District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 215/2022.
Date of Institution:19.4.2022.
Date of Order:17.05.2023.
Sunil Datt son of Shri Chander Singh, aged 47 years Resident of H.No 489, Jawahar Colony, NIT Faridabad at present residing at T-3/1103 Amolik Height Sec. 88, Faridabad.
…….Complainant……..
Versus
1. United India Insurance Co. Ltd., Divisional Office at SCO NO. 106, 2nd floor Commercial Complex, Sector-16, through its Divisional Manager/Principal Officer.
2. M/s. Safeway Insurane TPA (P) Limited, 815 Vishwa Sadan, District Centre Janak Puri, New Delhi through its Manager/principal Officer.
3. Anshu Hospital, Shiv Colony Sehatpur Road, Palla No.1, Faridabad through it sDirector/Manager.
…Opposite parties
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Kunal Kant, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 06.06.2022.
Sh. S.P.Sharma, counsel for opposite party No.3.
ORDER:
The facts in brief of the complaint are that the complainant availed the family mediclaim policy from opposite party No.1 bearing policy No.222100/28/20/P108/571806 for sum insured of Rs. 3,00,000/- for which complainant paid a premium as per demand by opposite party no. 1 and said policy was valid from 02.11.2020 to 01.11.2021. The said policy was firstly availed by the complainant in the year 2010 and till then it renewed from time to time regularly. On 23.10.2021 the wife of complainant namely Sunita got admitted for treatment of Febrile illness with TCP and Dengue fever with opposite party no. 3, and at that time opposite party no. 2 was the TPA of opposite party no.1 for providing the cash less facility. At the time of admission with opposite party no. 3, there were some shortage/ un- availability of beds in the hospitals due to Covid-19 and heavy viral of Dengue but there was no cashless facility in the hospital of opposite party no. 3 and they suggested filing the claim after discharge for reimbursement. The treatment of wife of complainant was continued and after discharge on 26.10.2021 complainant deposited the claim No. UN-1- 57574 of Rs. 40498/- for reimbursement with opposite party no. 2 but after passing more than 5-6 months opposite party no. 2 did not approve the claim of the complainant. The complainant contacted the opposite parties nos. 1 & 2 then they sent a letter dated 6.12.2021 to complainant for additional information required which was completed and sent back by the complainant but after clearance the all formalities opposite parties did not clear/approve the claim of the complainant and closed the same vide letter dated 2.3.2022. The complainant sent legal notice dated 25.03.2022 to the opposite parties through registered post but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay a sum of Rs. 40498/- as incurred amount on the treatment of the wife of complainant alongwith interest @ 24% per annum from the date of filling of the claim.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that at the very threshold the present complaint the complaint was not maintainable reason being the complainant had got treated his wife Sunita from Anshu Hospital, Faridabad but said hospital did not fulfil the criteria of a hospital as defined under clause No. 3 13 so incorporated in the insurance policy. Further, it was established from the claim documents as well investigation report so got conducted by the opposite parties No 1 that the claim of the complainant as to treatment of his wife was a fraudulent claim as defined under clause No. 5.7 so incorporated in the insuance policy. As such the issue under the present complaint did not hat under the peri-pheri of the provisions and more particularly the word "deficiency as defined under section 2(11) &word "service" as defined section 2(42) and the word "unfair trade practice as defined section 2(47)of the Consumer Protection Act, 2019. The complainant neither had any cause of action nor locus standi in lodging of the present complaint before this Hon'ble Commission reason being the complainant had submitted claim form dated 29.10.2021 alongwith relied upon treatment documents of his wife Sunita so taken from Anshu Hospital Faridabad betwixt 23.10.2021 to 26.10.2021 so received by the opposite party No 2 on 08.11.2021. After that the opposite party No 2 had sought some additional information from the complainant vide letter dated 24.11.2021 & reminder thereto vide dated 06.12.2021 but in reply to said queries the complainant had not forwarded any response in the stipulated period. Simultaneously matter was got investigated too and from the investigation report dated 13.01.2022, certain discrepancies were revealed so mentioned therein. Since the said treating hospital did not fulfil the criteria of a hospital as defined under clause No 3 13 & further, it was established from the claim documents & investigation report that the claim of the complainant was a fraudulent claim as defined under clause No 5.7 so incorporated in the insurance policy Hence, the insurance company had treated the subject claim as "No Claim" by closing the file in terms of "letter of intimation dated 02 03 2022, which decision cannot be termed unconscionable at all. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Notice issued to opposite party No.2 not received back either served or unserved. Tracking details filed in which it had been mentioned that “Item Delivery confirmed. Hence, opposite party No.2 was hereby proceeded against ex-arte vide order dated 6.6.2022.
4. Opposite party No.3 put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that there was no locus standi to file the present complaint against the answering respondent. It is submitted that on 23.10.2021 the wife of complainant namely Sunita got admitted for treatment of Febrile illness with TCP and Dengue fever with answering respondent and after the satisfactory treatment complainant paid hospital bill of Rs. 24050/- thereafter wife of the complainant discharged from the hospital on 26.10.2021 It was submitted that claim of the complainant had been wrongly declined by the respondent no. 1 & 2 on the basis of wrong facts mentioned in their letter dated 2.3.2022. It is submitted that the answering respondents fulfill the all formalities as hospital registered with 17 beded, with qualified doctors and qualified nursing staff in this way approx. twenty eights staff members were working with the hospital including doctors, nursing, ward boy, lab attendant, lab technician etc. and more than 900-1000 inpatients & outpatients treated per month in the Hospital. Opposite party No.3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
7. In this case the complaint was filed by the complainant against opposite parties–United India Insurance Co. Ltd.. with the prayer to: a) pay a sum of Rs. 40498/- as incurred amount on the treatment of the wife of complainant alongwith interest @ 24% per annum from the date of filling of the claim. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Sunil Datt,, Ex.C-1 – insurance policy valid from 02.11.2020 to 01.11.2021, Ex.C-2 (colly) – prescription, Ex.C-3 – Case summary & Discharge,Ex.C-4 – Claim form, Ex.C-5(colly) - invoice, Ex.C-6 - bill No. 2021-22/5744, Ex.C-7 – lab detail, Ex.C8 – legal notice,
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A – affidavit of Dinesh Kumar, administrative Officer, M/s. united India Insurance Co. Ltd., Divisional Office No. 10, SCO-106, 2nd floor, Shopping Complex, Sector-16, Faridabad. Ex.R-11 – insurance policy, Ex.R-12 – claim form, Ex.R-13 – Case summary & discharge,, Ex.R-14 – bill No. 2021-22/5744,, Ex.R-15 – lab detail,, Ex.R-16 – Additional information required, Ex.R-17 – Additional Information Required Reminder, Ex.R-18 – Standard investigation report, Ex.R-19 – prescription, Ex.R-20 – registration certificate,, Ex.R-21 – repudiation letter dated 02.03.2022.
As per evidence of opposite party No.3 Ex.RW1/A – affidavit of Shambhu Dayal, owner of Anshu Hospital, Shiv Colony, Sehatpur Road, Palla No.1, Faridabad, Ex.R-1 (colly) – list, Ex.R-2 – Bio Medical Waste Authorization certificate, Ex.R-3 Application for authorization or renewel of authorization,, Ex.R-4 – registration certificate, Ex.R-5 – certificate of permanent registration,, Ex.R-6 – Certificate of registration, Ex.R-7 – Work for insurance,, Ex.R-8 – Registration certificate,, Ex.R-9 – Certificate of approval MTP, Ex.R-10 – letter dated 29.3.2022,
8. In this case, the complainant obtained family mediclaim policy from opposite party No.1 bearing policy No.222100/28/20/P108/571806 valid from 02.11.2020 to 01.11.2021. for the insurance sum of Rs.3,00,000/-. On 23.10.2021 the wife of complainant namely Sunita got admitted for treatment of Febrile illness with TCP and Dengue fever with opposite party no. 3, and at that time opposite party no. 2 was the TPA of opposite party no.1 for providing the cash less facility. At the time of admission with opposite party no. 3, there were some shortage/ un- availability of beds in the hospitals due to Covid-19 and heavy viral of Dengue but there was no cashless facility in the hospital of opposite party no. 3 and they suggested filing the claim after discharge for reimbursement. The treatment of wife of complainant was continued and after discharge on 26.10.2021 complainant deposited the claim No. UN-1- 57574 of Rs. 40498/- for reimbursement with opposite party no. 2 but after passing more than 5-6 months opposite party no. 2 did not approve the claim of the complainant. Opposite party repudiated the claim of the complainant vide Ex.R-21 on the ground that “during investigation the case was found to have many discrepancies and has been staged to gain monetary benefits, as supported by the points mentioned in the investigation report available in the file. Since the hospital does not fulfil the criteria as mentioned in the policy for a clam to be admissible and recommended for repudiation by the servicing TPA under policy clause 3.13 which is read as “Hospital/Nursing Home means any institution established for in patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under the clinical establishments (Registration and regulation) Act 2010 or under the enactments specified under the schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
- Has qualified nursing staff under its employment round the clock.
- It has at least 10 inpatient beds in towns having a population of less than 10 lacs and at least 15 inpatient beds in all other places.
- Has qualified medical practitioners in charge round the clock.
- Has a fully equipped operation theatre of its own where surgical procedures are carried out.
- Maintain daily records of patients and makes these accessible to the insurance company authorized personnel.
5.7 – The company shall not be liable to make any payment under this policy in respect of any claim, if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his behalf. Keeping in view of the abovefacts and recommendations received from servicing TPA, the said claim is repudiated.
9. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is partly allowed. Opposite party No.1 is directed to pay 50% of the billed amount alongwith interest @ 6% p.a. from the date of filing of complaint till its realization, subject to submission of the original papers. Opposite party No.1 is also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 17.05.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
