District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.34/2021.

 Date of Institution: 19.01.2021.

Date of Order: 21.12.2022.

Bal Mukund Bansal S/o Shri Ram Sawroop, H.No.4, Gali No.2, Molarband Extn. Badarpur, Jailpur, South Delhi, Delhi.

                                                                   …….Complainant……..

                                                Versus

1.                M/s. Star Health and Allied Insurance Co. Ltd., Registered Corporate Office NO.1, New Tank Street, Valluvarkottan High road, Namgambakkam, Chennai – 34 through its Authorized Signatory.

2.                M/s. Metro Heart Institute, Sector 16A, Faridabad through its Authorized Signatory.

3.                National Insurance Co. Ltd., Service may effected through branch office, NH-5, NIT, Faridabad.

                                                                   …Opposite parties……

Complaint under section-12 of Consumer Protection Act, 1986

Now  amended  Section 34 of Consumer protection Act 2019.

BEFORE:            Amit Arora……………..President

Mukesh Sharma…………Member.

Indira Bhadana………….Member.

PRESENT:                   Mrs. Sonia Maheshwari,  counsel for the complainant.

                             Sh. O.P.Gaur, counsel for opposite party No.1.

                             Sh. Satender Adhana, counsel for opposite party No.2.

                             Sh. Jatinder Singh, counsel for opposite party No.3.

ORDER:  

                             The facts in brief of the complaint are that  the complainant was having mediclaim policy and renewed the same regularly and also renewed in the year 2020 vide product name Family Health Optima Insurance – 2017 bearing policy NO. P/161111/01/2021/001312 valid for 244.2020 to 23.04.2021 with  opposite party No.1.   The complainant got himself insured under mediclaim scheme with opposite party No.1 and paid an amount of Rs.22,574/- for family insurance as premium for the said insurance policy for which opposite party’s office bearer had issued the above said policy although since 4 years complainant wa shaving the said policy with opposite party No.1 and renewed the policy every year while paying a smart amount as premium.  In the month of June 2020 the complainant felt some problem on his person due to which he went to  opposite party No.2 for getting treatment and complainant consulted regarding the same from doctors, where complainant was got the concerned tests etc. and all the relevant tests as per requirements regarding the problem and after the final diagnosis complainant came to know that he was COVID 19+ve & due to seriousness doctor suggested complainant for admission and on that he got admitted in the said hospital situated at Sector-16A, Faridabad on 21^st June 2020

and remained there till 27 June 2020.  After getting the knowledge regarding the above said disease and before starting treatment complainant had sent intimation to opposite party No.1 but opposite party being in collusion with opposite party No.2 had passed the part claim amount i.e. Rs.61,103/- out of total claim amount i.e. Rs.1,08,811/- of complainant due to which complainant had to make remaining payment of Rs.47,708/- of the bill/expenditure etc. and after the discharge complainant had asked to opposite party’s office representative & made a number of requests to them but opposite party No.1 had neglected the requests of the complainant and for making remaining claim amount of complainant till date there was no response from their side regarding the payment of remaining mediclaim amount i.e. Rs.47,708/- spent on the treatment of complainant and according to bills and receipt sof doctor’s fee, medicines which had already been deposited to opposite party No.2 by the complainant due to non payment by opposite party No.1.  Even after submitting the required documents as per rule, opposite parties till date had not sent any response regarding payment of mediclaim amount. The complainant sent legal notice  dated 27.11.2020 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite parties to:

a)                make the payment of Family Health Optima Insurance – 2017 of Rs.47,708/- alongwith interest @ 24% from the date of bill till the realization of that amount to the complainant.

 b)                pay Rs.10,00,000/- as compensation for causing mental agony and harassment .

c)                 pay Rs. 11,000 /-as litigation expenses.

2.                Opposite party No.1  put in appearance through counsel and filed

written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that  the insured had got renewed the previous insurance policy and in furtherance thereof, obtained the Family Health Optima Insurance Plan vide policy NO. P/161111/01/2021/001312 for the period 24.04.2020 to 23.04.2021  for the insured sum of Rs.3,00,000/-..  The complainant neither had any cause of action nor locus standi in lodging the present complaint before this Commission.  It was submitted that the complainant had suppressed and concealed the true, material and vital facts & information from this commission.  It was further submitted that the subject mediclaim falls under the Family Health Optima Insurance Plan vide policy No. P/161111/01/2021/0001312 for the period 24.04.2020 to 23.04.2021.  The insurance company received a request for cashless hospitalization of patient – Bal Mukand Bansal on 22.06.2020 from metro heart Institute, estimating the medical expenses at Rs.60,000/- with stay of 2-3 days.  Pursuant to the request, the medical team of the insurance company observed the hospitalization of the patient as “provisionally diagnosed” Covid 19 + hence approved initial amount of Rs.20,000/- vide cashless authorization letter dated 22.06.2020 inter alia advising the hospital in admissible amount as per clause No. 14 therein.   It was also submitted that pursuant to further request for cashless authorization, the insurance company vide its letter dated 26.06.2020 enhanced the cashless hospitalization being additional amount  Rs.50,000/- reiterating the implications of clause No.14 therein.    Thereafter, on discharge of the patient, the hospital raised final bill dated 27.06.2020 alongwith discharge summary for the period 21.06.2020 to 27.06.2020  The details of the bill raised were as under:-

i.        Bill amount                                       :         Rs.1,08,811/-

ii.       Amount disallowed                           :         Rs.38,916/-

iii.      Maximum paid                                  :         Rs.68,895/-

As a result, the  insurance company vide its revised authorization letter dated 27.06.2020 approved the final amount at Rs.69,895/- duly communicated to the hospital.   It was also submitted that the complainant had claimed Rs.3,444/- for per-hospitalization expenses for which the insurance company paid a sum of Rs.944/- only, deducting Rs.2400/,  since the complainant had failed to submit receipt against such bill.  The complainant also claimed post hospitalization expenses at Rs.1,407/-, which amount was also paid. Hence, during reimbursement a sum of Rs.5,351/- had already been paid under mode of NEFT dated 21.10.2020.  Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                Opposite party No.2  put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that  the opposite party No.2 was having policy named Error and Omission – Medical Establishment issued by M/s. National Insurance Company Limited having its office Division 15 C-1 & 2, BP Railway Road, Neelam Chowk, Faridabad, in the name of M/s. metro Specialty Hospitals Pvt. Ltd., Sector-16A, Faridabad bearing policy No.361100491910000082 valid form 20.02.2020 to 19.02.2021.  The complainant Bal Mukund Bansal was admitted in opposite party No.2 hospital on 21.7.2020 with complaint of mild breathlessness, mild lower abdomen pain and bilateral lower limb numbness for 2-3 days.  Patient was investigated and evaluated.  SARS Covid-19 RT PCR was positive (outside_. HRCT chest was done which revealed multifocal patchy of homogeneous areas of ground glass attenuation with septal thickening in both lung fields with small mediastinal lymphadenopathy, likely to be infected etiology? Viral pneumonia.

Patient was  managed conservatively with injection tablet IV fluids and other symptomatic treatment.  Patient had responded well to the treatment.  Now  patient was being discharge on request on medication with advice.  Detailed advices in written form issued for same.  The answering opposite party raised bill amount R.1,08,811/- for the complete treatment done by opposite party No.2 hospital upon the complainant against which the opposite party No.1 i.e M/s. star Health and Allied Insurance Company Limited approved part amount/claim amount Rs.69,895/-, out of the total claim amount i.e. Rs.1,08,811/- of the complainant had paid remaining amount Rs.47,708/-.  Thus the doctors of the answering opposite party No.2  hospital had performed their duties to the best of their abilities and with due care and caution.  Thus, the treatment given to the complainant/patient was standard and recommended as per medical literature.  As such, there was absolutely no negligence on the part of the answering opposite party No.2 hospital with respect to the treatment provided by the answering opposite party No.2 to the complainant.  However, with respect to the mediclaim facility being provided by the opposite party No.1 company, it was worthwhile to mention that the answering opposite party No.2 had nothing to do with affairs of the opposite party No.1.  At the time of admission, answering opposite party No.2 had  instructed to the complainant and his wife patient about the estimated cost of the entire treatment to be conducted by hospital relating to the above said problem which was agreed by the complainant and his wife patient, however complainant appraised about the mediclaim policy of his wife patient through opposite party No.1 company.  Notwithstanding, answering opposite party No.2 before admitting the patient of the complainant clearly appraised him that in case, opposite party No.1 insurance company rejected the entire claim or approved part of the bill amount then in such

case, the complainant had to pay all hospital charges, as per current schedule of hospital charges in cash and clear all bill before discharge and the same was duly admitted by the complainant himself while signing the declaration form.  As per the procedure laid down for the TPA patients, answering opposite party No.2 had sent the preauthorization request form/cashless authorization to the opposite party No.1.  Opposite party No.1 finally approved some amount Rs.69,895/- against the bill Rs.1,08,811/-.  Patient paid the balance amount Rs.38,960/-. Opposite party No. 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

4.                Opposite party No.3  put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that the present complaint was not legally maintainable against the answering opposite party No.3 M/s. National Insurance Company Limited in any manner, whatsoever.  It was submitted that no any relief had been sought by the complainant against the answering opposite party No.3 M/s. National Insurance Company ltd., the insurer of Metro heart Institute, to whom the answering opposite party No3 issued Professional Indemnity Insurance Policy No. 361100491910000082 covering the insurance risk from 20.02.2020 to 19.02.2021.  the above mentioned insurance policy covers the risk of the opposite party No.2 in respect of any deficient or short service was pointed out and proved to be rendered negligently, the answering opposite party indemnifies the insured opposite party No.2 herein.  In the present cue, the dispute was not with regard to the rendering or negligent or short medical services by the opposite party No.2 in any manner, whatsoever.  As such the answering opposite party No.3 had been wrongly arrayed

as opposite party No.3 whose name was required to be deleted from the array of opposite parties. Opposite party No. 3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

5.                The parties led evidence in support of their respective versions.

6.                We have heard learned counsel for the parties and have gone through the record on the file  as well as written arguments submitted on behalf of the opposite party No.1 has been perused.

7.                In this case the complaint was filed by the complainant against opposite parties–M/s. Star Health and Allied Insurance Company Ltd. & Anr. with the prayer to: a)  make the payment of Family Health Optima Insurance – 2017 of Rs.47,708/- alongwith interest @ 24% from the date of bill till the realization of that amount to the complainant.  b) pay Rs.10,00,000/- as compensation for causing mental agony and harassment . c)  pay Rs. 11,000 /-as litigation expenses.

                   To establish his case the complainant  has led in his evidence,  ExCW1/A – affidavit of Bal Mukund Bansal, Ex.C-1 – Hospitalization Benefit  policy, Ex.C-2 – Bill Assessment Sheet – Hospital Payment, Ex.C-3 – final bill, Ex.C-4 – legal notice, Ex.C5 & 6 – postal receipts.

On the other hand counsel for the opposite party No.1 strongly

agitated and opposed.  As per the evidence of the opposite party  NO.1Ex.RW1/A – affidavit of  Sumit Sharma, Senor Manager, Star Health & Allied Insurance Company Limited, Ist floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi, Annx.R/1 – insurance policy alongwith terms and conditions, Annx. AIIMS Covid-19, Annx.R/3 – Guidelines charges for Covid-19 cases suggested by Niti Ayog Panel,, Annx.R/4 –Cashless request, Annx.R/5 – Cashless Authorization

dated 22.06.2020,  Annx.R/6 – Field visit report dated 23.06.2020, Annx.R/7 – Cashless enhancement authorization letter dated 26.06.2020, Annx.R-8 – Cashless authorization letter dated 27.06.2020 with dedication & approval,  Annx.R/9 – Claim Form, Annx.R-10 – Discharge summary dated 27.06.2020, Annx.R/11 Final bill, Annx.R-12 – Bill assessment sheet dated 14.10.2020.

                   As per the evidence of opposite party No.2, Ex.RW2/A – affidavit of Dr. Manjinder Singh Bhatti, medical Superintendent/Authorized Signatory metro heart Institute with Multispeciality, Sector-16A, Fairdabad,Ex.RW2/1 – Revision of Authorized amount.

                   As per evidence of opposite party No.3, Ex.RW1/A – affidavit of Shri Rameshwar Dass, Administrative Officer, M/s. National Insurance Company Limited, Divisional Office 5C-1&2, BP Railway road, Neelam Chowk, NIT, Faridabad.

8.                In this complaint, the opposite party has already paid Rs.61,103/- out of total amount of Rs.1,08,811/-.  As per the written statement  and written submissions  filed by  opposite party – M/s. Star Health & Allied Insurance company Ltd. In which it has been mentioned that:

                                    Details of bills & deduction

As per calculations, there are different heads where the opposite party – M/s. Star Health & Allied  Insurance Company Ltd. has deducted the money Approx. 40,000/- of the complainant like investigation, medicines and other common procedure.

9.                After going through the written statement and written submissions filed by opposite party. the Commission is of the opinion that the complainant is a layman and he is paying huge amount of premium to the opposite party. At the time of passing the claim, opposite party  has deducted unreasonable deductions.  In the interest of justice, the  complaint is allowed.

10.                Opposite party is directed to:

a)                 pay the whole amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization.

b)                pay Rs.2200/- as compensation on account of mental tension, agony and harassment.

c)                pay Rs.2200/- as litigation expenses to the complainant. 

Compliance of this order be made within 30 days from the date of receipt of copy of order.  Copy of this order be given to the parties  concerned free of costs and file be consigned to record room.

Announced on:  21.12.2022                                 (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.

                                                (Indira Bhadana)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.