Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.- 358/2016
Vipin Taneja s/o Late Sh. B.L. Taneja,
r/o 171-B, G-Block, Ansals, Palam Vihar,
Gurgaon, Haryana-122001 ...Complainant
Versus
OP1: M/s United India Insurance Company Ltd.
Through Branch Manager, D-14, IInd Floor,
Ranjit Nagar, Commercial Complex, Behind
Satyam Cinema, Patel Nagar, New Delhi-110008
OP2: Heritage Health Services (TPA) Pvt. Ltd.
411, 4th Floor, Laxmi Deep Building, Laxmi Nagar,
District Centre, Laxmi Nagar, New Delhi-110092 ...Opposite Parties
Date of filing: 07.10.2016
Date of Order: 31.07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Vyas Muni Rai, Member
ORDER
1.1. The present complaint has been filed by Sh. Vipin Taneja (in short the complainant) under Section 12 of the Consumer Protection Act, 1986 against M/s United India Insurance Co. Ltd. (in short OP1) and Heritage Health Service (TPA) Pvt. Ltd.
1.2. Complainant took a medi-claim policy (family medi-care policy) from OP1 having policy no. 040482/48/15/06/00000041 and the validity period of the policy was from 23.05.2015 to 22.05.2016. The insured in the policy are Mr. Vipin Taneja (self), Ms. Prerna Taneja (wife), Mr. Rishabh Taneja (son), Ms. Smridhi Taneja (daughter) and Mr Nikunj Taneja (son); sum insured was Rs. 10,00,000/- The total premium was paid of Rs. 21,584/-.
1.3. Master Nikunj Taneja, (son of the complainant) was suffering with high grade fever, pain abdomen, headache and redness in the right side eye with poor oral intake; complainant’s son visited doctor at Columbai Asia on 26.10.2015 and 31.10.2015, then he visited at Vasan Eye care on 06.11.2015 thereafter doctor Bhutani’s Clinic on 06.11.2015 followed by visits at Metro Hospital on 08.11.2015 and 09.11.2015, when the son of the complainant undergone the emergency treatment in Metro Hospital but he could not recover.
1.4. Thereafter, complainant’s son visited at the Ekansh Nursing Home on 09.11.2015 where he was advised by the doctor for hospitalization and his son was admitted there. On the next date i.e. 10.11.2015 the complainant sent the intimation of his son’s hospitalization through mail to the OP2.
1.5. Son of the complainant was discharged on 16.11.2015 and thereafter, complainant submitted his claim form for Rs. 75,083/- along with all the original documents to OP2 (TPA), through speed post. Complainant further pleads that one person namely Shakeel Ahmed, who represented himself as a physician on behalf of the OP2 visited at the Ekansh Nursing Home for the verification and he got the signature of complainant on blank paper “final opinion of the investigator about the case” with other supported documents; during the investigation the above named physician also supported the illness as described in the discharge slip given by the Ekash Nursing Home.
1.6. After getting no response from the OP regarding settlement of claim, the complainant checked his claimed status on the website of the OP2 on 30.11.2015 and found the status as ‘under process’; complainant received a query letter dated 01.12.2015 which was duly replied by the complainant through letter dated 08.12.2015 but no response was received from the OPs. The complainant again checked his claim status on 04.01.2016, and he was shocked to see that his claim was closed without any reason. Complainant has alleged deficiency of service and unfair trade practice on the part of OP as his claim was not passed with mala fide intention and ulterior motive.
1.7. Complainant has claimed an amount of Rs. 75,083/-(the expenses incurred on the treatment of his son) along with interest at the rate of 18% pa; Rs. 50,000/- as compensation for causing harassment, mental tension; apart from Rs. 25,000/- towards cost of litigation.
2.1. OP1 has filed reply under the signature of Sh. Jagdish Narang, Deputy Manager, UIIC; under the head ‘Preliminary Objections’ OP has submitted that it is the fake claim, complainant is trying to commit a fraud upon the OP by falsely fabricating the medical bills which do not have any authentic source as they are prepared by doctors with nexus to patient. The case was investigated by B.R. Sharma, ACP (Rtd.), D.P. and as per his report dated 01.06.2016 case of complainant’s son was found fake and fraudulent, hence, claim was repudiated vide letter dated 15.11.2016 (stated to be attached as Annexure A to reply but no such document has been submitted on record), copy of the policy having terms and conditions is also stated to have been attached as Annexure B but there is no such Annexure filed on behalf of OP1.
2.2. Ekansh Hospital has multiple litigation with OP1 and it has been committing frauds with public money on similar lines, One such case Sushil Gupta vs UIIC is pending before CDRF, Janakpuri, New Delhi and another case Sunit Gupta vs UIIC is pending before this Hon’ble Forum; complainant is in collusion with Ekansh Nursing Home. The complainant is residing at 171-B, G Block, Ansals, Palam Vihar, Gurugram, Haryana, which is far off from the Ekansh Nursing Home where son of the complainant’s was admitted. This fact creates suspicion and doubts on the claim of the complainant, OPs hired the service of B.R. Sharma (Rtd. ACP of D.P.) for verifying the facts and when the said surveyor inquired into the matter, he found number of irregularities and illegalities in the claim of the complainant and it was also revealed that the Ekansh Nursing Home is involved in various false claims against the OPs, thereby causing unlawful gains to the complainant and unlawful loss to the OPs, hence the claim of the complainant is total false.
3. The complainant did not file rejoinder. Complainant has filed affidavit of evidence under his signature with support of record. The facts and features of the affidavits are the same as pleaded in the complaint.
OP has also filed the affidavit of evidence under the signature of Sh. Jagdish Narang, Deputy Manager, UIIC which is the narration/ repeatation of the facts of reply but without any documents or exhibition as mention in affidavit.
4. Complainant and OP1 both have filed written arguments but contents of written arguments of both the parties are based on the pleadings & record as stated above. 5. We have considered the documents on record and the rival contentions of the parties.
6. It is admitted fact on record that son of the complainant was hospitalized in the Ekansh Nursing Home on 09.11.2015 and was discharged on 16.11.2015. He was treated for high fever, pain abdomen, headache, right eye redness and poor oral intake. His examination report and physical findings by the doctors have been submitted on record by the complainant (discharge summary dated 16.11.2015 is at page 38 of the complainant’s paper-book). It is also admitted fact that complainant had taken the medi claim policy from OP1 through OP2 which was valid for 23.05.2015 to 22.05.2016 and insured are family members; the sum insured was Rs. 10,00,000/- having total premium Rs. 21,584/- (Exh. CW1/1).
7. The complainant vide email dated 10.11.2015 to Heritage Health Service (TPA) Pvt. Ltd./OP2 informed about hospitalization of his son in Ekansh Nursing Home (copy of mail is at page 10/ CW1/2). Hospital Bill/ voucher for Rs. 60,908/- of the Ekansh Nursing Home has been filed and proved (which is available at page 39 of the complainant’s paper-book), however, amount of Rs. 75,083/- was claimed in complaint. The complainant vide his forwarding letter dated 23.11.2015 to the medical officer, Heritage Health service (TPA) Pvt. Ltd. by post submitted all the necessary documents (totaling 22 in number) was claimed in complaint and its details (letter dated 23.11.2015 is at page no. 9 of the complainant’s paper-book). Complainant has also proved copy of his claim form furnished to OP(Exh. CW-1/3). Besides the medical papers laboratory report etc. the other medical reports/ bills of the doctors/ hospitals where the son of the complainant was treated prior to the admission in the Ekansh Nursing Home. Status of the claim on the website, is mentioned as ‘closed’ (the claim closure report has been filed as Exh. CW1/7/ page 80).
8. The complainant has also proved letter dated 07.12.2015 from Dr. Amit (MBBS, MD), Consultant Pediatrician of Ekansh Nursing Home certifying the hospitalization, diagnosis, and treatment of Master Nikunj Taneja (page 70 of the paper-book of the complainant). The complainant by his letter dated 08.12.2015 responded to the query of OP2( copy of letter dated 08.12.2015 is at page 69 of the complainant’s paper-book) that raising unnecessary queries from the complainant is harassment and nothing else.
9. The allegations of OP1 that there are other fake and fabricated medical bills with regard to Ekansh Nursing Home where the complainant’s son was admitted are also pending before other Forums but there are no any such final finding/ order of any Forum / Tribunal and Court to establish that Ekansh Nursing Home has been in hand in glove with other parties/ complainants. No documentary proof has been submitted on record by OP1 to substantiate its stand to this effect, in affidavit of evidence of OP1 three documents are mentioned as is exhibited but no such documents are filed along with the reply. OP1’s case is that to verify the authenticity of medical bills Mr. B.R. Sharma, (rtd.) ACP, Delhi Police was entrusted the job to investigate and report. He submitted his report dated 01.06.2016 to OP1 and concluded that case was fake and fraudulent, hence, claim was repudiated, however, no such report dated 01.06.2016 of Sh. B.R. Sharma has been proved. Further, OP1’s other plea Ekansh Hospital is in multiple litigation with OP1 and some cases are pending in District Forum, Janakpuri and before this Forum have no force or substance as each case has to be decided on its own merits, the merits of this case cannot be ignored on general plea of OP in respect of other cases. Otherwise, no evidence is proved, as alleged. No policy documents containing the terms and conditions has been filed by the OP1. Registration certificate dated 24.09.2014 issued in favour of Ekansh Nursing Home by Directorate of Health Services, Govt. of NCT of Delhi having registration no. 657 proves that the registration certificate is valid upto 31.03.2017 while the son of the complainant was discharged from the nursing home on 16.11.2015 during the validity period of the registration of Ekansh Nursing Home.
10. From the aforesaid discussion/ deliberations and careful analysis it come to the conclusion that complainant has established his case since after the medical expenses and discharge from hospital complainant submitted his claim of Rs. 60,908/- as per bill voucher proved (though in complaint he has claimed Rs. 75,083/-) for reimbursement of the amount but OP1 did not reimburse/ refund. It is deficiency in service on the part of OP1; which caused harassment and mental agony to the complainant, therefore, complainant is held entitled for compensation of Rs. 15,000/- against OP1 and in favour of complainant as compensation/ damages; the complainant has been litigating since years together, we allow Rs. 10,000/- in favour of complainant as litigation expenses. Since son of the complainant was discharged from the hospital in the year 2015 and he paid hospital expenses Rs. 60,908/- as the same was not reimbursed by OP1 despite validity period of the insurance contract, the insured was deprived of his money to use the same, therefore we deem fit to allow 7% interest per annum on the amount of Rs. 60,908/- from the date of filing of the complaint till its realization.
11. Since the insurer is OP1. The contract of insurance policy is between OP1/Insurer and the complainant/ insured.
12. OP2/ M/s Heritage Health Services (TPA) Pvt. Ltd. acts on behalf of insurer/ OP1 as facilitator and service provider only.
13. We direct OP1 to pay Rs. 60,908/- the expenses spent by the complainant on treatment under medi-claim insurance policy to the complainant along with interest at the rate of 7% pa from the date of filing of this complaint till its realization, Rs. 15,000/- as compensation for mental agony and pain, apart from Rs. 10,000/- as litigations expenses within 30 days from the date of receipt of this order.
However, if the aforesaid amount is not paid to the complainant by OP1; within 30 days from the receipt of this order; the medi-claim amount of Rs. 60,908/- shall carry interest at the rate of 8% p.a. instead of 7% pa on this amount.
The complaint against OP2 is dismissed in view of the facts given in para no. 12 of this order.
14. Announced on this 31st July, 2023. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
