9DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No.425/2021

QUORUM:

Judgment By: Shri S.S. Malhotra (President)

JUDGMENT

By this judgment the Commission would dispose off the present complaint filed by the Complainant against OP w.r.t. deficiency in service on the part of OP who has not reimbursing the mediclaim of the complainant in full.

1. Brief facts as stated by the complainant are that the complainant had a policy from the OP1 for himself, his wife and two children having insurance value of Rs.5,00,000/-. The wife of the complainant Mrs. Meenu Jain was diagnosed  with COVID-19 ailment and was admitted to OP4 hospital and when the request for cashless was asked the same was not provided and complainant had to deposit the amount and thereafter she was discharged on 21.05.2021 and he paid Rs.3,11,500/- in the hospital. The complainant then lodged the complaint but OP paid only Rs.1,42,500/- against the claim of Rs.3,11,500/- which amounts to deficiency in service as Rs.1,69,000/- was not paid and accordingly it is prayed that OP be directed to pay Rs.1,69,000/- with interest @ 24% p.a. and compensation of Rs.2,00,000/-. 
2. OP1 and OP2 have filed written statement jointly interalia stating that complainant has approached this Commission for a sum of Rs.169000/- which was disallowed by the OP but the complainant has already settled the matter as per policy guidelines and as such complaint is now not maintainable. The issuance of the policy and the  treatment of the wife of the complainant and her making bill in the hospital is not denied but it is submitted that as per the General Insurance Council Policy  the claim of the complainant was processed and against his bill of Rs.311500/-, Rs.142500/- were allowed and remaining amount was disallowed as there was a policy of the government that hospital cannot charge more than that amount and therefore there is no deficiency on the part of the OP. It is specifically denied that Rs.169000/- has been deducted illegally as alleged and it is prayed that complaint of the complainant be dismissed.
3. Complainant has filed rejoinder in which he has denied the contents of the written statement and reaffirmed and reiterated the contents of the complaint.
4. Complainant has filed his own evidence and OP has filed evidence of Sh. Rakesh Kumar working as Deputy Manager (Law) of OP.
5. Both the parties have filed the documents which are not in dispute.
6. The Commission has heard the arguments and perused the record.
7. The issuance of the policy to the IDV of Rs.500000/-, the suffering of the complainant’s wife with COVID-19, payment of the bill of Rs.311500/- by the complainant to the hospital concerned are the facts which are not in dispute. The only contention of the OP is that as per the guidelines of the government council and as per the prescribed rates the insurance company has reimbursed the amount as per the guidelines given by the government w.r.t. the treatment of the COVID-19 patients in the various hospitals therefore nothing is due.
8. The Commission has enquired from Ld. counsel for the OP as to how these guidelines are binding upon the insurance as those guidelines were specifically given by the government to the hospitals and that they may not charge higher amount of medical treatment from the patient who have been infected with the COVID-19 disease, to which ld. Counsel for the OP has argued that these were the guidelines and deficiency if any is on the part of hospital who has charged more amount. The Commission is not in agreement with this contention as the basis on which the complainant has not been given Rs.169000/- by the OP was binding upon the hospital and were not binding upon the insurance company.  Even otherwise before it is held that they were binding upon the OP certain facts has to be taken care of and were required to be proved by the OP itself i.e. how many number of patients were there in that particular hospital or whether that hospital was fully converted into a COVID hospital by the government. It is also a fact of general awareness that some hospital were converted into COVID hospital completely whereas some hospital were reserved with certain beds for the purpose of treating patients who had been infected with covid -19 ailments. The guidelines which the OP is relying upon would have been applicable to the hospital or to the OP only if these facts would have been proved by the OP, but OP has not come forward with any such further explanation.  Even otherwise the guidelines which were promulgated by the Govt. of India/respective state were quite specific that in case the patient is infected with COVID-19 then these guidelines were not applicable to the insurance company. Therefore, it is a fit case where the complainant has been able to prove and OP has not been able to prove that there was any guidelines to the policy holder by which insurance company would not pay the complete amount to the treatment to the such policy holder. The Commission therefore hereby orders as follows:

• OP would pay Rs.169000/- to the complainant with interest @ 10%  along with compensation of Rs.20,000/- and litigation charges of Rs.10,000/-.

This order be complied with within 30 days from the date of receipt of the order and if not complied by OP an interest @ 13% would be given by OP on all above amount.  

Copy of the order be supplied / sent to the parties free of cost as per rules.

File be consigned to Record Room. 

Announced on 22.02.2024.