District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.250/2022.
Date of Institution:10.05.2022.
Date of Order: 13.02.2024.
Rishi Kumar Batheja son of late Shri Asha Nand, resident of house No. 936, First floor, Sector-16, Faridabad, District Faridabad. Aadhar card No. 2446 9284 2804 mobile: 8475995511.
…….Complainant……..
Versus
1. M/s. United India Insurance Company Limited, SCO 106, Commercial Complex, Sector-16, Faridabad, District Faridabad through its Divisional Manager/Principal Officer.
2. M/s. Paramount Health service TPA Private Ltd., Plot No. A-442, Road NO.28, M.I.D.C Industrial Area, Ram Nagar, Near Vithal Rukhmani Mandir, Wagle Estate, Thane (West) Pin – 400 604 through its Directors/principal Officers.
…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: Sh. J.S.Dagar , counsel for the complainant.
Sh. Ajay Kumar Sharma , counsel for opposite party No.1.
Opposite party No.2 exparte vide order dated 02.08.2022.
ORDER:
The facts in brief of the complaint are that the complainant obtained a Group Health Insurance Policy Tailormade Group Mediclaim Policy (Retirees) baring No. 5001002818P111142519 from the opposite party No.1, through the opposite party No.2 (being TPA) for an amount of Rs.4,00,000/- and Topup Medical Claim Insurance Policy No. 501002818P111164511 valid for the eriod form 01.11.2018 to 31.10.2019 for an amount of Rs.5,00,000/- and Medical claim Insurance Policy bearing NO. 500100/28/18/P1/11158060 covering the period from the year 2018 to 2019 (which includes the insurance of family members of the complainant) duly issued by the opposite party No.1. The wife of the complainant namely Ms. Manorama Batheja was suffering from dementia, DVT left leg. Bedsores and needed regular hospitalization. She was admitted in Chandana Medical Centre, Sector-18, Faridabad from 13.04.2019 to 18.04.2019 9vide claim Id No. 4245805) and from 29.06.2019 to 02.07.2019 in the same hospital. She was again admitted at QRG Healthcity, Sector-16, Faridabad form 12.07.2019 to 14.07.2019 and again she was admitted at Chandana Medical centre, sectoer-18, Faridabad from 18.10.2019 to 21.10.2019. In this regard following bills were submitted by the complainant under pre-post hospitalization scheme to the opposite party No.2, but the same were declined by the opposite parties and also on day care on 17.09.2019 in QRG. It was very surprised for the complainant that the opposite parties had declined the above said bills of the complainant after a
lapse of eight months by mentioning the clause No.1.1 of the insurance policy, without any sufficient reason. Whereas , as per Clause 5.5. of the above said insurance policy, it had been clearly stated “Post Hospitalization treatment (limit to 90 days) were eligible to be paid under the said insurance policy. Unfortunately the wife of the complainant namely Mrs. Manorama Batheja left for heavon on 22.11.2019. The complainant again and again approached the opposite parties to release the payment of claimed amount but always the opposite parties avoided it on one pretext or the other and did not make the payment. The complainant sent legal notice dated 15.07.2021 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) pay to the complainant amount of Rs.4,04,998/- alongiwth interest @ 18% p.a. from the dte of its due till realization of whole amount in lieu of amount duly incurred by the complainant on account of treatment etc. on the basis of Group Health Insurance Policy Tailormade Group Mediclaim Policy (Retirees) bearing NO. 5001002818P111142519 and topup Medical Claim Insurance Policy No. 501002818P111164511 valid for the period from 01.11.2018 to 31.10.2019 and medical claim insurance policy bearing No. 500100/28/18/P1/11158060 covering the period from the year 2018 to 2019 immediately.
b) pay Rs.1,50,000/- 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 answering opposite party had rightly repudiated the claim of the complainant as per clause No.1.1 the patient presented with complaints of
muscle weakness on 03.09.19 at Metro Heart Institute. Insured was diagnosed with Parkinsons Plus Syndrome. The submitted documents indicate oral medicines was administered. The discharge summary submitted/retrieved in the documents indicate. Patient was not hospitalized and took treatment on OPD basis. Hence, the claim was being denied under clause No.1.1 of the policy. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Case called several times since morning but none appeared on behalf of opposite party No.2 after issuing notice to opposite party No.2. Tracking details also filed in which it had been mentioned that “Item Delivery Confirmed”. Mandatory period of 30 days not expired. In the interest of Justice, Opposite party No.2 was hereby proceeded against ex-parte vide order dated 02.08.2022.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties–United India Insurance Company Limited with the prayer to: a) pay to the complainant amount of Rs.4,04,998/- alongwith interest @ 18% p.a. from the date of its due till realization of whole amount in lieu of amount duly incurred by the complainant on account of treatment etc. on the basis of Group Health Insurance Policy Tailormade Group Mediclaim Policy (Retirees) bearing NO. 5001002818P111142519 and topup Medical Claim Insurance Policy No. 501002818P111164511 valid for the period from 01.11.2018 to 31.10.2019 and medical claim insurance policy bearing No. 500100/28/18/P1/11158060 covering
the period from the year 2018 to 2019 immediately. b) pay Rs.1,50,000/- 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, Ex.CW-1/A – affidavit of Rishi Kumar Batheja, Ex.C-1 – claim form,, Ex.C-2 – list of Annexure, Ex.C-3 – Cashless Authorization letter,, Ex.C-4 – insurance policy valid from 01.11.2018 to 31.10.2019, Ex.C-5 – insurance policy valid from 01.11.2018 to 31.10.2019, Ex.C-6- insurance policy valid from 01.11.2018 to 31.10.2019, Ex.C-7 – Discharge summary, Ex.C-8 & 9– Discharge summary of Chandna Medical Centre., Ex.C-10 – Discharge summary, Ex.C-11 – Discharge summary of Chandna Medical Centre, Ex.C-12 – Discharge summary of QRG Health City,, Ex.C-13 – Death summary, Ex.C-14 – Final Impressions,, Ex.C-15 -
Claim form Part A,, Ex.C-16 – not readable,, Ex.C-17 – not readable,, Ex.C-18 – Detailed claim information, Ex.C-10 – letter dated 07.01.2020,, Ex.C-20 – photos,, Ex.C-21 – Identity card,, Ex.C-22 – death certificate, Ex.C-23 – letter dated 08.09.2019, Ex.C-24 – email, Ex.C-25 – claim form, Ex.C-26 – not readable,, Ex.C-27 – Adhaar card,, Ex.C-28 – legal notice, Ex.C-29 – postal receipt.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite parties Ex.DW1/A – affidavit of Kailash Taneja, Deputy Manager, United India Insurance Co. Ltd., Faridabad, Ex.R-1 -repudiation letter dated 05.11.2019, Ex.r-2 – repudiation letter dated 07.01.2020.
7. In this case, the complainant obtained a Group Health Insurance Policy Tailormade Group Mediclaim Policy (Retirees) baring No. 5001002818P111142519 from the opposite party No.1, through the opposite party No.2 (being TPA) for an amount of Rs.4,00,000/- and Topup Medical Claim
Insurance Policy No. 501002818P111164511 valid for the period from 01.11.2018 to 31.10.2019 for an amount of Rs.5,00,000/- and Medical claim Insurance Policy bearing NO. 500100/28/18/P1/11158060 covering the period from the year 2018 to 2019 (which includes the insurance of family members of the complainant) duly issued by the opposite party No.1 vide Ex.C4 & C5. The wife of the complainant namely Ms. Manorama Batheja was suffering from dementia, DVT left leg. Bedsores and needed regular hospitalization. She was admitted in Chandana Medical Centre, Sector-18, Faridabad from 13.04.2019 to 18.04.2019 9vide claim Id No. 4245805) and from 29.06.2019 to 02.07.2019 in the same hospital vide Ex. C-6. She was again admitted at QRG Healthcity, Sector-16, Faridabad form 12.07.2019 to 14.07.2019 vide Ex. C-7 and again she was admitted at Chandana Medical centre, sectoer-18, Faridabad from 18.10.2019 to 21.10.2019 vide Ex. C-8, She was admitted in Sarvodaya Hospital, Faridabad on .21.11.2019 and deceased on 22.11.2019. On the other hand, the claim of the complainant was repudiated on the ground of Clause No.1.1 the patient presented with complaint of muscle weakness on 03.09.2019 at Metro Heart Institute. Insured was diagnosed with Parkinsons Plus Syndrome. The submitted documents indicate oral medicines was administered. The discharge summary submitted/retrieved in the documents indicate. Patient was not hospitalized and took treatment on OPD basis. Hence the claim is being denied under clause No.1.1 of the policy.
“1.1. Now this policy witnesses that subject to the terms, conditions, exclusions and definitions contained herein or endorsed, or otherwise expressed hereon the company undertakes that during the period stated in the schedule or during the continuance of this policy by the renewal any insured person shall contract any disease or suffer from any illness (hereinafter called disease) or sustain any bodily injury through accident (hereinafter called injury) and if such disease or injury shall require any such insured person, upon the advice of a duly qualified physician/medical specialist/medical practitioner (hereinafter called Medical Practitioner) or of a duly qualified surgeon (hereinafter called surgeon) to incur hospitalization/domicilary hospitalization expenses for medical/surgical treatment at any Nursing Home/hospital in India as herein defined (hereinafter called hospital) as an inpatient, the company will pay through TPA to the hospital/Nursing Home or insured the amount of such expenses incurred as are medically necessary and reasonable and customary in respect thereof by or on behalf of such insured person, but not exceeding the sum insured in aggregate in any one period of insurance stated in the schedule hereto.
8. After going through the evidence led by the complainant, no doubt the treatment was taken by the complainant and the opposite parties was taking the premium of the policy. As per evidence led by the complainant the age of Manorama Batheja is 57 years in the 2019. Moreover, when the insured is above 45 years then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines.
9. After going through the evidence led by both the both the parties, the Commission is of the opinion that the repudiation done by the opposite parties are not justified. Hence, the complaint is allowed. Opposite parties Nos.1 & 2 are directed to process the claim of the complainant of the billed amount after deduction of 25% and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing complaint till its realization. The opposite parties are also directed to pay Rs.3300/- as compensation on account of mental tension, agony and harassment alongwith 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 this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 13.02.2024. (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.
