The complainant Geeta Dalmia (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against Raksha TPA Health Insurance and another (here-in-after referred to as opposite parties).
Briefly stated the case of the complainant is that complainant is having an account with Oriental Bank of Commerce, Zila Parishad Branch. On the allurement of the advisor of the opposite party, the complainant agreed to purchase the Health Insurance of opposite party No.2. For this, the said advisor got the signatures of the complainant on some blank printed form and also got the consent of the complainant for deduction of the premium from her bank account. The said advisor also disclosed that the said policy covered entire family of the complainant to the tune of Rs.5,00,000/- which was valid from 30.08.2017 to 29.08.2018. The complainant received only one page policy bearing; No. 233200/48/2018/1992 and no terms and conditions of the policy ever received by the complainant form the said bank or the insurance company.
It is alleged that on 17.06.2018, daughter of complainant was uncomforted due to abdominal discomfort and felt breathing ascent. After getting checked from nereby doctor, complainant took her daughter to DMC & H, Ludhiana, for proper treatment in emergency. The attending doctor of the said Hospital admitted the daughter of the complainant on 17.06.2018 and discharged on 20.06.2018 after giving full treatment and charged Rs. 26,125/-. The said hospital issued the bills in the name of patient namely Miss. Himanshi. The complainant pleaded that she has only one child.
The complainant further alleged that after discharge from the said Hospital, the complainant lodged claim under the policy for reimbursement and sent entire documents in original to the opposite party No.1 through registered post on 10.12.2018. The opposite parties registered a claim number 55651819126985. The opposite parties issued a letter for providing break-up bill and actual problem of the patient from the treating doctor. On this, the complainant sent a e-mail and disclosed the reason that the concerned hospital is not ready for providing the same. Thereafter, the opposite parties again issued letter for providing the demanded documents. The complainant requested the concerned hospital for providing documents as required by opposite parties. After getting documents, the complainant forwarded the same to opposite party No. 1 . In the month of January, 2019 the opposite parties conveyed that the claim under the policy was closed by them for the reason of pre-existing disease.
The complainant further alleged that her child was hale and hearty and this fact also mentioned by the concerned doctor that the disease is not an old one rather the same developed 2 months earlier. The opposite parties rejected the claim of the complainant on surmises and conjectures basis and without going through the entire documents provided by the complainant. So, the rejection of the claim under the policy is not legal rather the same is liable to be quashed.
On this backdrop of facts, the complainant has prayed for directions to opposite party No. 2 to release the medical expenses with interest and pay her compensation to the tune of Rs. 10,000/- besides Rs. 5,000/- as litigation expenses.
On the statement of learned counsel for complainant, name of opposite party No. 1 was deleted from the array of the parties vide order dated 29-8-2019.
Upon notice, opposite party No. 2 appeared through counsel and contested the complaint by filing written reply raising legal objections that intricate questions of law and facts are involved in the complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act'. That the complainant has concealed material facts and documents from this Commission as well as the opposite party,
It has been pleaded that complainant has concealed the fact that the claim in question is not payable under clause 5.5 of the policy and the claim was lodged beyond the mandatory period of 7 days from the discharge from the hospital for submission of documents. The opposite party No. 2 sought the documents (i) original bill, receipts and discharge certificate/card from the hospital (ii) Medical history of the patient recorded by hospital (iii) Original cash memo from the hospital/chemist supported by proper prescription, (iv) Original receipt, pathological and other test reports from a pathologist/ radiologist including film etc. supported by the note from attending medical practitioner/surgeon demanding such tests, (v) Attending Consultants'/ Anaesthetists'/ Specialists' certificates regarding diagnosis and bill/receipts etc, in original, (vi) Surgeons' original certificate stating diagnosis and nature of operation performed along with bills/ receipts etc. (vii) Any other information required by TPA/ the company. The said documents were to be submitted by the complainant to opposite party and complainant has failed to submit the documents to opposite party & 'TPA. The insurance policy is always subject to its terms and conditions.
It has been further pleaded that the opposite party No.1 which is third party administrator sent letters dated 30/07/2018, 18/08/2018 and 27/09/2018 calling upon the complainant to submit documents mentioned therein, but complainant failed to send required documents. Thus, the opposite party No 1 recommended repudiation of claim vide letter dated 16.11.18 and claim of the complainant was repudiated vide letter dated 29.11.2018.
Further legal objections are that the complainant is not consumer. That the complainant has no locus standi or cause of action. That the complaint is not maintainable in the present form and that the complaint is bad for non-joinder of necessary parties as the complainant has not impleaded Oriental Bank of Commerce as party who is otherwise necessary party to present complaint.
On merits, the opposite party No. 2 reiterated its version as pleaded in legal objections and detailed above. After controverting all other averments of the complainant, the opposite party No. 2 prayed for dismissal of complaint.
In support of his complaint, the complainant has tendered into evidence affidavit of complainant (Ex. C-1) and documents (Ex. C-2 to Ex. C-8).
In order to rebut the evidence of complainant, opposite party No. 2 tendered into evidence documents (Ex. OP-2/1 to Ex. OP-2/7) and affidavit of Ashwani Kumar (Ex. OP-2/8) .
The learned counsel for the parties reiterated their stand as taken in their respective pleadings.
We have heard learned counsel for the parties and gone through the record.
In the case in hand, there is no dispute regarding insurance policy and claim filed by complainant/insured for reimbursement of medical expenses incurred by complainant on the treatment of her daughter Himanshi.
The opposite party No. 2 vide letter dated 29-11-2018 (OP-2/5) denied the claim of the complainant on the ground of non-submission of documents i.e. (i) original bill, receipts and discharge certificate/card from the hospital (ii) Medical history of the patient recorded by hospital (iii) Original cash memo from the hospital/chemist supported by proper prescription, (iv) Original receipt, pathological and other test reports from a pathologist/ radiologist including film etc. supported by the note from attending medical practitioner/surgeon demanding such tests, (v) Attending Consultants'/ Anaesthetists'/ Specialists' certificates regarding diagnosis and bill/receipts etc, in original, (vi) Surgeons' original certificate stating diagnosis and nature of operation performed along with bills/ receipts etc. (vii) Any other information required by TPA/ the company.
The submission of learned counsel for opposite party No. 2 is that the complainant has not submitted the required documents demanded vide letter 27-9-2018 within 15 days from the date of issuance of this letter due to which claim of the complainant was denied whereas on the other hand, learned counsel for complainant submitted that despite submission of original documents by complainant, opposite party No.2 denied the genuine claim of the complainant.
A perusal of file reveals that complainant has placed on file photostat copy of bills and other documents. So, there can be no reason that the complainant would not have submitted/deposited the documents with the opposite parties for getting insurance claim.
Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh, in case titled The Oriental Insurance Co. Ltd.& Another Vs. M/s Puneet Pasricha, First Appeal No.1579 of 2004, decided on 05.03.2010 held that :-
“......The appellants cannot be permitted to frustrate the insurance claim on the technicalities.”
Hon'ble Punjab & Haryana High Court in the case titled New India assurance Co. Ltd., Vs. Usha Yadav 2008(3) RCR Civil 111 has observed that :
“Cash rich Insurance Company indulging in luxury litigation to repudiate claim of the insured – It seems that the Insurance companies are only interested in earning the premiums and find ways and means to decline the claim,
Thus, there is deficiency in service on the part of opposite party No. 2 in rejecting the genuine claim of the complainant without any basis and the complainant is entitled to the insurance claim.
In the result, this complaint is partly allowed with Rs. 10,000/- as cost and compensation against opposite party No. 2. The opposite party No. 2 is directed to pay to complainant insurance claim as per medical bills submitted by complainant with interest @ 8% p.a. with effect from three months, of submission of bills till payment.
The compliance of this order be made by opposite party No. 2 within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to covid pandemic and heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record.
Announced :
19-5-2022
(Kanwar Sandeep Singh)
President
(Shivdev Singh)
Member
(Paramjeet Kaur)
Member
