ORDER | ORDER
SH. RAKESH KAPOOR, PRESIDENT
In complaint no. 236/14, it is alleged that on 23.5.2013 the complainant was admitted to M/s Ekansh Nursing Home and was discharged on 27.5.2013. The intimation about the admission was sent to OP2 on 23.5.2013. The complainant had submitted a claim for Rs. 39529/- which was not settled which led to the filing of this complaint.
In complaint no. 237/2014, it is alleged that on 20.9.2013, the complainant was admitted to M/s Ekansh Nursing Home and was discharged on 27.9.2013. Intimation about the admission was given to OP2 on 21.9.2013. The complainant had lodged a claim for Rs. 54,792/- which has not been settled. Hence, the complaint.
In complaint no. 240/2014, it is alleged that on 27.9.2013, the son of the complainant Master Vishesh was admitted to M/s Ekansh Nursing Home and was discharged on 7.10.2013. Intimation about the admission was given to OP on 28.9.2013. The complainant had lodged a claim for Rs. 67,351/- which has not been settled. Hence, the complaint. In complaint no. 241/2014, it is alleged that on 11.3.2014, the complainant’s wife Mrs. Rumlavati was admitted to M/s Ekansh Nursing Home and was discharged on 18.3.2014. Intimation about the admission was given to OP on 12.3.2013. The complainant had lodged a claim for Rs. 55,961/- which has not been settled. Hence, the complaint.
The OP has filed separate written statements in all the aforesaid cases wherein it has denied any deficiency in service on its part and has claimed that the complaints are liable to be dismissed. It has, however, admitted that the claimants in all the cases were holder of mediclaim polices issued by it and had lodged separate claims which have not been settled by it. In complaint no. CC 236/2014 & CC 237/2014, the OP has taken the following defense in Para 7 & 8 of the preliminary objections.
7.That the record of treating, Hospital is very suspicious. After the investigation of the opposite party No. 2, it is revealed that the treating I hospital does not carry a good reputation and under investigation of the opposite parties as the same is involved in fraudulent activity.
8. That the complainant is trying to cover up his own wrong of not providing the reply of queries despite e-mail dated 30-08-2013, letter and reminders dated 09.10.2012, 28.11.2013 and 10.03.2014. The opposite party has received a letter sent by complainant on 02/10/2014 without the reply of any query. The Reply of certain query raised by opposite party No. 2 was required for process the claim. The answering respondent required documents pertains to leave certificate of patient, status of claim raised under group mediclaim policy of the insured but the complainant was failed to provide the documents. which were essentially required to the answering respondents for evaluation and assessment of the claim. Owing to lackadaisical attitude of insured, present claim is still pending under query.
In Complaint no. 240/2014 and 241/2014, Para nos 7 ,9 and 10 of the para-wise reply of written statement filed by the OP is relevant for the disposal of these complaints and is reproduced as under:
7.That the contents of the para No. 7. of the complaint are wrong and denied. It is submitted that Opposite Party No. 2 has raised a query from the complainant regarding the Doctor who has advised for admission in the said Hospital but the same was refused by him. It is further submitted that opposite Party 2 has also raised a query for the treatment which was taken prior to the Hospital, but same was also refused by the complainant, the letter dated 01.01.2014 issued by the opposite party No. 2 is already placed on record
9. That the contents of the para No. 9 of the complaint are wrong and vehemently denied. It is submitted that the present claim is under process. It is also declared on the website of opposite party No. 2 and is admitted by the complainant itself. It is further submitted that said Hospital has not been cooperating to the investigator of the opposite Party No.2. Due to non cooperation of the treating Hospital, the investigation of the opposite Party No. 2 could not be completed.
10.That the contents of the para No. 10 of the complaint are wrong and vehemently denied. It is submitted that the opposite parties have received many complaints against treating Hospital regarding its involvement in fraudulent activity. As such, the treating Hospital is under strict scrutiny. The claim filed by the complainant can be settled only after completion of investigation both against the Hospital as well as treatment given to the complainant.
We have heard arguments advanced at the bar and have perused the record.
The learned counsel for the insurance company has contended that all the claims filed in the aforementioned complaints are bogus. He has also contended that the hospital was non cooperative and had not given information which was sought by the TPA. It is also contended that the complainants had also not given the required information as asked for by the TPA which is why the claims could not be processed.
We have considered the contentions raised by the learned counsel on behalf of the Op insurance company. A perusal of the record shows that the insurance companies had not settled the claims without any rhyme or reason. In complaint numbers 236/2014, 237/2014
the defense of the insurance company is that it had written letters to the insured which were not replied to has been found to be false. The insurance company has not placed on record any letter written by it to the insured seeking information either with the written statement or with their evidence. The letters written by the TPA to the insured seeking information have duly been replied to by the insured. In complaint numbers ,240/2014 and 241/2014 the defence of the insurance company is that the hospital had not cooperated with it and had not supplied the required information . No document has been placed on record by the insurance company in order to show that its TPA had sought information from the Hospital which the latter had refused to provide. But be that as it may ,it was a matter between the Insurance Company and the hospital. The insured had nothing to do with the same . He was merely obliged to give a consent letter to the TPA authorizing it to access the record of the hospital with respect to the treatment given to the patient . In all the complaints , information about the admission of the patients was given to the TPA either on the date of admission or on the day next following. It appears that the TPA of the insurance company had not done its job in the right earnest. It had not verified the admission of the patients or the treatment undertaken by them . Merely alleging that the claims lodged with the insurance company were bogus does not help the cause of the insurance company. If the insurance company genuinely believed that the claims were bogus , it should have held an inquiry , lodged an FIR or appointed an investigator . The insurance company has not acted against the hospital in any manner whatsoever nor has blacklisted it in the face of the allegations being leveled against the hospital before us. We are, therefore, constrained to hold that the OP insurance company was not justified in not settling the claims lodged by the complainants. We, therefore, hold the OP insurance company guilty of deficiency in service and direct it as under:
In Complaint No. 236/14 Simarjeet Singh Vs UIC:
1. Pay to the complainant a sum of Rs. 35,529/-. In Complaint No. 237/2014 Simarjeet Singh Vs UIC: 1. Pay to the complainant a sum of Rs. 54,792/-. In Complaint No. 240/2014 Gorakhnath V/s UIC:
1. Pay to the complainant a sum of Rs. 67,351/-. In Complaint No. 241/2014 Gorakhnath V/s UIC:
1. Pay to the complainant a sum of Rs. 55,961/-. The OP insurance company shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. IF the OP insurance company fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
The original order shall be kept in complaint no. 236/14 and its copies shall be kept in Complaint Case Nos, 237/2014,240/2014 and 241/2014 Copy of the order be made available to the parties as per rule.
Files be consigned to record room.
Announced in open sitting of the Forum on..................... | |