BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 367 of 2019 Date of Institution : 11.07.2019
Date of Decision : 27.02.2020.
Kumar Sanjeev Gautam @ Kumar Gautam aged about 37 years son of Sh. Vinay Kumar Singh, resident of Chopra Bazar, Ward No.5, Ramnagar Farsahi Poornia, Bihar- 854102, now posted as Branch Manager/ Senior Manager, Central Bank of India, Branch, Ellenabad, Distt. Sirsa.
……Complainant.
Versus.
1. United India Insurance Co. Ltd., 1st Floor, above OBC, City Thana Road, Sirsa, Tehsil and Distt. Sirsa through its Branch Manager (Ph. 01666-232253).
2. MDIndia Health Insurance TPA Pvt. Ltd., S. No. 46/1, E-Space, A-2, Building, 4th Floor, Pune Nagar Road, Vadgaonsheri, Pune- 411014, through its authorized person. Email-customercare@mdindia.com.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SMT. SUKHDEEP KAUR…………… MEMBER
Present: Sh. Amit Goyal, Advocate for the complainant.
Sh. Kapil Sharma, Advocate for opposite parties.
ORDER
In brief, the case of the complainant is that complainant is an employee in Central Bank of India and at present working as Branch Manager at Branch Ellenabad, District Sirsa since more than last two years. The Central Bank of India purchased health insurance for the employees including complainant and their families under Group Mediclaim Tailor Made scheme from op no.1 through op no.2. The op no.2 is service provider and working as a mediator/ agent of the op no.1. The complainant including his wife namely Nahar Neha have been insured by op no.1 vide policy No. 500100/28/18/P109951263 dated 1.10.2018 valid from 1.10.2018 to 30.9.2019 for sum assured of Rs.4,00,000/- and MDID no. MD15-0029773772, Emp. No. 068875. The Bank deducts a lump sum amount out of the salary of the complainant for providing health insurance facilities and pays the same to the ops against health insurance cover. The health insurance policy of complainant and his family is still continuous with the op. It is further averred that wife of complainant was got admitted in Gupta Nursing and Maternity Hospital, Ellenabad for delivery on 5.1.2019 and after successful delivery of a baby boy, she was discharged on 7.1.2019. The complainant duly intimated to the ops about the admission within requisite time period on the very day of admission. The above said health insurance policy was cashless policy but no hospital was located in the Ellenabad which were in the list of the ops under cashless scheme at the relevant time and therefore, the complainant himself spent whole expenditure of Rs.18,705/- and lodged the claim with the ops vide claim no. MD14636866. That thereafter complainant submitted the claim to the ops alongwith original bills as well as medical summary etc. alongwith detailed expenditure incurred by him on treatment excluding loss of income and expenses incurred on special diet and medicines after discharge. That thereafter, op no.2 vide email dated 27.2.2019 put the following objections:-
The claim documents were submitted on 11.2.2019, therefore, there was delay of submission of 20 days. The claim documents were not submitted within 15 days of date of discharge from the hospital. Hence we request you to provide clarification for the delay in submission of the documents.
Please provide attested photocopy of valid hospital registration certificate with mentioned registration number with expiry date registration certificate and number of beds.
2. It is further averred that complainant submitted the clarifications wherein he specified that all the relevant documents were submitted to his branch on 18.1.2019 and branch forwarded the same to their Regional Office on same day and enclosed the branch forwarding letter and doctor confirmation letter. That everything was made clear and was clarified to the ops but ultimately, the ops repudiated the claim of the complainant vide email dated 18.3.2019 on the ground that “As per claim documents it has been observed that the hospital is less than 10 bedded since this hospital does not fall under the definition of hospital/ Nursing home, the claim is not payable.”
3 It is further averred that concerned treating doctor has duly clarified vide his clarification that “No need of registration of Nursing Home in the small area (Semi Urban) and the total number of bed is 05 in our nursing home”. However, the op without giving any justifying reason has repudiated the medi claim of complainant and same is liable to be set aside. It is further averred that no nursing home is required to have compulsory registration having less than 10 beds and being semi urban area no other registered hospital is located having more than 10 beds in Ellenabad, therefore, the alleged rules under which the claim of complainant has been repudiated is not applicable. That later on the complainant provided all the relevant documents as demanded by ops for verification and for settlement of medical claim and ops started lingering the matter on one pretext or another and finally refused to entertain the claim of complainant on unreasonable ground without passing any speaking order. That ops have also committed an offence of cheating and complainant reserves his right to initiate criminal proceedings against the ops. That as per norms and rules of ops/ health insurance policy cover, the disease of wife of complainant is covered under the policy. That ops by their act and conduct have been indulged in unfair trade practice and have also committed gross deficiency in service towards the complainant due to which complainant has undergone harassment and mental tension. Hence, this complaint.
4. On notice, opposite party no.1 appeared and filed written statement taking certain preliminary objections. It is submitted that insured has violated the terms and conditions of insurance policy, which rendered himself disentitled to any claim whatsoever. The liability of answering op is subject to terms and conditions as laid down under the policy. The wife of complainant has been treated in a hospital having less than 10 bedded, since the hospital in which wife of insured was treated does not fall under the definition of hospital/ nursing home, which is in violation of the clause No.218 of the terms and conditions of the policy and as such complainant is not entitled to reimbursement of the bills of the treatment received from the hospital/ nursing home, which is not having atleast 10 beds and as such claim of complainant was rightly repudiated by the TPA vide letter dated 2.4.2019. It is further submitted that in case otherwise the complainant/ insured has submitted the documents on 11.2.2019 after delay of 20 days in violations of the terms and conditions of the insurance policy, which also rendered him disentitled to get any claim from the answering op. As per the terms and conditions of the policy, the complainant was bound to submit documents within 15 days from the date of discharge but he has failed to do so. It is submitted that complainant/ insured has concealed the true and material facts from this Forum and has not come with clean hands, hence he is not entitled to get any relief. The objections raised by answering op are legal, valid, genuine and binding upon the complainant. The liability of answering op is subject to terms and conditions as laid down under the policy and any disease is subject to the terms and conditions of the policy. Remaining contents of complaint are also denied and prayer for dismissal of complaint made.
5. Opposite party no.2 failed to appear despite notice sent through registered cover and as a period of more than 30 days elapsed, so op no.2 was proceeded against exparte.
6. The parties then led their respective evidence.
7. We have heard learned counsel for the parties and have gone through the case file carefully.
8. Learned counsel for complainant has contended that it is proved case of complainant that complainant was working as Branch Manager in Central Bank of India branch Ellenabad and bank purchased health insurance for its employees including complainant and their families under Group Mediclaim Tailor Made Scheme with op no.1 through op no.2. The complainant including his wife namely Nahar Neha have been insured by op no.1 vide policy No. 500100/28/18/P/109951263 dated 1.10.2018 valid from 1.10.2018 to 30.9.2019 with sum assured of Rs.4,00,000/-. The bank deducts a lump sum amount out of the salary of complainant for providing health insurance facilities and pays the same to ops against health insurance cover. During validity of this policy, wife of complainant Nahar Neha was got admitted in Gupta Nursing and Maternity Hospital, Ellenabad, District Sirsa for delivery of child on 5.1.2019 and she was discharged on 7.1.2019 after successful delivery of baby boy. He spent Rs.18,705/- on account of delivery charges and hospitalization etc. Claim was lodged and queries were raised by ops, but however, lastly the claim was repudiated on the ground that hospital in which wife of complainant gave birth to child is having less than 10 beds as a result of which claim was repudiated. The act of repudiating claim of complainant clearly amounts to deficiency in service and unfair trade practice on the part of ops.
9. On the other hand, learned counsel for op no.1 has strongly contended that it is proved fact on record that hospital in which wife of complainant gave delivery and remained admitted in the hospital was not having more than 10 beds and does not come under the definition of hospital/ nursing home. As per terms and conditions of the policy, where a hospital is of less than 10 beds, op no.1 is not bound to reimburse hospitalization charges of a patient insured with op. Learned counsel for op no.1 has relied upon judgment of Hon’ble National Commission in case titled as United India Insurance Co. Ltd. vs. Rajesh Katiyar, 2018 (3) CPR 752 in which complainant being a patient of jaundice had got himself admitted in Suyash Hospital, Bhopal where he was treated and that hospital was not a 15 bedded hospital as was required for reimbursement under the mediclaim policy and such claim was repudiated and Hon’ble National Commission dismissed the complaint of complainant.
10. We have considered rival contentions of the parties and have gone through the record as well as judgment relied upon by learned counsel for op no.1.
11. The perusal of evidence of complainant reveals that complainant has furnished his affidavit Ex.C1 in which he has deposed and reiterated the averments made in the complaint. He has also furnished copy of letter Ex.C2, copy of insurance card Ex.C3, copy of letter dated 26.2.2019 Ex.C4, copy of certificate of hospital Ex.C5, copy of letter dated 18.1.2019 Ex.C6, copy of discharge payments Ex.C7, copy of receipt Ex.C8, copies of medical bills Ex.C9 to Ex.C11, copy of delivery notes etc. Ex.C12, copy of ID card Ex.C13, copy of adhar card Ex.C14 and copy of email Ex.C15. On the other hand, op no.1 has furnished affidavit of Sh. Balram Bhadu, Senior Divisional Manager in which he has deposed and reiterated all the averments made in the written statement. Op no.1 has also furnished copy of policy Ex.R2, copy of repudiation letter dated 2.4.2019 Ex.R3, copy of additional document request Ex.R4, copy of certificate of hospital Ex.R5, copy of forwarding letter Ex.R6, copy of discharge payments Ex.R7 and copy of delivery notes Ex.R8.
12. It is an admitted fact on record that complainant is serving as Branch Manager in Central Bank of India at its Ellenabad branch. As per allegations of complainant, Ellenabad is a small town and wife of complainant was pregnant and delivery was due and complainant had no other option except to get timely delivery of his wife at Gupta Nursing and Maternity Home at Ellenabad where she remained admitted from 5.1.2019 to 7.1.2019 and gave birth to a baby boy. Op no.1 has not disputed qua admission and discharge of insured patient and further not disputed the bills for which reimbursement has been sought. The only objection of op no.1 insurance company is qua the fact that in the hospital where delivery of wife of complainant had taken place was having less than 10 beds and does not fall under the definition of hospital. No doubt, hospital where delivery of wife of complainant took place was having five beds but however, it appears to be genuine in case of delivery that one cannot exercise any option to move any faraway place in order to get delivery of his wife. During course of arguments, learned counsel for complainant has strongly contended that it was under compelling circumstances to get delivery of wife of complainant at nearby Gupta Nursing and Maternity Home since district headquarter was at a distance of more than 40 Kms. where medical facilities are available with number of approved hospitals. This contention of learned counsel for complainant has not been denied by learned counsel for op no.1 and same appears to be genuine. Moreover, judgment relied upon by learned counsel for op no.1 is having different facts from the facts of present case. So, non payment of claim amount of complainant clearly amounts to deficiency in service on the part of opposite parties.
13. In view of our above discussion, we allow this complaint and direct the opposite parties to settle and pay the claim of complainant as per terms and conditions of the policy within 30 days from the date of receipt of copy of this order, failing which complainant will be entitled to interest @7% per annum on the claim amount from the date of order till actual payment. We also direct the opposite parties to pay a sum of Rs.3000/- as compensation for harassment and Rs.2000/- as litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:27.02.2020. Member District Consumer Disputes
Redressal Forum, Sirsa.
