District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 247/2022.
Date of Institution:10.05.2022.
Date of Order:24.03.2023.
Sunil Nagar son of Shri Partap Singh Nagar, resident of House NO. 5J/52, NIT, Faridabad, Haryana.
…….Complainant……..
Versus
National Insurance Company Limited, 5C/1-2, B.P. Railway Road, Neelam Chowk, NIT, Faridabad – 121001, Haryana through its authorized person.
…Opposite party
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. Harish Hussain , counsel for the complainant.
Sh. Jatinder Singh , counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant had obtained health insurance policy No. 361100502010012720 dated 24.01.2021 for sum of amount of Rs.9,00,000/- which was valid from 24.01.2021 to 23.01.2022 and paid premium of Rs.16,982/-. Under this health insurance policy had been covered complainant, his wife and his daughter, his son having customer ID 9515838855 and complainant and his family have covered amount upto Rs.9,00,000/-. The complainant was having mediclaim policy since 24.01.2015 to 23.01.2022 . The complainant went to Jaipur, Rajathan for his personal work and complainant Sunil Nagar met wth accident at Jaipur, Rajasthan on 13.01.2022 and on the same day i.e. on 13.01.2022 complainant was admitted in RAO Hospital, Plot NO.3, Usha colony, New Loha Mandi Road, Macheda, Sikar Road, Near 14 NO. Bypass, Jaipur, Rajasthan and sustained various injuries and suffered from pain, swelling in right elbow and solder pain, swelling, abhmission around right ear, headache and complainant admitted in ICU and complainant had obtained treatment of the said ailment form 13.01.2022 to 14.01.2022 and paid expenses of Rs. 24,250/- for his treatment. The complainant was admitted in Rao Hospital, Plot NO.3, Usha colony, New Loha Mandi road, Macheda, Sikar Road, Near 14 No. Bypass, Jaipur, Rajasthan on 13.01.2022 after road traffic accident, patient/complainant was having head injury with severe swelling around right elbow and arm and after the CT scan of complainant head he was remained under observation because patient was having dizziness and severe headache at the time of admission. The complainant was having cashless family mediclaim policy with opposite party having policy No. 361100502010012720 dated 24.01.2021 which was valid from 24.01.2021 to 23.01.2022. As per the terms & conditions of the Health Insurance policy, at the time of admission of the patient in the said hospital complainant approached to opposite party through concerned doctor of the Rao Hospital, Jaipur (Rajasthan) for payment of cashless facility/treatment to be provide don behalf of opposite party complainant. But without any bonafide reason opposite party deliberately and intentionally declined the legitimate request of the complainant through concerned doctor after submission of required report and documents by the hospital authority. Letter dated 11.02.2022 issued by TPA of opposite party, TPA of opposite party had deliberately and intentionally without any bonafide reason had declined the cashless treatment despite of submission of all the necessary documents as report as per requirement of TPA of opposite party. The complainant had claimed the amount which he had made expenses of Rs.24,250/- on his treatment from 13.01.2022 to 14.01.2022 and also claimed Rs.50,000/- on account of mental harassment, tension, agony and deficiency in service by non sanction of alleged treatment amount which was to be paid directly to the Rao Hospital Management, Jaipur, Rajasthan and opposite party infringed the terms and conditions of the policy and trade usages and opposite party work and conduct was against the principles of natural justice. The complainant sent legal notice dated 23.03.2022 to the opposite party through registered post but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the payment of Rs.24,250/- on account of treatment/expenses of complainant alongwith interest @ 24% p.a. from the date of admission of the complainant in hospital i.e 13.01.2022 till the realization of the amount to the complainant.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had failed to mention as to how the complainant met with an accident, whether he sustained injuries on his own or the alleged accident was caused by some other vehicle. The complainant has further concealed the fact as to whether at the time of alleged accident was on foot or was driving any vehicle. The complainant had also not placed any MLR/MLC on the Commission’s record to show as to where he was got firstly admitted and medico legally examined as it was mandatory under the law to get the MLR/MLC conducted in case any patient was brought to hospital with injuries sustained in accident. The complainant ahd also failed to disclose as to whether any DDR/FIR was got registered in respect of the accident in which the complainant sustained injuries on his person. In absence of the above mentioned information and connected documents, the competent authority of the opposite party insurer right observed that “Expenses related to any admission primarily for diagnostic and evaluation purposes only were excluded as per clause 4.4 of the insurance policy”, meaning thereby that since no other active line of treatment was given during the time of hospitalization and the patient was admitted in hospital solely for investigation, the claim was non-admissible. The present complaint was not sustainable as the complainant had failed to pin point any deficient or short services rendered by the opposite party while rendering the insurance services under insurance policy No. 361100502010012720 covering the insurance risk from 24.01.2021 to 23.01.2022, whereby 4 members of the family of the complainant Sunil Nagar were insured under National Parivar Mediclaim policy i.e (i) Sunil Nagar (complainant), (ii) Priyanka (wife of Sunil Nagar), (iii) Chahak (daughter of Sunil Nagar) and (iv) Ritik Nagar (son of Sunil Nagar) for total sum insured of Rs.9,00,000/-. As per available record, the complainant after the alleged accident, which took place on 13.01.2022 was brought to Rao Hospital Jaipur with history of pain and swelling in right elbow and shoulder, pain swelling and abhmission around right ear in road traffic accident, the complainant was advised for x-rays of right elbow, right shoulder and CT scan head and accordingly the same was carried out and the patient was admitted for monitoring, where the complainant remained hospitalized from 13.01.2022 at 12.04 pm till 14.01.2022 at 6.03 p.m. The complainant as discharged but no other active line of treatment was give during the time of hospitalization and was admitted solely for investigation and evaluation. The alleged expenses made upon investigation and evaluation were not permissible and as such the same were declined. The complainant submitted the mediclaim claim form for an amount of Rs.29,268/-. Upon receipt of all the required documents, M/s. Safeway Insurance TPA pvt.ltd., Faridabad, the TPA of the opposite party insurer M/s. national Insurance company ltd., processed the claim file and the claim was found non- admissible and was recommended for repudiation under clause 4.4. investigation and evaluation which states that “expenses related to any admission primarily for diagnostic and evaluation purposes only, were excluded” Accordingly, opposite party repudiated the claim of the complainant vide letter dated 09.03.2022 uly sent to the complainant. Opposite party 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 party–National Insurance Co. Ltd. with the prayer to: a) make the payment of Rs.24,250/- on account of treatment/expenses of complainant alongwith interest @ 24% p.a. from the date of admission of the complainant in hospital i.e 13.01.2022 till the realization of the amount to the complainant. b) pay Rs. 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.CW1/A – affidavit of Sunil Nagar, Ex.C1 – Adhaar card, Ex.C2 – Insurance policy, Ex.C-3 – certificate of Rao Hospital,, Ex.C4 – final bill, Ex.C-5 – certificate of Rao Hospital, Ex.R-6 – repudiation letter dated 11.02.2022, Ex.C-7 – legal notice, Ex.C8 – postal receipt.
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW-1/A – affidavit of Rameshwar Dass, Assistant Manager, M/s. National Insurance Company Limited, Divisional Office 5C-1 & 2, BP Railway Road, Neelam Chowk, NIT, Faridabad. Ex.R-1 – insurance policy, Ex.R-2 – terms & conditions, Ex.R-3 – passion for caring,, Ex.R-4 – certificate, Ex.R-5 – CT Scan of the head-Palin,, Ex.R-6 – discharge summary,, Ex.R-7 – final bill, Ex.R-8 – claim form,, Ex.R-9 – recommendation to insurer letter dated 11.02.2022, Ex.R-10 – repudiation letter dated 9.3.2022.
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith 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. File be consigned to the record room.
Announced on: 24.03.2023 (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.
