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.....................