Haryana

Karnal

181/14

Sh. Kuldeep Singh - Complainant(s)

Versus

United India Insurance Company - Opp.Party(s)

Sh. Randeep Lather

30 Sep 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                              Complaint No.181 of 2014

                                                             Date of instt.:07.07.2014

                                                               Date of decision30.09.2016

 

Kuldeep Kumar son of Shri Karam Singh resident of House no.489, Jattan Gate, Karnal.

                                                                   ……..Complainant.

                                      Vs.

1. The United India Insurance Company Ltd. through its Divisional Manager, Divisional Office: 010500 at “Catholic Centre” 64 Armenian Street Chennai-600001.

2. Indian Bank, through its Branch Manager, Branch at Ambedkar Chowk, Old G.T.Road, Karnal.

                                                                   ………… Opposite Parties.

 

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:-      Shri Randeep Lather Advocate for complainant.

                    Shri  Sudhakar Mittal Advocate for opposite party no.1

                    Opposite party no.2 exparte.

                    

 ORDER:

 

                   This complaint has been filed by the complainant u/s 12 of the Consumer protection Act 1986, on the averments that he was maintaining his Saving Bank Account in Indian Bank, Karnal. He got himself insured with opposite party no.1 through opposite party no.2 and obtained cashless policy in the year 2012, which was got renewed in the year 2013, vide policy no.2013/48410000354 against the payment of premium of Rs.3641/- on 16.8.2013 towards medical insurance under Arogya Raksha-Plan-B.  During subsistence of the policy, he suffered with episode of syncope with frothing from mouth and loss of consciousness on 11.05.2014. He was got admitted in Rajiv Gupta’s Amritdhara Hospital Chaura Bazar, Karnal, but after providing the first Aid the doctor referred him to Fortis Escorts Heart Institute, Okhla Road, New Delhi, where he had to undergo so many tests regarding disease and remained admitted from 12.05.2014 to 14.05.2014 and an amount of Rs.56,124/- was spent on doctors fee and special diet etc. As per clause 10 of the policy cashless treatment was to be provided through 3^rd party Administrators (TPA) , therefore, he approached the TPA alongwith all documents and completed the formalities. Documents were forwarded by the TPA to the company for necessary action, but the company refused to pay any expenses and rejected his claim, vide letter dated 14.05.2014 without any rhyme or reason and he had to pay entire amount of his treatment of his own pocket. Such acts and conduct on the part of the opposite parties amounted to deficiency in service  and unfair trade practice due to which he suffered mental pain, agony and  harassment apart from financial loss.

2.                Notice of the complaint was given to opposite parties. Opposite party no.1 put into appearance and filed written statement controverting the claim of the complainant. Objections have been raised that the complaint is bad for non-joinder of TPA as necessary party and that there was no deficiency in service on the part of the opposite parties.

                   On merits, it has been submitted that the claim of the complainant was processed and rejected by M/s Vidal Health TPA Pvt. Ltd. and not by the opposite parties. The complainant was having similar complaint in the past and there was no question of emergency. Moreover, there was no active line of treatment and the expenses were paid by the complainant only for diagnostic purposes, which were not payable as per terms and conditions of the policy. Therefore, the claim was rightly repudiated by the competent authority.

3.                In response to the notice concerned Manager of the opposite party no.2 appeared, but none put into appearance on its behalf on 6.1.2015 when the case was fixed for filing written statement and last opportunity was given for that purpose, therefore, exparte proceeding were initiated against it.

4.                In evidence of the complainant, he tendered his affidavit Ex.C1 and documents Ex.C2 to C15.

6.                On the other hand, in evidence of the opposite party no.1, affidavit of  S.S. Vasudeva Ex.O1 and documents Ex.O2 and Ex.O3 have been tendered.

6.                We have heard the learned counsel for the opposite parties and have gone through the case file carefully.

7.                Admittedly, the complainant had obtained cashless policy of opposite party no.1 and during subsistence of the said policy he remained admitted in Fortis Escorts Heart Institute, Okhla Road, New Delhi from 12.05.2014 to 14.05.2014. The copy of discharge summary is Ex.C6. The complainant had produced the bill of the hospital Ex.C10 for total amount of Rs.56,124/-. The claim of the complainant was repudiated only on the ground that no active treatment was given, therefore, cashless was not possible. The copy of the letter issued by TPA in that regard is Ex.C13.

8.                 As per the case of the complainant he suffered with episode of syncope with frothing from mouth and loss of consciousness on 11.05.2014 due to which he was admitted in Rajiv Gupta’s Amritdhara Hospital Chaura Bazar, Karnal, but after providing the first Aid the doctor referred him to Fortis Escorts Heart Institute, Okhla Road, New Delhi, where he remained admitted from 12.05.2014 to 14.05.2014. The discharge summary Ex.C6 also shows that in the history of illness it was mentioned that the complainant had an episode of syncope with frothing from mouth and loss of consciousness on 11.05.2014 and he was having similar history in the past. Even at the time of admission his pulse was 58 per minute. He was evaluated both clinically and with propr investigations. Various tests were conducted and the problem was managed conservatively. The cause of syncope could not be found. However, at the time of discharge he was advised some medicines. EEG was suggestive of occipital sharp waves. When the complainant suffered from the episode of syncope with frothing from mouth and loss of consciousness on 11.05.2014, it cannot be said by any stretch of imagination that there was no emergency to get him admitted in the hospital. The concerned doctor thought it proper to admit him in the hospital for further management of his problem. In such a situation, it cannot be accepted that the complainant intentionally got him admitted just for getting some tests conducted in order to claim cashless benefit of the policy from the opposite party no.1. A patient has to act as per the advice of the doctor, therefore, complainant could not refuse for his admission in the hospital when the doctor advised him so. The opposite party no.1 could not bring to our notice any term or condition of the insurance policy according to which an insured would not be compensated for the treatment taken by him from some hospital on the ground that he was having similar complaint in the past or that there was no emergency and only investigations were done in the hospital. The problem of the complainant was managed conservatively and even at the time of discharge he was advised some medicines. Therefore, plea of the opposite party no.1 cannot be accepted that no active treatment was given to the complainant. Looking into all such facts and circumstances, we have no hesitation in observing that the complainant was entitled to reimbursement for the expenses incurred by him on his treatment while he remained admitted in the hospital. Rejection of the claim by the opposite party no.1 certainly amounted to deficiency in service.

8.                As a sequel to the foregoing discussion, we accept the present complaint and direct the opposite party no.1 to pay Rs.56,124/- to the complainant  alongwith interest thereon @ 9% per annum from the date of filing of complaint till its realization. We further direct the opposite party no.1 to pay Rs.3300/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 30.09.2016

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member