BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 385 of 2015

Date of Institution: 10-06-2015

Date of Decision: 17-03-2016  

Ankush Bhalla (aged 35 years)  son of Sh.Kuldip Bhalla, resident of 17-Race Course Road, Amritsar. 

Complainant

Versus

1. United India Insurance Company Limited, DO-II, Chennai, Office Type. DO, Building Name, Sudharshan Building, Door No. 14, New No.27, Floor No.2, Road Name, Whites Road, Locality/ Area Royalpettah, City Chennai-600014.
2. Vidal health TPA Private Limited # 88, 2^nd Floor, Anmol Palani, G.N.Chetty Road, T-Nagar, Chenai-600017.
3. United India Insurance Company Limited, Divisional Branch No.1, II Post Box No.7, Madan Mohan Malvia Road, Amritsar-141001.

Opposite Parties

Complaint under the Consumer Protection Act.

Present: For the Complainant: In person.

              For Opposite Parties No.1 and 3: Sh.P.N.Khanna Advocate.

              For Opposite Party No.2: Exparte.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Ankush Bhalla  under the provisions of the Consumer Protection Act alleging therein that  he got mediclaim policy  bearing No. 01110148140660000389 from Opposite Parties valid for the period from 20.7.2014 to 19.7.2015 for  sum insured Rs.2 lacs by paying premium of Rs.3805/-. On 10.2.2015 the complainant was admitted in Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar as he was suffering from high grade fever with acute abdominal pain, general weakness and pain in the whole body. The complainant was discharged on 14.2.2015 and spent Rs.26,213/- to Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar. After discharge from the hospital, the complainant sent all the bills alongwith all the test reports, medical bills, discharge summary and all the documents to Opposite Party No.2-TPA on 21.2.2015. Thereafter, the complainant received a letter dated 3.3.2015 from Opposite Party No.2-TPA to prove  two queries i.e. i) need payment receipts for Rs.15,900/- and ii) need treating doctor to provide the detail of treatment giving during hospitalization. However, the complainant had already sent the receipt of Rs.15,900/- alongwith all the documents on 21.2.2015. Again on 25.5.2015, the complainant received e-mail alongwith NOC form to fill and give authorization to them so that Opposite Party No.2-TPA could collect the required query from the treating hospital. Accordingly, the complainant filled the requisite form and sent the same to Opposite Party No.2-TPA. But the Opposite Party No.2-TPA harassing the complainant by sending one to another letters to provide query.  Alleging the same to be deficiency in service, complaint was filed seeking directions to Opposite Parties  to pay the claim amount of Rs.26,213/- alongwith interest @ 12% per annum alongwith Rs.10,000/- being the litigation expenses.
2. On notice, Opposite Parties No.1 and 3  appeared and filed written version in which it was submitted that certain documents were demanded by Opposite Party No.2-TPA from the complainant, but the complainant could not get the said documents from the hospital and for which Opposite Parties  No.1 and 3 obtained NOC from the complainant and approached directly to the concerned hospital authorities for obtaining the required reports. As per the documents received from the hospital, it was found that the patient’s record i.e. present complainant shows 100.4 degree Celsius fever during admission. It was  further observed that lab report dated 10.2.2015 from City Diagnostic Centre had no reading as to Vidal Test conducted and also in the report dated 13.2.2015, but hand written mention of the same Vidal Positive is found on the report given by Pulse Hospital (Lab Investigation). Under these circumstances, the matter was referred to the independent doctor at Chennai by Opposite Parties  No.1 and 3 for second opinion in addition to the decision taken by Opposite Party No.2-TPA and the said doctor has also given opinion that the patient could not have suffered from typhoid fever from the record  submitted. Further the patient could have been treated on outpatient case itself. So, the hospital authorities have misguided the patient and provided the treatment which is otherwise not necessary. Therefore, the claim was repudiated under clause No. 3.23 of the terms and conditions of the policy. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Party No.2 not appeared despite service, so Opposite Party No.2 was proceeded against exparte vide order dated 11.8.2015 of this Forum.
4. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C19 and closed the evidence on behalf of the complainant.
5. Opposite Parties  No.1 and 3 tendered into evidence affidavit of Sh.Surinder Singh, Divisional Manager Ex.OP1 & 3/1 alongwith documents Ex.OP1 & 3/2 to Ex.OP1 & 3/12  and closed the evidence on behalf of Opposite Parties  No.1 and 3.
6. We have carefully gone through the pleadings of the parties; arguments advanced by the complainant and ld.counsel for Opposite Parties  No.1 and 3  and have appreciated the evidence produced on record by both the parties with the valuable assistance of  ld.counsel for Opposite Parties  No.1 and 3.
7. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that  the complainant got mediclaim policy  bearing No. 01110148140660000389 from Opposite Party No.1 valid for the period from 20.7.2014 to 19.7.2015 with sum assured  Rs.2 lacs. On 10.2.2015 the complainant fell ill and he was admitted in Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar for  high grade fever with acute abdominal pain, general weakness and pain in the whole body. The complainant was medically treated there and  was  discharged on 14.2.2015. The complainant  paid Rs.26,213/- to the hospital authorities vide Ex.C2. The complainant lodged claim with Opposite Party No.2-TPA on 21.2.2015. Said Opposite Party No.2-TPA raised query to the complainant vide letter dated 3.3.2015 Ex.C3  to produce the treating doctor alongwith detail of the treatment given to the complainant during hospitalization. The complainant gave authorization to Opposite Parties  No.1 and 3 vide Ex.C11 to take the medical treatment record directly from the hospital i.e. Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar on behalf of the complainant. But even then Opposite Parties did not settle the claim of the complainant. Ld.counsel for the complainant  submitted that all this amounts to deficiency of service on the part of the Opposite Parties qua the complainant.
8. Whereas the case of the Opposite Parties No.1 and 3 is that certain documents were demanded by Opposite Party No.2-TPA from the complainant, but the complainant could not produce said documents. The complainant gave NOC to the insurance company for collecting the said relevant documents directly from the hospital authorities. As per the documents received from the hospital, the patient’s record shows that he was having 100.4 degree Celsius fever during admission. It was  further observed from the lab report dated 10.2.2015 from City Diagnostic Centre that complainant had no reading as to Vidal Test. However, in the report dated 13.2.2015 Ex.OP1 & 3/9 which is hand written, it is  mentioned ‘Vidal Positive’ on the report given by Pulse Hospital (Lab Investigation). Resultantly, the  matter was referred to the independent doctor at Chennai by Opposite Parties  No.1 and 3 who gave his report Ex.OP1 & 3/3 that the patient could not have suffered from typhoid fever  and he could have been treated on outpatient care. Under these circumstances, the Opposite Parties repudiated the claim of the complainant under   clause No. 3.23 of the terms and conditions of the policy. Ld.counsel for Opposite Parties  No.1 and 3 submitted that there is no deficiency of service on the part of the Opposite Parties.
9. From the entire above discussion, we have come to the conclusion that  the complainant got mediclaim policy  bearing No. 01110148140660000389 from Opposite Party No.1 valid for the period from 20.7.2014 to 19.7.2015 with sum assured  Rs.2 lacs. On 10.2.2015 the complainant fell ill and he was admitted in Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar for  high grade fever with acute abdominal pain. The complainant was medically treated there and during admission, the complainant was  tested ‘Vidal Positive’ as per Lab  Investigation of  Pulse Hospital Ex.OP1& 3/9. The complainant was discharged on 14.2.2015 as per discharge summary Ex.C2 and paid Rs.26,213/- to the hospital authorities as per bills of Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar attached with discharge summary Ex.C2. The complainant lodged claim with Opposite Party No.2-TPA on 21.2.2015. The complainant also gave authorization to Opposite Parties  No.1 and 3 (Ex.C11) to take medical treatment record  directly from the hospital  i.e. Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar and the Opposite Parties got the medical treatment record of the complainant from that hospital. Opposite Parties  repudiated the claim of the complainant vide letter dated 13.7.2015 Ex.OP1 & 3/11 on the basis of certificate issued by Dr.R.Senthil Kumar, Child Specialist Ex.OP1, 3/3 who gave his opinion  that patient could not have suffered from Typhoid fever  as per the records submitted, he could have been treated as out patient case itself. Opposite Parties  repudiated the claim of the complainant on the basis of this certificate dated 30.6.2015 Ex.OP1,3/3 issued by empanelled doctor  of Opposite Parties. Here we do not agree with this contention of the Opposite Parties  because the record of Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar where the patient was medically treated and lab investigation Ex.OP1, 3/4 of the complainant fully proves that the complainant was tested Vidal Positive. How the empanelled doctor of the Opposite Parties  while sitting at Chennai can state through  his certificate Ex.OP1,3/3 that the patient could not have been suffered from typhoid. This certificate itself does not appear to be proper because as per the opinion of this doctor,  the patient could not have been suffered  from typhoid fever. He has not given opinion  that the patient was not suffering from typhoid fever. Whereas the treatment record of the complainant at Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar Ex.OP1,3/9 fully proves that the complainant was tested ‘Vidal Positive’ and for that purpose he was admitted in the hospital on 10.2.2015 and was discharged on 14.2.2015 and it can not be stated that this treatment could be done in OPD. So, the Opposite Parties  were not justified in repudiating the claim of the complainant.
10. Resultantly, we allow the complainant of the complainant with costs and the Opposite Parties  are directed to  reimburse the amount of Rs.26,213/- spent on the medical treatment of the complainant  at Pulse Hospital, Maqboolpura Chowk, Mehta Road, Amritsar, to the complainant within one month from the date of receipt of copy of this order, failing which the Opposite Parties shall be liable to pay interest @ 9% per annum on this amount of Rs.26,213/-, from the date of filing of the complaint till the payment  is made to the complainant. Opposite Parties are also directed to pay to the complainant  the litigation expenses to the tune of Rs.2,000/-.   Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 17-03-2016.                                                   (Bhupinder Singh)                                                                                                                                                                                                   President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)    

                                                     Member                         Member