Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.414/05.12.2014
Shri Devender Trivedi s/o Lt. Sh. Bheru Lal,
Resident of 1-4/39, Sect-15,
Rohini, Delhi-110085 …Complainant
Versus
OP1- United India Insurance Company Ltd.,
(through branch manager)
30, 31 A Jeevan Vikas Building, 4th Floor,
Asaf Ali Road, New Delhi-110002.
OP2- Vipul Medcorp TPA Pvt. Ltd.,
515, Udyog Vihar, Phase-V,
Gurgaon (Haryana)-122016 ...Opposite Parties
Date of filing 05.12.2014
Date of Order: 10.08.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
ORDER
Inder Jeet Singh , President
1. (Introduction to case of parties) – The complainant alleges allegation of deficiency of service, since the complainant/ insured get his wife treated from the Ekanash Nursing Home for Dengue Fever but OP declined the medical claim of Rs. 29,706/- without plausible reasons. Whereas, the OP denies the allegations that complainant was given opportunities to furnish record and authorization for admission was not signed by insured.
2.1. (Case of complainant) –Succinctly, the complainant is medi-claim policy holder from OP1 vide policy no. 040200/48/13/97/00001098 with effect from 07.08.2013 to 06.08.2014 against payment of premium of Rs. 11,544/-. OP2 is TPA of OP1.
2.2. On 13.09.2013, complainant’s wife Mrs. Saroj Trivedi was admitted to Ekansh Nursing Home for treatment for dengue fever with thrombocytopenia, she was discharged on 05.10.2013. On 01.10.2013 the OP2/ Vipul Med Corp (TPA) Pvt. Ltd. was informed by email about hospitalization of wife of complainant. On 12.10.2013, after discharge of patient, the complainant submitted claim of Rs. 19,705/- with all original documents to OP2 by speed post. The OP2 made an enquiry dated 05.12.2013 and it was responded with relevant documents by speed post letter dated 30.01.2014.
2.3. The complainant was waiting for response from OPs, however, no response was received from them. It was 14.05.2014 when complainant browse on the website of OP2 to check the status of claim, then it was found the status of claim ‘closed’. The complainant never received any information or response/ correspondence of letters of complainant for releasing the amount Rs. 29,706/- and it is manifest from the status being shown on the website of OP2 that OPs have no intentions to reimburse the claim. The complainant made his best efforts by approaching the OPs but he failed miserably because of OPs. It is deficiency of services and unfair trade practices by OPs, as their acts are showing dishonesty & disadvantageous to complainant, apart from negligent acts of OP2 which caused harassment, mental tension and agony. That is why the complaint for refund of Rs. 29,708/-, compensation of Rs. 50,000/- and cost of Rs. 25,000/- besides other relief.
2.4. The complaint is accompanied with covering letter, intimation of hospitalization of 01.10.2013, copy of policy, claim form along with documents, advices & authorization for admission, discharge summary, bills, complainant’s reply dated 30.01.2014 to OP2 asking certificate and record from treating doctor, letter dated 27.01.2014 of certificate issued by the treating doctor, letter dated 05.12.2013 and other correspondence exchanged.
3.1 (Case of OP1)- The OP opposed the complaint vehemently by denying the allegations of deficiency of service or of unfair trade practice but admitting certain facts of issue of insurance policy, its tenure, premium amount as well as certain other allied facts stated to be matter of record, including status of ‘claim closed’ on website of OP2. The OP1 denies specifically that letter dated 30.09.2013 for authorization was not signed by the insured and claim was not settled, since the complainant was required to submit correct letter of authorization for admission. Moreover, the authorization dated 29.09.2013 for admission was incomplete and deficient record called was not furnished. The complaint is without cause of action. The complaint is bad and it is liable to be dismissed.
3.2. There is no reply by OP2.
4.1 (Evidence)- The complainant led his evidence by his detailed affidavit, it is on the pattern of complaint supplemented with the documents filed with the complaint.
4.2. The OP1 led evidence by filing affidavit of Ms. Reema, Deputy Manager and it is based on oral narration alike written statement without documents.
5. (Final hearing)- Both the parties have filed their written arguments and at the stage of oral submissions, Sh. Tanuj Sharma, Advocate for complainant presented the submissions and Sh. V.P. Malhotra, Advocate had appeared for the OPs.
7.1 (Findings)- The contentions of both the sides are considered keeping in view the record of evidence (either oral narration in the form of affidavit or documentary record) apart from the contentions raised during final hearing.
It does not require to reproduce their contentions, since the case of parties have already been detailed in paragraphs 2 and 3 above.
7.2. By taking into account stock of all the material and circumstances, the following conclusions are drawn, which will answer and determine issues and will also dispose off the contentions of the parties:-
(i) There is discharge summary (on page no. 20 of the paper book of complaint), the date of admission is 30.09.2013 and of discharge is 05.10.2013 in respect of treatment of Smt. Saroj Trivedi wife of insured/complainant. It is not disputed that she had undergone treatment for Dengue fever and thrombocytopenia. However, the OP1 has reservations that admission authorization does not bear signature of insured.
(ii) The complainant has filed medical papers. One of the record is of date 29.09.2013 [at page no. 54] about examination of patient and at page-19, it is record of 30.09.2013, it advises hospitalization of the patient. There is other medical record/papers at page-44 & 45 of the paper book, which also gives details about the admission and discharge of Smt. Saroj Trivedi inclusive of authorization for admission. The OP1 had asked complainant certificate from treating doctor about such authorization as well as justification for stay for five days in the hospital, the same was furnished as treating doctor of hospital & issued certificate dated 27.01.2014 while explaining all the circumstances and requirement for treatment of ailments for stay in the hospital, by specifying that in dengue fever treatment the platelet count is not the exclusive criteria but other symptoms and general conditions of patient are also considered for treatment to a dengue patient, which was also the case of Smt. Saroj Trivedi.
There are signatures of the treating doctor on all such records of 29.09.2013, 30.09.2013, discharge summary and letter dated 27.01.2014. It is surprising to note that OP1 is not disputing documents issued by treating doctor either discharge summary or other letters issued except suggesting deficiency of signature of insured is not present on card dated 29.09.2013 (page 54 of paper-book). Whereas, authorization of admission on page 45 bears the signature of insured as a witness, which are further counter signed and seal by the Ekansh Nursing Home. The card dated 29.09.2013 is by treating doctor, it does not mention column/space for signature of insured. The objections raised on behalf of OP1 do not sustain.
(iii) The complainant in para-8 of the complaint pleads that on 14.05.2014, when the website of OP2 was browsed, it showed that claims status as ‘closed’ and the OP1 in its written statement responded that it is matter of record, which is also the evidence of the parties. It is admitted fact by OP1.
However, OP1 further claims that let the complainant to furnish correct letter of authorization so that claim may be decided. The OP1 is taking inconsistent plea and stand that on the one hand the OP2 is mentioning ‘closed of the claim’ under the instructions of OP1, which OP1 is confirming in written statement and on the other side OP1 is projecting as if the claim is yet to be decided after furnishing of correct authorization. The OP1 further maintains this stand in the written arguments, however, it does not sustain in view of the aforementioned conclusion in this sub-paragraph that OPs have closed the claim. It is not the case of OP1 to be re-opened claim.
(iv) The documentary record proved by the complainant in the form of medical advises, indoor patient record, the treatment rendered, authorization for admission, physician progress report and other medical bills are in sequence, which depicts that firstly complainant was examined and thereafter because of medical need the complainant’s wife was admitted in the hospital and she remained there as indoor patient for five days, the medical expenses are pertaining that hospitalization and treatment. The complainant has proved valid medical claim.
(v) Since, the circumstances are establishing case of medical treatment and expenses, which are covered within the medical policy as well as during the tenure of policy but OP1 failed to reimburse that amount of Rs. 29,706/-. For want of reimbursement of valid claim by OPs, it amounts to deficiency of services.
(vi) The complainant made efforts for reimbursement of the claim, he could not succeed. but he faced all kind of harassment/trauma. The complaint is competent.
7.3. Thus, the facts on record proves case of complainant that he lodged valid medical claim of amount of Rs. 29,706/-. Thus, complainant is entitled for reimbursement of Rs.29,706/-..
7.4. The complainant has sought interest @ 18% pa, however, considering facts & features of case as well as complainant was deprived of his claim, interest @ 8% pa would be justified for both ends, interest will be computed from the date of complaint till realization of amount against the OP1.
7.5. The complainant has also sought damages of Rs.50,000/- towards harassment, mental tension and agony and also by repudiating the claim & costs of Rs.25,000/-; considering totality of circumstances of case of both sides, damages are quantified as Rs 15,000/- apart from cost of litigation of Rs.10,000/-in his favour and against the OP1
7.6. Since OP2 is TPA, who facilitates the process of claim for OP1, therefore, no order against OP2, the complaint is dismissed against OP2.
7.7. Accordingly, the complaint is allowed in favour of complainant and against the OP1 to reimburse medical bills amount of Rs. 29,706/- along-with simple interest @ 8%pa from the date of complaint till realization of amount; apart from, to pay damages of Rs.15,000/- & costs of Rs.10,000/- to complainant.
OP1 is also directed to pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, the interest will be 10% per annum on amount of Rs. 29,706/-.
8. Announced on this 10th August 2023 [श्र!वण 19, साका 1945].
9. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [InderJeet Singh]
Member Member (Female) President
