Delhi

South Delhi

cc/318/2005

SONI SAGAR - Complainant(s)

Versus

UNITED INDIA INSURANCE COMPANY LTD - Opp.Party(s)

12 Feb 2016

ORDER

CONSUMER DISPUTES REDRESSAL FORUM -II UDYOG SADAN C C 22 23
QUTUB INSTITUTIONNAL AREA BEHIND QUTUB HOTEL NEW DELHI 110016
 
Complaint Case No. cc/318/2005
 
1. SONI SAGAR
257/7 -B RAILWAY OFFICERS FLATS, BASANT LANE PANCHKUIAN ROAD CONNAUGHT PLACE NEW DELHI
...........Complainant(s)
Versus
1. UNITED INDIA INSURANCE COMPANY LTD
8TH FLOOR HIMALAYA HOUSE K G MARG NEW DELHI
............Opp.Party(s)
 
BEFORE: 
 HON'BLE MR. JUSTICE N K GOEL PRESIDENT
 HON'BLE MRS. NAINA BAKSHI MEMBER
 
For the Complainant:
none
 
For the Opp. Party:
none
 
ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi-110016.

 

                                        Case No.318/2005

 

 

1.      Ms. Soni Sagar

         D/o Sh. N. R. Sagar,

 

2.      Sh. N. R. Sagar

         S/o Late Sh. Mohan Lal

         (father and natural guardian of Complainant No.1)

 

         Both R/o

         257/7-B, Railway Officers’ Flats,

         Basant Lane, Panchkuian Road

         Connaught Place, New Delhi                              ….Complainants

 

Versus

 

1.       United India Insurance Company Ltd.

          8th Floor, Himalaya House, K. G. Marg,

          New Delhi

 

2.       M/s Family Health Plan Limited

          Aditya Towers, 8-2-120/86/9/A & B

          3rd Floor and 4th Floor, Room No.2

          Hyderabad-500034

 

3.       Sitaram Bhartia Institute of Science and Research

          B-16, Qutab Institutional Area,

New Delhi-16                                              ……Opposite Parties

 

                                                          Date of Institution          :  23.03.05                                                           Date of Order        :  12.02.06   Coram:

Sh. N.K. Goel, President

Ms. Naina Bakshi, Member

O R D E R

 

Briefly stated, the Complainant No.2 is the father and natural guardian of Complainant No.1(who has become major during the pendency of the complaint). They got insured under the mediclaim policy No.041100/48/03/00015 from OP No.1 and the policy was valid from 24.04.2003 to 23.04.2004. The Complainant No.1 slipped from the stairs and fell down on or about 30.5.2003 as a result she had sprained her ankle and got injured in knee cap. On or about 15.7.2003 she visited the local doctor and the doctor suggested her to go to a specialized orthopedic doctor for treatment. She visited the OP No.3 on 17.7.2003. The OP No.1 admitted the fact that the OP No.3 is on their panel for cashless/paid treatment. The OP No. 3 after examination admitted her and the doctor decided to operate her right knee and the OP No.3 operated her on 17.07.03.  At the time of admission she informed the OP No.3 that she is insured under the mediclaim policy issued by OP No.1 and showed them the identity card and other papers received from OP No.2 and that the policy was for cashless hospitalization. OP No.3 hospital issued a bill for Rs.41,821/- vide Bill No.76057 dated 18.07.13 and they were asked to pay the bill amount. On enquiry, OP No.3 told them that their claim had been rejected on the advice/direction of OP No.2 and they had to make the payment of the bills.  The bill of Rs. 41821/- was paid to OP-3 through credit card on which the complainants had to pay a hefty interest @ 27% per annum.  Due to this, complainant No. 1 who was minor and of tender age took the matter to heart and remained under constant mental pressure and  could not attend her school for a considerable time which had a bad effect on her performance in the annual examination as detailed in Para 13.  Hence, pleading deficiency in service on the part of OPs the Complainants have prayed as under:-

  1. Direct the OPs jointly and severally to pay Rs.41,821/- to the Complainants being the amount of bill.
  2. Direct the OPs, jointly and severally, to pay Rs.1,00,000/- to the Complainants for stress, mental agony and depression caused by the OPs.
  3. Direct the OPs, jointly and severly, to pay Rs.50,000/- to the Complainants as compensation for negligence, dereliction and deficiency in service.
  4. Direct the OPs, jointly and severaly, to pay interest @ 12% per annum from the date of making the payment of bill till final payment.

In the written statement OP No.1 has stated that the complaint is premature as the Complainants had not submitted claim statement with the third party administrator and as such no claim has been rejected by them.  The Complainant No.1 was having difficulty in walking for past seven months prior to the policy and had a history of fall with jerking sensation on right knee for three to four episodes which is clear from the hospital report filed alongwith with the complaint (at page No.12).     Clause 4.1 of the mediclaim policy is relied upon which reads as under:-

“The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of all diseases/injuries which are pre-existing when the covered incepts for the first rime”.

 

OP No.1 has stated that the Complainants had approached OP No.2 for cashless hospitalization for the first time for a pre-existing disease and OP No.2 was unable to issue the authorization/credit letter to the OP No.3 Hospital but it was clarified  that “ denial of authorization for cashless access does not mean denial of treatment and does not in any way prevent the policy holder from seeking necessary medical attention or hospitalization/claiming for reimbursement.” The Complainants did not file any claim for reimbursement of the treatment expenses with OP No.2 who is the Third Party Administrator which is mandatory under the policy to be filed within 30 days from the date of discharge from the hospital. OP No.1 has prayed for dismissal of the complaint being premature with cost of Rs.10,000/-.

OP No.2 has been proceeded exparte vide order dated 22.07.05 passed by our predecessors.

OP No.3 in the written statement has inter-alia stated that for the purpose of providing cashless service to the Complainants it was necessary that an approval from the Third Party Administrator with whom they had a privy was given but on the instruction of OP No.2 the cashless hospitalization was not provided to the Complainants on the grounds of “pre-existing condition” and they had no other option but to charge for the services rendered by them.   The Complainants have failed to establish any case of deficiency in service or negligence on their part. OP No.3 has prayed for dismissal of the complaint with heavy cost.

Complainant has filed separate rejoinders to the written statements of OP No.1 & 3.

Complainant No.2 has filed his own affidavit in evidence. On the other hand, affidavit of Sh. Mukesh Kumar, Administrative Officer has been filed in evidence on behalf of OP No.1 who has stated that after filing of their written statement the Complainants submitted the claim on 23.09.05 and the originals documents/papers had already been referred to the OP No.2 for necessary action and the reimbursement, if any, shall be made as soon as the papers are processed.

Affidavit of Dr. Anjali Raj Kumar and additional affidavit of Sh. Abhishek Bhartia have been filed in evidence on behalf of OP No.3.

Written arguments have been filed on behalf of the Complainant, OP No.1 & 3.  We have gone through the record.

According to OP-1, request for a cashless hospitalization was denied to the complainants.  It is undisputed fact that after getting treatment from OP-3 Hospital and paying Rs. 41,821/- towards treatment charges, the complainants did not file any claim before OP-1 and OP-2.  However, as per the averments made in the written statement of OP-1, the complainants filed the claim with OP-1 after filing of the written statement.

Order-sheet dated 27.7.06 records that it was states on behalf of OP-1 that the claim was still under process by OP-2 TPA.  Now, we are in February 2016.  Thus, more than 9 years have elapsed and we do not know about the fate of the claim.  Whether it has been rejected or whether it has been accepted by OP-2 is one’s imagination work.  Therefore, despite the fact that the complainants did not lodge the claim  with OP-1 & 2 before filing the present complaint, it was the duty of OP-1 & 2 to process the claim filed during the pendency of the complaint and decide it according to the relevant rules within a reasonable period of time and to inform this Forum about the fate of the same but, however, they have not done so.

In any case, the case of the OP-1 is that the disease in question was a pre-existing disease and the complainant-1 had been suffering from the said disease for the past seven months prior to the policy and had the history of fall with jerking sensation on right knee for three to four episodes.  OP-1 has relied on the history record filed on behalf of the complainants. Copy of the discharge summary of complainant-1 has been placed on the file as Annex. C by the complainants.  The brief summary has been given as under:

“Brief Summary: Complaints of pain and instability – right knee

                           Difficulty in walking for 7 months.

                           History of fall with jerking sensation on right                                   knee for 3-4 episodes.

                           No history of Diabetes                                                                       mellitus/Hypertension/Cardiac                                                      illness/Asthma/Allergy”

 

Therefore, from the copy of the discharge summary filed on behalf of the complainants themselves, complainant-1 had the pain and instability in right knee and difficulty in walking for 7 months and also that she had the history of fall with jerking sensation on right knee for three to four episodes.  Therefore, in our considered opinion, the disease in question was a pre-existing disease.  Accordingly, as per the provisions contained in Clause 4.1  of the medical claim policy which has been reproduced hereinabove, the complainants were not entitled to reimbursement of the said amount.

In view of the above discussion,  we do not find any merit in the complaint and dismiss it with no order as to costs.   

     Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations.  Thereafter file be consigned to record room.

 

 

(NAINA BAKSHI)                                                                                                                                                     (N.K. GOEL)  MEMBER                                                                                                                                                                    PRESIDENT   

 

Announced on  12.02.2016.

 

Case No. 318/05

12.02.2016

Present –   None

 

        Vide our separate order of even date pronounced, the complaint is dismissed.     Let the file be consigned to record room.

 

(NAINA BAKSHI)                                                                                                                                             (N. K. GOEL)  MEMBER                                                                                                                                                            PRESIDENT

 

 

 
 
[HON'BLE MR. JUSTICE N K GOEL]
PRESIDENT
 
[HON'BLE MRS. NAINA BAKSHI]
MEMBER

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