Daultpur, Delhi-110042 is valid up to 31st March 2017; and the complainant was admitted in the said nursing home on 24.02.2017 and was discharged on 02.03.2017; during the validity of the said registration certificate, issued by Directorate of Health Services, Government of NCT of Delhi; OP1 has nowhere disputed about the veracity of the said registration certificate of Ekansh Nursing Home, in which the complainant was hospitalized for his treatment.
8.1. Having gone through the totality of the circumstances, the complainant has succeeded in establishing his case and proved deficiency in service and unfair trade practice against OPs in denying his just claim of Rs. 58,401/-, causing harassment, mental tension and expenses of litigation.
8.2. In view of the aforesaid discussions/ deliberations and careful analysis, we allow the complaint of the complainant for Rs. 58,401/- the claim/ expenses of his medical treatment, Rs. 10,000/- for causing harassment, mental tension, apart from Rs. 5,000/- as litigation cost to be paid by OP1.
However, if the aforesaid amount is not paid by the OP1 within 30 days from the receipt of the copy of this order, then amount of Rs. 58,401/- would be payable to the complainant with interest at the rate of 6% pa from the date of filing of the complaint till its realization.
9. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
10. Announced on this 09th May, 2023.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-207/18.08.2017
Sh. Lalit Kumar
s/o Sh. Partap Singh
r/o House No.-57, Village Bhorgarh
Narela, Delhi-110040 ...Complainant
Versus
OP1: The United India Insurance Company Ltd.
D.O. No. VII 10203, Jamuna House 3rd Floor
Padam Singh Road, Karol Bagh,
New Delhi-110005
OP2: The MD India Healthcare Services (TPA) Pvt. Ltd.
18/13, WEA, Ground Floor, Ganga Plaza,
Pusa Lane, Karol Bagh, New Delhi-110005 ...Opposite Party
Order Reserved on: 25.01.2023
Date of Order: 09.05.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Vyas Muni Rai
ORDER
1.1. This complaint has been filed u/s 12 of the CP Act, 1986 by Sh. Lalit Kumar (in short complainant) against OPs i.e. 1. United India Insurance Co. Ltd. (in short the OP1) and 2. MD India Healthcare Service (TPA) Pvt. Ltd. (in short the OP2).
1.2. The complainant is mediclaim policy (family medicare policy 2014) holder of the OP1, vide policy no. 0407002816P117594657 which was valid from 28.03.2017 to 27.03.2018. OP2 is the TPA of the OP1.
1.3. On 16.04.2017 to the complainant’s wife, namely, Shrimati Anju visited the Ekansh Nursing Home with complaint of swelling and pain in her left breast; Dr. Ashok Tandon of the nusing home advised her some pathological and radiological test; thereafter, she again visited the said nursing home on 19.04.2017 and met Dr. Ashok Tandon with test report; Doctor advised her some more tests followed by hospitalization on 20.04.2017 for surgery under his care; accordingly she was hospitalized in the said nursing home on 20.04.2017.
1.4. The complainant sent one email dated 19.04.2017 to OP2; prior to the hospitalization [ copy of email dated 19.04.2017 is Ex. CW1/2 / page no. 9 of the paper-book]. The complainant’s wife got discharged on 21.04.2017 [page no. 51]; thereafter; complainant submitted claim form for Rs. 1,06,959/- along with all the original mediclaim documents to the OP2 through speed post vide receipt no. ED194284730IN on 28.04.2017 with a covering letter [page no. 53 of the paper-book].
1.5. Subsequent thereof, on 24.05.2017, complainant got SMS on his mobile from OP2; vide which he was informed that one query has been raised by OP2, then the complainant checked the said query on the website of OP2 and found query dated 24.05.2017, thereafter complainant replied to the said query through letter dated 27.05.2017 [ letter dated 27.05.2017 is Ex. CW1/4- Page no. 52 of the paper-book] along with required documents through speed post on 27.05.2017[ proof of speed post dated 27.05.2017 is at page no. 52 of the paper-book].
1.6. On 01.06.2017, one official of OP2 visited at the house of the complainant for investigation and verification, who introduced himself as Mr. Srikant having employee code-5988, and he took the written statement of the complainant.
1.7. Complainant has pleaded that on various occasions, he called to the customer care number of OP2; then, officials/ phone attendant told the complainant every time that the present claim is under process but complainant never received any response from OPs and his claim remained unpaid.(bill details/ expenses on treatment are at page no. 16-17 of the paper-book)
1.8. The complainant has pleaded deficiency in service & unfair trade practices against OP for acting dishonestly to the disadvantage of complainant; the OP1 is responsible for OP2’s negligent action; as itss exercises supervision and control over the latter.
On perusal of the family medicare policy shows that the complainant has been taking the policy from OP since 2013 and sum insured is Rs. 5,00,000/-, with the total premium of Rs. 15,030/- [ policy document is Ex. CW1/1- page no. 10 of the paper-book].
1.9. In view of the alleged deficiency and unfair trade practice on the part of OPs, complainant has prayed to direct OPs to pay the amount of Rs. 1,06,959/- along with 18% interest pa, Rs. 1,00,000/- as compensation; for causing harassment, mental tension, besides a sum of Rs. 50,000/- towards cost of litigation
2.1. OP1 has filed the written statement under the signature of Sh. Rajeev K Gupta, AM under the head of 1. ‘Preliminary Objections’ and 2. ‘Reply on Merits’- in its reply, OP has pleaded that complaint is not maintainable under the law as the present complaint is premature; as the claim in question is still under process and the claim has not been repudiated by the TPA; present complaint is liable to be dismissed.
2.2. It has also been pleaded by OP1 that Ekansh Hospital/ Nursing Home is the same hospital, where the patients are being shown admitted there, just for the claim purpose only; whose complaint cases are pending before the CDRF- Janakpuri, New Delhi as well as complaint before this Hon’ble Forum title as Vipin Taneja vs UIIC and Sunil Gupta vs UIIC. It has also been alleged by OP1 that earlier number of false cases against OPs were pending and some of them have been challenged before the Hon’ble State Commission, New Delhi, therefore, the present complaint is not maintainable under the law and claim of the complainant is liable to be dismissed. The complainant has not come with clean hands before this Forum and has concealed and suppressed the material facts. In reply on merits, OP has denied the contents of the complaint being wrong and false or denied for want of knowledge and has also denied that OP1 is not responsible for OP2’s negligent action or of any deficiency of service or unfair trade practice or harassment, mental tension.
2.3. OP2 (TPA) has not file reply to complaint.
3. Complainant opted not want file rejoinder, as per proceedings dated 23.03.2018.
4. Both the parties have filed their affidavits of evidence. The complainant has filed affidavit of evidence under his signature and OP has filed the affidavit under the signature of Sh. Rajeev K. Gupta, AM; in the affidavits of both the parties, There is narration and repetition of the pleadings in the complaint and the reply respectively.
5. Both the parties have also filed their written arguments/ submissions and perusal of the same, no new facts have been found except the narration of the facts in their pleadings and reply.
6. We have considered and analysed the contentions and rival contentions of the parties, perused the documents on record and also considered the oral submissions addressed on behalf of the counsel for complainant, however, OP chose not to address the oral submissions despite opportunity given for the same.
OP2(TPA) has neither filed affidavit of evidence and the written submissions.
7. The complainant’s mediclaim policy [Family Medicare Policy] was valid for the period w.e.f. 28.03.2017 to 27.03.2018 and the inception period of the first policy is since 2013; mediclaim policy which is subject matter in this complaint is having sum insured of Rs. 5,00,000/- and the premium of Rs. 15,030/-. The complainant also submitted necessary documents to process his claim [ page no. 8 of the paper-book] and intimation of admission to the OP2 was vide email dated 19.04.2017 that his wife is to be hospitalized at Ekansh Nursing Home on 20.04.2017 for the operation of Fibroadenoma of the left breast. It is requested in the said email to register intimation and also send to a claim form. We also find letter dated 24.05.2017 from OP2(TPA) addressed to the complainant requiring some additional documents [ page no. 51 of the paper-book]. The said letter dated 24.05.2017 of the OP2 have been replied by the complainant vide his letter dated 27.05.2017 [page no. 52 of the paper-book] wherein, inter alia, he has stated that the documents asked by OP2 have already been submitted with original claim papers with a covering letter dated 28.04.2017 having acknowledgement of letter dated 27.05.2017 in its contends; details of treatment given to the wife of the complainant in the Ekansh Nursing Home, coupled with medicine details, hospital bills and receipt, discharge summary, pre-hospitalisation lab investigation reports and receipts etc. are also on record.
8. The complainant in his letter dated 27.05.2017 to OP2, inter alia, has also stated that the claim has been scrutinized by an incompetent doctor/ quack as necessary details have already been submitted to OP2. Discharge summary dated 21.04.2017 of the Ekansh Nursing Home [ Page no. 35 of the paper-book] has also been submitted by the complainant having history, past history; details of treatment and operation note are also described.
9. The stand of the OP1 in its reply that case is premature; as the claim in question is still under process and the claim has not been repudiated by the TPA does not stand to the scrutiny of law and IRDA guidelines/ regulations, 2002. OP’s stand that Ekansh Hospital/ Nursing Home is the same hospital where patients were treated; whose claim cases are pending before CDRF- Janakpuri, New Delhi against UIIC are not sufficient reason to suffice the stand of OP1, unless there are findings/ final orders in favour of OP1; nor any such order and finality of judgment has been submitted by OP1 in support of its stand.
10. OP’s stand that complainant has not come with clean hands and has concealed and suppressed the material facts have also no legs to stand of its own for want of documentary proof; this stands has not been substantiated in any manner; allegations of OP1 against the Ekansh Nursing Home about pendency of bogus claims by other claimants in different Commissions have also not been proved or any such final order has been submitted on record; mere allegations without documents cannot stand to the scrutiny of law.
11.1. As per the Act word ‘deficiency’ means any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained by or under any law for the time being in force or has been undertaken to be performed by a person in pursuance of a contract or otherwise in relation to any service and includes-
(i). Any act of negligence or omission or commission by such person which causes loss or injury to the consumer; and
(ii). Deliberate withholding of relevant information by such person to the consumer;
Having gone through the totality of the circumstances, the complainant has succeeded in establishing his case and proved deficiency in service and unfair trade practice against OPs in denying his just claim of Rs. 1,06,956/-, causing harassment, mental tension and expenses of litigation.
11.2. In view of the aforesaid discussions/ deliberations and careful analysis, we allow the complaint of the complainant for Rs. 1,06,956/- the claim/ expenses of his medical treatment, Rs. 10,000/- for causing harassment, mental tension, apart from Rs. 5,000/- as litigation cost to be paid by OP1.
However, if the aforesaid amount is not paid by the OP1 within 30 days from the receipt of the copy of this order, then amount of Rs. 1,06,956/- would be payable to the complainant with interest at the rate of 6% pa from the date of filing of the complaint till its realization.
12. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
13: Announced on this 9th May, 2023.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
