Punjab

Ludhiana

CC/14/233

Rajeev Malhotra - Complainant(s)

Versus

Universal Sampoo Gen.Ins.Co.Ltd - Opp.Party(s)

-

19 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 233 of 07.03.2013

                                                                                                                    Date of Decision: 19.02.2015

                                                                                                                   

Rajeev Malhotra, Advocate s/o Sh.G.R.Malhotra, Chamber no.532, District Courts, Ludhiana.

……Complainant

Versus 

Universal Sompo General Insurance Company Ltd. (E-Meditech) Branch at 5^th Floor, SCO-10-11, Feroze Gandhi Market, Ludhiana, through its Branch Manager.

 

…..Opposite party 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                    Sh.Sat Paul Garg, Member

                   Smt.Babita, Member

 

Present:       Sh.Sanjeev Malhotra, Advocate for complainant.

                   Sh.Rajeev Abhi, Advocate for OP.

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Rajeev Malhotra, Advocate s/o Sh.G.R.Malhotra, Chamber no.532, District Courts, Ludhiana (herein-after in short to be referred as ‘complainant’) against Universal Sompo General Insurance Company Ltd. (E-Meditech) Branch at 5^th Floor, SCO-10-11, Feroze Gandhi Market, Ludhiana, through its Branch Manager (herein-after in short to be referred as ‘OP’)- directing them to Rs.85,411/- being the mediclaim lodged by the complainant alongwith interest @ 18% p.a. from lodging of claim till payment and to pay Rs.50,000/- as compensation on account of mental pain and agony to the complainant alongwith any other additional or alternative relief to which the complainant is found entitled.

2.                Brief facts of the complaint are that complainant purchased cashless insurance policy no.2817/51152345/02/B00 from OP valid from 2013 to January 2014 for medical purposes for risk cover of Rs.1.00 lac. On 18.8.13, the complainant fell ill and approached Arora Neuro, Hospital, Ludhiana for treatment and said doctors advised the complainant to admit in the hospital. In this regard the complainant also informed OP on 19.8.13. After going through the documents and reports of the doctors the OP sent sanction of Rs.20,000/- for the treatment of the complainant and Rs.3500/- per day for the rent of room of the complainant in the hospital. Thereafter the hospital authorities assured the complainant that the OP has given sanction for the treatment of the complainant and complainant will be treated at the expenses of the OP. In this regard the OP sent written consent letter to the hospital authorities. Thereafter the hospital authorities started treating the complainant and the complainant remained admitted in the hospital for treatment from 19.8.13 to 31.8.13. On 31.8.13, when complainant was discharged by the hospital authorities, the hospital authorities demanded a bill of Rs.85,411/- as the OP had refused to pay the said amount. Under the compelling circumstances, the complainant paid the said amount from his own pocket and got discharged from the hospital. Thereafter complainant lodged his respective claim with all the documents as required by OP. Thereafter the complainant several times requested the OP for bill amount/claim, but OP refused to pay anything to the complainant. Claiming the above act as deficiency in service on the part of the OP, the complainant has filed this complaint.

3.                On notice of the complaint, OP appeared through his counsel and filed written statement taking preliminary objections that complaint is barred u/s 26 of the Consumer Protection Act; the present complaint is not maintainable since no claim has been lodged by the complainant with the OP. Arora Neuro Centre Pvt. Ltd. had sent cashless authorization a/c Rajiv Malhotra under policy no.2817/51152345/02/BOO with E-Meditech (TPA) Services Ltd, who vide letter dated 20.8.13 approved an amount of Rs.20,000/- as admissible limit; pre-authorization certificate was valid for active line of treatment and is subject to deduction of non payables and OP sought certain documents from the complainant within 7 days for the discharge of the beneficiary with specific instructions that otherwise the claim shall be marked as no claim as per the instruction of the insurance, which is as under:-

i). A copy of the pre approval certificate(s) with undertaking duly signed by the beneficiary.

ii). Hospital bill with complete breakup (Authenticated by patient’s signature).

iii) Original detailed discharge summary.

iv) All investigation reports, doctors’ prescriptions and pharmacy bills/cash memos.

v) Duly filled and signed claim form.

 

                   The documents sought for were material documents required for processing the claim of the complainant. The complainant as well as Arora Neuro Centre had failed to sent the documents referred above, as such, the claim file of the complainant was marked as ‘no claim’ by M/s E-Meditech (TPA) Services Ltd;

the complainant is established by his own act and conduct from filing the present complaint and is not coming to the Forum with clean hands; the present complaint is not maintainable as complicated question of law and facts are involved, which can be decided by civil court of competent jurisdiction. On merits, contents of para no.1 admitted to the extent of obtaining the insurance policy and further contents of para no.2 admitted to the extent that cashless pre-authorization was received from Arora Neuro Centre Pvt. Ltd. Ludhiana on 19.8.13 and pre-approval certificate dated 20.08.13 was sent. Further submitted that the complainant had never informed the OP regarding his admission and the OP has not sent any sanction of Rs.20,000/- for treatment and Rs.3500/- per day for rent of the room as alleged. However, it is submitted that Arora Neuro Centre Pvt. Ltd. a/c Rajiv Malhotra had sent cashless pre authorization to M/s E-Meditech TPA Services Ltd. On 19.8.13 and the said E-Meditech TPA Services Ltd had sent pre approval certificate, vide their letter dated 20.8.13 for Rs.20,000/.. Further denying the contents of all other remaining paras, OP prayed for the dismissal of the complaint.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Rajeev Malhotra, s/o Sh.G.R.Malhotra, Chamber no.532, District Courts, Ludhiana Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C26. On the other hand, Ld. counsel for OP has adduced the evidence by way of duly sworn affidavit of Sh.Piyush Shankar, Officer, Universal Sompo General Insurance Co. A-201, Crystal Plaza, 2^nd Floor, Opp. Infiniti Mall, Link Road, Andheri (W) Mumbai Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and affidavit of Sh.Anil Kumar Gupta, s/o Late Sh.Nand Kishore, Resident of A-36, Jai Shiv Appartment, West Enclave, Pitampura, Delhi-34 Authorized Signatory M/s E-Meditek (TPA) Services Ltd., Plot no.577, Udyog Vihar, Phase V, Gurgaon Ex.RB, wherein, he deposed that M/s E-meditek (TPA) Services Ltd. is working as Third Party Administrator and dealing with the payment/rejection of the claims. The complainant have preferred a cashless claim bearing no.100081308373 under IOB Health Care Plus (Floater) Policy bearing no.2817/51152345/02/B00 of Universal Sompo General Insurance Co. Ltd. in respect of the hospitalization/medical expenses incurred for the period from 19.8.13 to 20.08.14 for treatment at Arora Neuro Centre Pvt. Ltd. Ludhiana and also attached documents Ex.R1 to Ex.R5.

5.                Case was fixed for arguments. Ld. counsel for complainant argued orally that complainant fell ill, as such approached Arore Neuro Hospital, Ludhiana and the OP sent sanction of Rs.20,000/- for the treatment of the complainant and Rs.3500/- per day for the rent of room of the complainant in the hospital and thereafter the hospital authorities assured the complainant that OP gave sanction for the further treatment of the complainant. The complainant was discharged on 31.08.13 and the bill of Rs.85,411/- was raised, but the OP refused to pay the same, which the OP is bound to pay with compensation.

6.                Refuting the allegations leveled by the complainant, Ld. counsel for OP filed written arguments, wherein submitted that the OP has already filed the written statement taking various defences, which are detailed in the written statement and the grounds of repudiation are given in the repudiation letter dated 9.12.13. Further averred that Insurance policy is a contract in itself and the  parties are bound by the terms and conditions of the policy and as per the condition no.3 (b) of the policy, the complainant was supposed to intimate regarding the hospitalization within 48 hours or within 24 hours, after the treatment of hospitalization in case of emergency. Further as per the conditionno.3 (a), complainant was supposed to intimate immediately within 7 days from the date of hospitalization and claim must be filed within 30 days from the date of discharge from the hospital or completion of treatment and the claim must have been accompanied by the original bills, receipts, certificates etc. as required by the insurance company, which the complainant has failed to do. However, pre-authorization amount of Rs.20,000/- was sanctioned at the time of the admission of the complainant. Ld. counsel for OP also relied upon the judgements passed in cases titled as United India Insurance Co. Ltd. Vs Sangeeta Singh-2010 (II) CPJ 237 (NC), Dijabar Sahoo Vs New India Assurance Co. Ltd.-2008 (II) CPJ 307 (NC), Priya Gopal Stores Vs National Insurance Co. Ltd.-2009 (I) CPJ 22 (NC), New India Assurance Co. Ltd. Vs Rajendra Pal Singh-2009 (I) CPJ 492 (Uttarakhand State Commission, Dehradun), United India Insurance Co. Ltd. Vs Harchand Rai Chandan-2004 (IV) CPJ 15 (SC) etc.

7.                We have gone through the pleadings as well as defence taken by the OP and have also perused the entire record placed on file and also have gone through the judgements cited above. As such, the complaint is maintainable.

8.                It is evident that complainant availed cash less insurance policy no.2817/51152345/02/B00 from OP for the year 2013 to 2014 and the complainant was admitted in Arora Neuro Hospital, Ludhiana on 18.8.13 for his treatment and complainant intimated the OP regarding the same. Complainant incurred Rs.85,411/- on his treatment. But as alleged by OP, the complainant failed to submit the requisite documents as required by the OP. As such, an amount of Rs.20,000/- was sanctioned by the OP as pre-authorization. However, the OP has not been able to prove as to which documents were required to be submitted by the complainant. The complainant averred that he has already supplied all the relevant documents to the OP.

9.                Sequel to the above discussion, the present complaint is partly allowed and complainant is directed to submit the documents, if still pending to be filed before the OP within 15 days on the receipt of the copy of the order. Further OP is directed to settle and pay the claim, which would be allowable as per the terms and conditions of the policy within next 45 days on receipt of the documents. No order as to cost is passed.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.

Dated:19.02.2015 

Hardeep Singh