District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.421/2020.

 Date of Institution: 05.11.2020.

Date of Order: 26.07.2022.

Suman Tyagi, Resident of Gali No.5, Bhudutt Colony, Faridabad.

                                                                   …….Complainant……..

                                                Versus

1.                The New India Assurance Company limited, 87, M.G.Road, Fort Mumbai – 400 001. Through its Divisional Manager.

2.                The new India Assurance Company Limited, NH-5, R/2/Near Badshaha Khan Chowk, NIT, Faridabad – 121001.

                                                                    …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.

PRESENT:                    Sh. P.K.Tyagi, counsel for the complainant.

                             Sh.  Sanjeev Bansal, counsel for opposite parties. Nos.1  & 2.

ORDER:  

                             The facts in brief of the complaint are that  the  complainant had taken the family medicare health policy bearing No. 3213003419280000003 and the complainant had paid the premium amount pertaining to the above said policy to the opposite parties without any delay.  During the mediclaim policy, the complainant was admitted in Asian Hospital, Sector-21A, Faridabad on dated 16.09.2019 and was discharged on 19.09.2019 and the hospital had raised the bill amount of Rs.90,000/- approximately and at that time the complainant intimated to the representative of the opposite parties through telephonically call and the representative of the opposite parties assured the complainant that his claim file No. 191200175216 would be definitely approved but no fruitful result came out and the said amount had paid by the complainant form their own pocket and later on the complainant had sent all related documents regarding the treatment of the complainant for getting the imbursement of the mediclaim amount but no fruitful result came out.  The complainant several times requested to the opposite parties to make the respective mediclaim amount of Rs.90,000/- but the opposite parties linger on the matter on one pretext to the another.  The complainant sent a legal notice dated 18.06.2020 through registered A.D post 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 mediclaim amount of  Rs.90,000/- approximately under the policy No. 32130034192800000003 alongwith interest @ 18% p.a to the complainant which had been beared complainant from his own pocket during the insurance mediclaim policy.

b)                 pay Rs.1,00,000/- as compensation for causing mental agony and harassment .

c)                 pay Rs.22,000/ - as litigation expenses .

2.                Opposite parties  put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that  the claim of the complainant was not  tenable as per clause and terms and conditions of the policy of insurance and the claim of the complainant had been duly considered and after observation of the documents, the TPA of the complainant i.e. HITPA given opinion that “On scrutiny of the documents of the complainant, we observed that she was treated for PIVD (Pain & Treatment) was given EPIDURAL INJECTION. OPD  Treatment had been converted into IPD…. Claim is not payable as it is not listed under Day Care Procedure:- In view of the above, we regret to inform you that the claim was being denied on account of the above mentioned reasons.  As such the complaint of the complainant was liable to be dismissed on this score alone.  It was worth mentioning that after denial of the claim of the complainant by the TPA of the complainant, the complainant never lodged any claim with answering opposite party. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

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

4.                 We have heard learned counsel for the parties and have gone through the record on the file.

5.                In this case the complaint was filed by the complainant against opposite parties – New India Assurance Co. ltd. & Ors. with the prayer to : a)  make the mediclaim amount of  Rs.90,000/- approximately under the policy No. 32130034192800000003 alongwith interest @ 18% p.a to the complainant which had been beared complainant from his own pocket during the insurance mediclaim policy. b)  pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs.22,000/ - as litigation expenses .

                   To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Mrs. Suman Tyagi, Ex.P-1 – Discharge summary, Ex.P2 – Final Bill details,, Ex.P-3 – Final Bill Summary, Ex.P-4 – Bill cum receipt, Ex.P-5 – Tax Invoice, Ex.P-6 – Bill cum receipt, Ex.P-7 – Tax invoice,, Ex.P-8 – Bill cum receipt, Ex.P-9 – Tax invoice, Ex.P-10 – Identity card,, Ex.P-11 – Pre-authorization denial letter, Ex.P-12 – legal notice, Ex.P-12 Postal receipt, ex.P-13 – courier receipt.

                   On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties, affidavit of Shashi Parkash, The New India Assurance company Limited, Faridabad,, Ex.R-1 -  Terms and conditions,

6.                As per  repudiation letter the objection was taken by the opposite party is this kind of treatment can be treated as the OPD patient  but on the other hand, the counsel for the complainant argued at length and stated that she was admitted on 16.09.2019  and discharged on 19.09.2019.   It is evident from letter dated 04.12.2019 in which it has been mentioned that “As per HITPA recommendations, the diagnosis during the hospitalization mentioned as PIVD radiculopathy comes under OPD treatment and not listed under day care procedure list also.  In this case OPD treatment converted into IPD.”

7.                After going through the evidence led by parties, the Commission is of the opinion  that  the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days  of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint  till its realization.  The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties  concerned free of costs and file be consigned to record room.

Announced on:  26.07.2022                                 (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.