Delhi

North East

CC/100/2016

Shri Raj Kr. Sharma - Complainant(s)

Versus

United India Insurance Co. - Opp.Party(s)

06 Oct 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 100/16

In the matter of:

 

		Shri Raj Kumar Sharma R/o 1/10115, Gali No. 3, West Gorakh Park, Shahdara, Delhi-110032.		Complainant
		Versus
	1       2       3	United India Insurance Co. Ltd. 10, Raj Block, GT Road, Walraj Mandir Shahdara, Delhi-110032   Medi Assist India Pvt. Ltd. (TPA) B-20, Sector-2, Near Sector-15, Metro Station, Opp. HCL Commet, NOIDA-201301   Santosh Aggarwal, Agent United India Insurance Co. Ltd. 10, Raj Block, GT Road, Walraj Mandir, Shahdara, Delhi-110032.		Opposite Parties
			DATE OF INSTITUTION:		04.04.2016
			JUDGEMENT RESERVED ON :		25.09.2017
			DATE OF DECISION      :		06.10.2017

 

N.K.Sharma, President:-

Ms.Harpreet Kaur Charya, Member:-

Order by Shri N.K.Sharma, President:-

 

ORDER

1. Present complaint has been filed by Shri Raj Kumar Sharma against M/s. United India Insurance Co. Ltd.- OP1, M/s. Medi Assist India Pvt. Ltd. (TPA)- OP2 & Shri Santosh Aggarwal agent- OP3, under section 12 of the Consumer Protection Act 1986 alleging deficiency in services and unfair trade practice.

The facts of the present complaint are that the complainant had purchased a Family Medicare Policy on the assurance of OP3 in 2011 where he got insured himself alongwith his wife, son and daughter.             The complainant has been paying the premiums regularly thereon.             The claim is under instant policy bearing  No. 2215032815P102742928, which is for a period from 15.06.2015 to 14.6.2016 issued by OP1, upon payment of premium of Rs. 10,480/-. The daughter of the complainant Ms. Vanshika Sharma was admitted from 23.09.2015 to 25.09.2015 in Khandelwal Hospital & Neurology Centre due to high fever because of dengue. OP2 was informed by the complainant but cashless facility was denied due to which the complainant had to pay Rs. 22,523/- as medical expenses. It has further been stated that the claim was submitted to OP2 with all necessary documents on 30.09.2015 and an investigator was appointed. It is stated that there has been a delay of 143 days by OP for deciding the claim. Legal notice dated 23.02.2016 demanding reimbursement of Rs. 22,523/- alongwith interest @18% was sent to OP which was neither replied nor complied with. Hence, the present complaint seeking directions to OPs to pay Rs. 22,523/- alongwith 18% interest from the date of claim till realization, Rs. 50,000/- for compensation on account of harassment and mental agony, Rs. 20,000/- for litigation expenses.

The complainant has annexed copy of Family Medicare Policy 2014, Discharge Summary for the period 23.09.2015 to 25.09.2015, Claim Form, Surveyor Report and Legal Notice alongwith postal receipt.

2. OP1 filed their reply upon service of the notice in present complaint, where they took preliminary objection that the complainant had no locus standi to file the present complaint as the complaint was pertaining to admission of Ms. Vanshika Sharma. It was also submitted that the claim was not pending and had been repudiated vide letter dated 16.05.2016. Further, it was stated that in the claim filed with the TPA, it was found that there was no medical emergency and the investigator appointed also verified the same. It was also stated that there was no requirement of admission in Hospital. OP1 in their reply have stated that as per the calculation sheet and TPA, claim payable, if any, was found to be Rs. 19,450/-. Rest of the contents of the complaint were denied. Repudiation Letter dated 16.05.2016 as Annexure AA, Policy document for the year 2014 alongwith terms and conditions as Annexure A, Surveyor report dated 14.11.2015 as Annexure B, calculation sheet by TPA as Annexure C have been annexed with the reply.

OP2 and OP3 neither appeared nor filed any reply. Hence they were proceeded ex parte.

3. In rejoinder to the reply of OP1, it was stated that as the complainant had taken the family Medicare Policy for his family members and the premium was being paid to OP1 and Ms. Vanshika Sharma, being dependent on him, the complainant had locus standi to file the present complaint. It was also denied that there was no medical emergency as the patient was having high fever because of dengue, perimubilical pain, nausea, headache and severe weakness. Rest of the contents of reply were denied and those of the complaint were reaffirmed.
4. Evidence by way of affidavit was filed by the complainant, Shri Rajkumar Sharma, who deposed the contents of the complaint on oath. He stated that claim of Rs. 25,523/- was not reimbursed by OP1, which amounted to deficiency in service.

Shri Y.R. Kanojia, SDM of OP1 was examined as RW1 and stated that the claim of complainant was repudiated on 16.05.2016 and got exhibited repudiation letter as exhibit RW1/AA, copy of policy terms & condition as exhibited RW1/A, copy of report of agency RW1/B, copy of calculation sheet as exhibited RW1/C.

Ms. Sunita Gupta, Director of Probus Associates & Consultants Pvt. Ltd was examined, as RW2 and she got exhibited opinion given by them as exhibit RW1/B.

Shri Jitender Aggarwal, Central Head working with M/s Medi Assist India TPA Pvt Ltd. was examined as RW3 and stated that the claim of complainant was repudiated on 16.05.2016 and got exhibited repudiation letter as exhibit RW1/AA.

5. We have heard the arguments on behalf of Ld. Counsels for both the parties and have perused material placed on record.

Existence of policy cover is not disputed. The locus of the complainant to file the present complaint has been disputed by OP1. The complainant one of the insured under the policy in question and being the father of Ms. Vanshika can file the present complaint. Now coming to the merits of the complaint, it has been stated by OP1 that there was no medical emergency thus hospitalization was not required. If we take a look at discharge summary it reads that the patient was suffering from high grade fever alongwith perimubilical pain, nausea, headache and severe weakness, when patient has been admitted in the hospital and doctor being a specialist is the best person to judge the line of treatment and method to be adopted. Had there been no requirement of hospitalization the patient would not have been admitted. If in the instant case it was considered that hospitalization was is the best interest of the patient, then the complainant should not be made to suffer by repudiating claim.

Hence, we direct OP to reimburse Rs. 19,450/- alongwith 9% interest from the date of filing of claim till realization. We also award compensation of Rs. 7,500/- as OP have failed to settle the claim of the complainant and issued repudiation letter only after the filing of present complaint. This order shall be inclusive litigation expenses. Order shall be complied within 30 days from the receipt of copy hereof.  

6. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
7. File be consigned to record room.

(Announced on   06.10.2017)        

 

(N.K. Sharma) President

(Harpreet Kaur Charya) Member