BEFORE THE CONSUMER COURT,
NEW DELHI ,
IN THE MATTER OF :-
S. K. Sharda
842/7, 3rd Floor,
New Delhi – 110019 Complainant
Royal Sundaram Alliance Insurance Co.Ltd
1505-1506, 15th Floor, Ambadeep Building,
14, K. G. Marg, Connaught Place,
New Delhi - 110 001
M/s Royal Sundaram Alliance Insurance Company Limited.,
Sundaram Towers 45 & 46,
Whites Road, Chennai 600 014 Opposite Party
Complaint under Section 12 of the Consumer Protection Act 1986.
Most respectfully showeth:-
1. That this a complaint under Sec 12 of the Consumer protection Act 1986 (herein called the Act for the sake of brevity) with a view to obtain any relief provided by or under this Act.
2. That the complainant is a consumer who purchased a health shield insurance policy opting for medisafe plan for himself, for his wife Ms. Suman Sharda and two of their sons, Master Tarun and Master Rupesh in the month of August 2004 on payment of Rs.2847.00 through SBI Credit Card. After few days he got a welcome kit containing Health Shield Insurance Certificate no. HS00011632000100 bearing Master Policy no. HLSBIL0008 mentioning the period of coverage of Insurance from 01/09/2004 to 31/08/2005, Health Shield Quality Health Insurance Medisafe Card for all 4 members, Policy cover note alongwith List of Hospitals. The copy of Insurance Policy Cover Note alognwith list of hospital issued by the OP are annexed as Annexure - C-1.
3. That the Opposite Party is a company incorporated in India as per the Companies Act 1956 and registered with Insurance Regulatory and Development Authority as a general insurance company for sale of various general insurance and health insurance policies through various branches, amongst one of which is doing the business of general insurance business in the Delhi at the aforesaid address.
4. That the complainant renewed the health shield insurance policy bearing master policy no. HLSBIL0008 having Medisafe Plan on payment of premium from time to time between 2005 to 2008 and has been issued Insurance Certificates no. HS00011632000101, HS00011632000102, HS00011632000103 and HS00011632000104 for the period of Insurance from the date 01/09/2005 to 31/08/2009.The certificates are annexed as Annexure - C-2.
5. That in the month of August 2009, the complainant further renewed the Health Shield Insurance on payment of Rs.3765.00 and has been issued a new Insurance certificate No. HS00011632000105 for the period of Insurance from the date 01/09/2009 to 31/08/2010 for the same master policy no. HLSBIL0008.The copies of certificates are together annexed as Annexure - C-3.
6. That the Opposite Party offers list of Benefits to the Complainant in their Terms & Conditions forming part of insurance policy, the copy of which is annexed as Annexure - C-4.
The Policy covers Reasonable and Customary expenses incurred towards hospitalization for the disease, illness, medical condition or injury contracted or sustained by the Insured Person during the Period of Insurance stated in the Schedule subject to terms, conditions, limitations and exclusions mentioned in the Policy.
For a claim to be admitted under this Policy, the Insured Person should be hospitalised as an In- Patient during the Period of Insurance for a minimum period of 24 hours. However this time limit is not applicable to the following specific treatments:
Cataract Tonsilectomy, Eye Surgery, Lithotripsy (Kidney Stone removal) and D & C
In the event of any claim becoming admissible under the Policy, the Company will pay to the Proposer, the Reasonable and Customary expenses, subject to the various limits mentioned hereunder, but not exceeding the Sum Insured and the Cumulative Bonus, if any, mentioned in the Schedule for all claims admitted during the Period of Insurance.
a. Expenses covered under the Policy
(i) Room, Boarding Expenses as provided by the Hospital / Nursing Home, subject to a limit of 1.5% of the Sum Insured per day and for Intensive Care Unit 3% of the Sum Insured per day.
(ii) Nursing Expenses incurred during In-Patient hospitalization.
(iii) Surgeon, Anaesthetist, Medical Practitioner, Consultants & Specialist Fees.
(iv) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy Radiotherapy, Donors medical expenses towards Organ transplant, Cost of Pacemaker, Artificial Limbs, Cost of Organs.
(v) Pre-Hospitalisation and Post-Hospitalisation expenses when the claim for hospitalization is admitted under the policy.
(vi) Treatment relating to catart are subject to a limit of Rs. 7500/- per policy.
The following additional benefits are payable in addition to the hospitalization expenses, subject to admissibility of a claim for hospitalization under this policy. The limits for the following benefits are applicable in respect of all claims preferred by each insured person for the period of insurance.
Hospital Cash Benefit:
The Insured person is eligible for benefit to extent of Rs.150/- per day of hospitalization subject to a maximum of 10 days.
Convalescence Benefit :
If the period of hopitalisation exceeds 15 days, a lump sum Convalescence Benefit of Rs.15000/- is payable.
ICU Benefit :
If the period of hospitalization exceeds 7 days in ICU at a Hospital/Nursing Home with a minimum of 300 Beds, a lump sum recovery benefit of Rs.10000/- is payable.
Critical Illness Benefit:
A lump sum benefit of Rs. 15000/- is payable is the person diagnosed and treated for Cancer or Stroke or undergoes CABG/Organ Transplant. This benefit is payable from second year and is payable once during the lifetime of the Insured Person per illness.
b. Additional Features:
(i) Cashless Facility: (Through Third Party Administrators - TPA)
a. In network hospitals, provided pre-admission authorisation in writing is taken from TPA appointed by Us, Insured need not pay for the eligible expenses at the hospital. The TPA will pay it directly.
b. TPAs will also provide 24 hour helpline and free ambulance referral facility.
c. TPAs will be guided by TPA regulations formed by IRDA.
d. In non-network hospitals, hospitalisation expenses will only be reimbursed.
(The cashless facility can be availed subject to compliance of the procedure laid down in the information handbook issued along with this Policy.)
7. That the wife of the complainant Mrs Suman Sharda who is also an insured person under the Health Sheild Insurance issued by the OP got an unbearable pain in stomach in the night on 24-08-2009.The complainant had to approach the Emergency Department of Batra Hospital, New Delhi. Doctor attending her had administered some drugs and advised for admission in the Hospital immediately. The details of treatment undertaken in Batra Hospital are annexed as Annexure – C –5.
8. That thereafter the complainant had gone to admission department of M/s Batra Hospital to enquire whether the insured persons under the coverage of Health Shield Insurance issued by the OP are covered by cash less medical benefit and whether the same could be extended to the wife of the complainant. To his utter surprise the complainant had come to know that Batra Hospital is not accepting Royal Sundaram Card for extending cash less medical benefit, although it has been named in the List of Hospitals issued to the complainant by the OP at the time of taking health insurance. Further, the complainant has been advised by Batra Hospital to deposit Rs.25,000/- in cash for admission of his insured wife if he is interested to undertake medical treatment therein.
9. That thereafter the complainant had contacted the officials Mr.Satish and Ms. Bharti of the Royal Sundaram and sought advise as to how to undertake cash less treatment for his insured wife through Heath Sheild who advised the complainant to take treatment any where upon payment of cash and send the bills and medical documents alongwith claim form to Royal Sundaram’s Claim department for necessary reimbursement.
10. That due to non acceptability of Royal Sunderam Card by Batra Hospita had forced the complainant to shift his insured wife from there to Agarwal Medical Centre in the same day i.e. 24.08.09 which accepted the Royal Sundaram’s Cards. After administration of drugs and various pathological tests, the insured wife of the complainant had the sigh of temporary relief , thus she was relieved on the same day from the hospital annexed as Annexure - C-6.
11. That immediately after 2 days, i.e. 27th night, the insured wife of the complainant had developed pain again in the stomach who was again taken to Dr. Neeraj Aggarwal’s Medical Centre, situated at E-234, Grater Kailash-I, New Delhi-110 048 As per advise of Dr Neeraj Aggarwal attending her, she was immediately admitted in his hospital who refused to accept the Royal Sundaram’s Card.
12. That the insured wife of the complainant was diagnosed of acute severe UTI electrolyte imbalance and as per advise of Dr Agarwal she was hospitalized from 28.08.09 to 31.08.09 for undergoing the treatment. Since Royal Sundaram Card was not accepted by the Hospital, the complainant had to deposit the whole bill amount of Rs.11,990/- (Rupees Eleven Thousand Nine Hundred Ninety Only) in cash annexed as Annexure – C –7.
13. That after discharge of the insured wife of the complainant from Agarwal Medical Centre, the complainant had sent bills amounting Rs.11990/- (Rs. Eleven thousands Nine Hundred Ninety only) along with all medical documents on 05-09-2009 through courier for necessary reimbursement annexed as Annexure – C –8.
14. That on 24-09-2009, the representative of OP Mr. Sonu Goswami came to the complainant at home for verifications of documents and asked photocopies of all bills, documents, copy of PAN Card and Copy of Bank Statement for Address proof and these same were provided to him. Thereafter the representative of the OP assured of submitting the report to OP within 24 hours and you get the claim of the complainant released within 7 working days.
15. That even after lapse of 7 days, the complainant approached the claim department several times for release of claim amount but could not get any satisfactory reply from the OP. Thereafter, the complainant received a letter no. NIL dated October 13, 2009 RE: Cancelling the Insurance Policy Number: HS00011632000105 annexed as Annexure – C-9.
16. That upon receipt of letter the complainant contacted to the claim department of OP who successfully replied that “they had already sent a communication to the complainant repudiating the claim”, but no such communication allegedly sent by the OP has been received by the complainant.
17. That the Opposite Party was under legal obligations to provide cash less treatment in the Hospitals in the list provided to the insured in the case of hospitalization/indoor treatment.
18. That the complainant lodged a complaint on 28.10.09 to the Insurance Regulatory and Development Authority reporting illegal cancellation of insurance policy and repudiation of claim for medical treatment by the Opposite Party annexed as Annexure – C –10.
19. That the Opposite Party is liable for deficiency of service and manipulation of conditions of service as they have failed to provide the services of cash less medical benefit in hospitals in their panel or alternatively reimbursement of medical bills of Rs.11,990/- as promised at the time of purchase of insurance policy and acknowledgement of consideration for providing assured/promised policy.
20. That the Opposite Party has become liable to pay compensation to the complainant for the loss and injury suffered by him due to negligence of the Opposite Party. Although no amount of money can compensate the mental agony , harassment and risk to life of family members of the complainant , besides loss of invaluable time for following up with the OP, for the purpose of awarding monetary compensation , it has been reasonably assessed for an amount of Rs.1,00,000 (Rupees One Lakh).
21. That this Hon’ble Forum has got pecuniary jurisdiction to entertain this Complaint as the compensation claimed does not exceed Rs.1,11,990/-.
22. That this Hon’ble Forum has got the territorial jurisdiction to adjudicate and decide the same as the cause of action has arisen by acknowledgement of consideration against sale of the said refrigerator within the jurisdiction of this Hon’ble Forum.
Therefore, in the facts and circumstances of the case as stated above , it is most respectfully prayed that this Hon’ble Forum may be pleased to :-
a) direct the Opposite Party to reimburse the bills of Rs.11,990/- for the treatment undertaken by the insured wife of the complainant ;
b) direct the Opposite Party to pay the complainant a compensation of Rs.1,00,000 (Rupees One Lakh) for the loss , injury , harassment , mental agony and risk of life to the insured wife of complainant;
c) award costs of the proceedings of Rs.7,500 (Rupees Seven Thousand Only) , in favour of the complainant and against the Opposite Party;
d) and pass such other and further orders as may be deemed fit and proper in the facts and circumstances of the case.
VERIFICATION I Sushil Kumar Sharda, resident of 842/7, 3rd Floor, Gali No. 7, Govindpuri, Kalkaji, New Delhi -110019, hereby declare that I have not misrepresented any facts nor have tried to hide any information in my above complaint. All the facts mentioned herein are true to the best of my knowledge.