Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-78/2017
Smt. Raj Rani w/o Late Sh. Mahavir Singh,
Through LR Babita,
r/o House No.-959, Pana Paposiya,
near Vijay Chowk, Narela, Delhi ...Complainant
Versus
OP1: United India Insurance Co. Ltd.
Through its Authorized Signatory,
At- 18/13, WEA, G/F, Ganga Plaza,
Pusa Lane, Karol Bagh, New Delhi-110005
OP2: MD India Healthcare Services (TPA) Pvt. Ltd.
Through its A.S./ Director, At- no.-46/1, E-Space,
A Wing, 3rd floor, Pune Nagar Road, Vadgaonsheri
Pune-411014
Also at:- 18/13, WEA, G/F Ganga Plaza, Pusa Lane,
Karol Bagh, New Delhi-110005 ...Opposite Parties
Date of filing: 09.03.2017
Date of Order: 06.07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Vyas Muni Rai
ORDER
1.1. This complaint was filed by Raj Rani ((in short complainant now deceased) and being represented by her LR Ms. Babita under Section 12 of the Consumer Protection Act 1986 against United India Insurance Company (in short OP1) and MD India Health Services (TPA) Pvt. Ltd. (in short OP2/TPA). Raj Rani took health insurance policy under the bank employee scheme to cover diseases as specified by OP1; in the said scheme Raj Rani deposited premium amount with OP1 vide policy no. 500/00/28/15/P113019799 and thereafter OP2 issued ID no. MDIS-0030042201.
1.2. As per the guidelines, said scheme was cashless, whereas OP1/ the Insurance Company shall pay of expenses incurred in the course of medical treatment availed by the beneficiary in the empanelled hospital for illness/ disease/ injury/ sickness; all diseases under the said cover was to be covered from day one i.e. person suffering any disease prior to inception of the policy, which also includes 07 days pre-hospitalization and 30 days post hospitalization.
1.3. The complainant felt pain in left side of the chest with dyspnea, unconsciousness and breathing problem on 12.10.2016 and she preferred to take medical treatment from Inderprasth Apollo Hospital, Sarita Vihar, New Delhi, she was attended by the doctor and as per the advice, treatment was given to the complainant.
1.4. During the course of treatment, the attending doctor advised complainant to undergo bilateral mammography and she was further advised to undergo PET/MRI SCAN of whole body. During the treatment, hospital authorities started processing the claim form with OP1 and OP2; however, hospital authorities conveyed to the complainant on 14.10.2016 that her claim has been rejected by OPs. Complainant was recommended for discharge by the Apollo Hospital; however, when she came to know about the rejection of the claim, complainant immediately fell unconscious, thereafter she was again taken care of by hospital authority; the complainant was not in a position to pay the amount of Rs. 56,960/- to the hospital on 14.10.2016, therefore, she was compelled to take loan from friends and relatives and deposited the said amount in cash in hospital and got discharged on 15.10.2016.
1.5. Rejection of the claim by the OP is unsustainable in law as OPs were bound to pass the claim of the complainant as per the terms and conditions of the employee scheme. It is further pleaded that during the course of hospitalization on 12.10.2016; policy was in existence; the ground of rejection was conveyed by OP2 to the hospital that patient was not required to be admitted in hospital for treatment.
1.6. It was for the treating doctors to decide about the course of treatment and necessity for admission and in such circumstances patient has to follow and obey the directions of the doctor, which was done so.
1.7. The complainant also informed OP1 and OP2 regarding the amount spent by her but OP1 instead of paying heed started threatening the complainant with dire consequences. Feeling aggrieved, complainant sent legal/ demand notice dated 12.01.2017 to OP1 and OP2 through her counsel but OP1 with mala fide intention intentionally did not receive the legal notice and got it endorsed from the postal authority that no such company was in existence at the given address, however, OP2 received the legal notice on both the addresses but no initiation in processing the claim of the complainant.
1.8. Complainant has alleged deficiency of service on the part of OP1 and OP2 and has prayed for direction to be issued to OP1 and OP2 to pay some of Rs. 56,960/- + Rs. 2,663/- the amount spent during hospitalization; Rs. 2,00,000/-towards mental pain and agony; and also to pay interest at the rate of 24% pa on the entire claim amount from the date of discharge from the hospital that is 15.10.2016 till its realization.
2.1. OP1 has filed the reply under the signature of Sh. Gyanprakash, Administrative Officer in the company of OP1. Insurance is a matter of contract between the insurer and the insured and is governed by the terms and conditions of the contract; and OP1 is not liable for any claim which is either not covered under the policy or is in violation of the terms and conditions of the contract; insurance policy is not admitted for want of confirmation from concerned office(complainant was the employee and retired from erstwhile Indian Overseas Bank).
2.2. OP1 took objection that date of discharge of the complainant from hospital was 15.10.2016 and claim documents were submitted on 02.01.2017, therefore, there was delay of 49 days in submissions of the documents; the claim of the complainant was not considered for want of documents i.e. clarifications for delay in submissions of documents with approval from the bank’s Nodal Officer; the required documents including all the paid receipts made to the hospital for Rs. 56,960/-, Raj Rani was admitted for diagnosis of hypertension and for investigation purpose only, the investigation is not covered under the insurance policy, the claim was closed on the ground of non-compliance of required documents, claim is not maintainable in the absence of all necessary parties.
2.3. Raj Rani (complainant) expired on 27.12.2017; an application on behalf of Babita, d/o Raj Rani- w/o Rohtash Singh was moved as only legal representative of the deceased, however, by permitting such application will be in violation of Hindu Succession Act, without obtaining probate of the ‘Will’ dated 01.06.2017 of Raj Rani, as there are other surviving members as legal heirs of the deceased, though, other legal heirs are also to be represented/ impleaded as necessary party, the order of the Commission is not tenable in eyes of law.
2.4. Complainant did not approach Hon’ble Forum with clean hadns and Indian Overseas Bank was not made necessary party before the CDRF, ISBT, New Delhi with whom the contractual relationship exist with the insurance company. The present claim petition is not maintainable because of mis-joinder and non-joinder of the parties. No deficiency of services on the part of OP1, complaint is liable to be dismissed against OP.
2.5. The present complaint is not maintainable as it involves complex question of law and facts which cannot be decided on summary basis.
3. Rejoinder has been filed on behalf of complainant. It has been denied that there was delay of 49 days in submission of documents; the complainant got 35 pages of the relevant record of treatment on 20.10.2016 (15.10.2016 date of discharge from the hospital). The complainant submitted all the required documents to the Indian Overseas Bank (employer of the deceased complainant). Although, complainant is not liable to furnish the documents as at is OP2(TPA) liable to convey all the messages and documents to the insurance company but OP2 failed to do so. Ms. Babita is daughter of the complainant; so she is entitled to maintain the present complaint and to represent before the Hon’ble Forum; address of OP1 (where the notice was sent) is correct. The OP1 did not issue any final copy of the policy to the complainant but it was sent to the OP2. There was no delay in sending the treatment and medical history/ summary through the concerned authority. The complaint is reiterated as correct.
4.1. Complainant during her life time filed her affidavit and evidence under her signature with documents and the same is narration of facts/ documents of the complaints.
4.2. Ms. Geetanjali Chauhan, Assistant Manager ( of OP1) has filed the affidavit of evidence, which is on the line of reply/ document.
5.1. Complainant’s legal representative has filed the written argument under the signature of her counsel. It is contended that OP2 sent a request to Indian Overseas Bank by email on 12.01.2017 and 08.01.2018 for sending the document but Indian Overseas Bank did not provide the medical summary/ documents to OP2; whereas the complainant had handed over all the medical summary/ documents along with claim to the bank (documents are at page 10 to 41 with complaint).
5.2. OP1 in para 2 of its reply requested to provide necessary documents (which are mentioned in para no. 2.2 of this order) with the approval from the Bank’s Nodal Officer. Indian Overseas Bank is associate of OP1 and the documents of the treatment were duly handed over to Indian Overseas Bank on 26.10.2016 under acknowledgement. Rest of the contents of written arguments are repetition of the complaint.
5.3. OP has filed the written argument, through its Advocate, which are on the lines of facts and figures in reply.
5.4. Sh. Brijpal, Advocate for complainant and Sh. H.N. Hans, Advocate for OP1 also made oral submissions on 27.03.2023.
6.1. We have carefully considered the case of parties, rival contentions, oral submissions, pleadings and documents on record.
6.2. At the outset, perusal of record reflects that OP1 was proceeded ex-parte on 16.05.2017 by this Commission against which RP no. 99/2018 was filed before the Hon’ble State Commission to set aside the said ex-parte order and Hon’ble State Commission vide its order dated 15.10.2018 accepted the R.P. and impugned order was set aside; the parties were directed to appear before the District Forum on 26.10.2018, petitioner/OP1 was directed to file WS on the said date, parties appeared on the said date but WS was not filed as directed by the Hon’ble State Commission. OP1 again filed an application in the said R.P. for extension of time to file WS. Hon’ble State Commission vide its order dated 22.04.2019 allowed the application of OP1 and directed to file the WS on 13.05.2019 (date fixed before the District Forum) and also imposed cost of Rs. 5,000/- being the case of repeated default by the petitioner in filing WS; thereafter, OP1 appeared before the District Forum on 13.05.2019 and filed the WS.
6.3. OP1 in its reply has taken the plea for non-processing and finalizing the claim of the complainant mainly on the following grounds:-
(i) Delay of 49 days in submitting the documents by the complainant;
(ii) Complainant has not approached the Forum with clean hands;
(iii) non-joinder of necessary parties;
(iv) The deceased complainant approached to the hospital for the investigation of her ailment, therefore, hospitalization was not necessarily required;
(v) Complaint is not maintainable as it involves complex question of law and facts which cannot be decided on summary basis, we will discuss these objections of OP1 one by one.
7. OP1’s plea that documents/ treatment papers were submitted belatedly after 49 days from the date of discharge from hospital, in this context, domicilary treatment- claim form, is dated 26.10.2016 containing 35 pages and it was received on 26.10.2016 duly stamped and signed by Indian Overseas Bank (page 8 of the complainant’s paper-book). OP1 in para 2 of its written statement under preliminary objections has mentioned some documents required to be submitted by the complainant; but all relevant documents were already submitted by the complainant as mentioned in para 5.2 of this order. In discharge summary of the hospital (at page 11 of the complainant’s paper book) all the details i.e. diagnosis, present illness, history of present illness, family and social history, clinical examination and course in the hospital and discussion and advice on discharge have been given. The discharge summary mentions that patient had no history of hyper tension etc. Document dated 06.11.2015 related to staff welfare “implementation of medical insurance scheme for the retired/ resigned officers/ employees etc. in lieu of existing REMAS was circulated from Indian Overseas Bank to all India Branches/ regional offices/ zonal offices/ other offices having all the details of the coverage of medical insurance scheme; wherein, in para 11 under the head ‘general conditions’ it has been specifically mentioned that “bank shall act only as an intermediary in providing the data to the insurance company and is in no way responsible for reimbursement under the scheme except what is admissible/ payable by the insurance company in the said documents. It is also mentioned that the scheme also includes the benefit of cashless treatment facility in hospitalization under scheme worked by the banks and the hospitals under a common insurance scheme; it also covers pre-existing disease/ ailments, all diseases and ailments covered under the policy without any waiting period; so, if all the necessary documents was submitted by the complainant with claim form dated 26.10.2016 (date of discharge from hospital 15.10.2016) to the Indian Overseas Bank (employer of the complainant), it was on the part of the bank to transmit those documents to the OP1 directly or through OP2(TPA) which was not done and complainant/ her legal representative is not to suffer due to fault/ default on the part of the employer bank.
8. OP2(TPA) represents OP1 only to facilitate and mediate for processing the claim of the insured and TPA acts as facilitator and mediator between the insured and the insurer for the purpose of processing the claim. It should have been on the part of OP2 to interact directly with the hospital where the complainant was admitted for treatment to collect all the necessary papers required by OP1 and to submit the same to OP1 for processing and finalizing the claim which was not done so, otherwise too, the general conditions of the medical insurance scheme of the Indian Overseas Bank provides cashless facility, therefore, necessary formalities for the submission of necessary documents after taking from the hospital for submission to OP1 was the duty of OP2, therefore, based on the aforesaid discussion, we do not find delay on the part of complainant in submission of the required treatment papers.
9. With regard to objection no (ii) mentioned in para no. 6.3 above. That complainant has not come before the Commission with clean hands has not been substantiated by the OP1 as to what was concealed by complainant; merely taking such stand in routine; in absence of documents in support of it does not validate the stand of OP1; therefore, this stand of OP1 has no substance and it is rejected.
10. So far objection (iii) mentioned in Para 6.3 above. non-joinder of the parties is concerned, the complaint had bequeathed her properties & claim in favour of her daughter by registered ‘Will’ dated 01.06.2017. The proceedings of present case is summary in nature. Prime facie view can be taken, particularly, when no other has come forward, since proceedings of complaint are summary in nature. Moreover, it is settled law in Santosh Kakkar & Others vs Ram Prasad & Ors., 1998 I AD (Delhi) 938, dod-.06.01.1998, that in Delhi Letters of Admn/ or probate is not compulsory. Lastly, the OP has not assailed order of bringing LR on record. More so, Indian Overseas Bank- employer of the deceased complainant was also not necessary party as per the general conditions of the medical insurance scheme devised by the bank, therefore, this stand of the OP1 does not sustain being not sustainable and tenable in law.
11. Objections (iv) of OP1 that deceased patient had contacted doctor in Apollo Hospital for the purpose of only investigation and the hospitalization was not required; has also no force because when a patient in pain and duress of indifferent health goes to the hospital for the purpose of examination/ treatment; it is for the consulting doctor of the hospital to decide and to conduct required medical course to their best of judgment and in such circumstances patient is to act as per the medical advice of the attending doctor and if after medical examination and conducting of tests, doctor comes to the conclusion that patient requires hospitalization, then in that circumstances no option is left with the patient to act otherwise except to follow the advice of consulting medical experts; therefore, this objection of OP1 has no force and unjustifiable, hence, it does not sustain.
12. Objection of OP1 is para 6.3 above is also dismissed, as no reason behind this objection has been given as to what are the complex question of law and facts.
13. Perusal of the record and documents of medical insurance scheme dated 16.11.2015 for the retired/resigned officers/employees etc. and its terms & conditions shows that the contention of OP1 that complainant submitted necessary documents related to treatment/hospitalization after 49 days has no substance as it was incumbent on the part of OP2 (TPA) and erstwhile Indian Overseas Bank (employer of deceased Raj Rani) to secure necessary documents for sending to OP1; more so, the complainant submitted all the treatment/hospitalization documents containing 35 pages duly attested by hospital to her employer bank which was received on 26.10.2016 under acknowledgment by the bank duly signed and stamped (attested documents are with the affidavit of the complainant which are at page no-8 to page no. 35). The correspondence available in the case file are from OP2 (TPA) to the hospital authorities and to the bank also establish that it was for the OP2 and the Bank to procure the necessary documents from the complainant and from the hospitals for sending to OP1 for processing the claim; clarifications if any required by OP1 for delayed submissions of the documents was to be clarified by the erstwhile Indian Overseas Bank; as TPA had sent letter of clarification to the bank and not to the complainant; on OP2’s such letter dated 12.10.2016 addressed to the Medical Director, Indraprasth Apollo Hospital for some of the required documents was responded by the hospital authorities on the body of said letter itself. Even the letter of denial of the claim has also been sent by OP2 (TPA) to Medical Director, Indraprasth Apollo Hospital which suggest that all such development and necessary correspondence with regard to the submission of the documents were exchanged amongst OP2, hospital authorities and the bank; and it was the duty of the bank and OP2 to send the documents submitted by the complainant on 26.10.2016 (under acknowledgment/ receipt to the OP1).
14. Complainant in para-2 of rejoinder, on merit, states that OP1 did not issue any final copy of policy directly to complainant but to OP2, OP2 is ex-parte vide order dated 16.05.2017 since it abstained from proceedings; OP1’s plea that legal notice sent by the complainant at wrong address has not been proved; legal notice sent is duly supported by the postal receipt. The complainant has proved the medical bill paid.
15. The complainant has submitted medical bills duly authenticated by the treating doctor of the hospital which includes consultation and investigation charges. The payment voucher for Rs. 56,960/- dated 15.10.2016 (page 15 of the complainant’s paper-book) of date of discharge of complainant from the hospital, in addition to Rs. 56,960/-. Complainant also paid Rs. 2,663/- as consultation charges; details of the bills/ payment voucher are available at page 9 and at page 16-21 of the complainant’s paper book. All the bills are duly signed and stamped by the consulting doctor of the hospital, therefore, the complainant has proved the medical bills paid by her. We come to conclusion that complainant has successfully proved her case and deficiency on the part of OP1.
16. From the aforesaid discussions/deliberations and careful analysis; we come to the conclusion that the complainant through her L.R. has succeeded to establish her medi-claim amounting to Rs. 59,623/- (Rs. 56,960/- +Rs. 2,663/-); complainant has also claimed Rs. 2,00,000/- as compensation/ damages towards mental pain and agony due to negligence and deficiency in service on the part of OP1 and OP2 along with 24% interest on the entire claim amount from the date of discharge from hospital i.e. 15.10.2016 till its realization but no justification has been given; however, in the circumstances, compensation of Rs. 15,000/- in favour of the complainant/ L.R. will meet the ends of justice.
17. Since, the insurer is OP1 (through the Indian Overseas Bank) and the contract of insurance policy is between OP1/Insurer and the complainant/Insured.
18. OP2/M.D. India Health Care Service (TPA) Pvt. Ltd. acts on behalf of insurer/OP1 is facilitator and service provider only. No order against OP2/TPA.
19. We direct OP1 to pay Rs. 59,623/- the amount spent on treatment under medi-claim policy to the complainant/ through LR along with interest @ 7% pa from the date of filing of complaint till its realization; Rs. 15,000/- as compensation for mental agony and pain; apart from Rs. 5,000/- as litigation cost within 30 days from the date of receipt of this order.
However, if aforesaid amount is not paid to the complainant by OP1 within 30 days from the receipt of this order; the amount of Rs. 59,623/- shall carry interest @ 8% pa instead of 7% pa.
20. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
21. Announced on this 6th July, 2023.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
