CONSUMER DISPUTES REDRESSAL COMMISSION – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110016
Case No.475/2013
Ms. Aruna Mittal
W/o Shri Anil ittal
R/o Flat No.212, Aashirwad Enclave Apartment
Plot No.104, Patparganj, I.P. Extension
Delhi-110092. …..COMPLAINANT
Vs.
- The United India Insurance Company Ltd.
042382-UII, BO Jangpura, Bhogal
Micro Office Bhogal 44/2, Church Road
Jangpura Bhogal, New Delhi-110014.
Through its Senior Branch Manager.
- M/s Vipul Medicorp TPA Pvt. Ltd.
TPA (Third Party Administrator)
B/416, Ansal Chamber I, Bhikaji Cama place
New Delhi-110066.
Through its Chief Executive Officer …..RESPONDENTS
Date of Institution-11.09.2013
Date of Order- 03.05.2024
O R D E R
RITU GARODIA-MEMBER
- The complaint pertains to deficiency in service on part of OP in repudiating the medical claim of complainant.
- The husband of the complainant purchased an Individual Health Insurance Policy 2010 bearing No.042382/48/12/97/00000232 for himself and his wife valid from 9.9.2012 to 8.9.2013 for an amount of Rs.1,50,000/-.
- On 12.11.2012, the complainant fell at home, sustaining injuries including fractures of upper limb (L) arm. On 15.11.12, the complainant was admitted in Shanti Mukund Hospital for medical treatment and was discharged on 19.11.2012.
- OP denied cashless reimbursement of the said bill. The complainant paid a total sum of Rs.88,284.00/- (inclusive all treatment expenses i.e. Bills of hospital/pharmacy/doctor treatment). A claim was filed. OPs repudiated the claim vide letter dated 05.04.2013.
- The complainant served a legal notice dated 10.07.2013 for processing of the claim. OP-2 sent a letter dated 20.07.2013 informing the complainant that “the claim filed by the complainant is under query.” OP-2 vide letter dated 30.07.2013 requested the complainant to provide duly filled claim form and copy of policy. The complainant clarified that he had submitted the filled up claim form along with medical certificate of the treating doctor.
- The complainant prays for disbursal of claim amount of Rs.88,284/- with 24% interest, Rs.1,00,000/- for compensation and mental agony and Rs.25,000/- for litigation expenses.
- OP-1, the insurance, in its reply submits that the complainant was covered under Individual Health Insurance Policy and the sum assured was Rs.1,50,000/. The complainant filed a claim and OP-1 had deputed OP-2, i.e., the TPA, to assess the claim. OP-2 reported to OP-1 that the claim is liable to be repudiated under Clause 5.4 of Individual Health Policy.
- OP-1 further submits that it has never repudiated the claim of the complainant. It is alleged that on investigation, it was found that complainant had not filled the complete details in the claim form. Various reminder letters dated 20.07.2013, 29.07.2013, 02.09.2013 and 20.9.2013 were sent to OP. The complainant failed to submit duly filled claim form along with requisite documents.
- OP-1 has relied on clause 5.4 of Individual Health Policy.
“Condition 5.4:Upon the happening of any event which may give rise to a claim under this policy notice with full particulars shall be sent to the TPA named in the schedule immediately and in case of emergency Hospitalization, within 24 hours from the time of Hospitalization.”
- OP-1 alleges that the complainant has filed the claim after one month of her discharge from the hospital. Hence the claim was rejected vide letter dated 13.3.2013. On receiving the representation dated 19.6.2013 from the complainant, the claim file was reopened. The complainant was sent letters requiring certain documents which are as follows:
“a) To Provide duly filled claim form
b) Details of since when the insured is covered under the medi-claimpolicy supported by policy copy.”
- No reply was filed on behalf of OP-2, the TPA, third Party Administration.
- The complainant has filed the following evidence by way of affidavit:
- Copy of Policy document and receipt of premium payment are exhibited as Ex.CW-1/A and Ex.CW1/A1 and ID card is Ex.CW1/B respectively.
- Copy of Registration Certificate of Hospital is exhibited as Ex.CW-1/C.
- Copies of bills are exhibited as Ex.CW-1/D.
- Copy of Registration Certificate is exhibited as Ex.CW-1/D.
- Copy of letter dated 05.4.2013 is exhibited as Ex.CW-1/E.
- Copy of legal notice along with postal receipts is exhibited as Ex.CW-1/F
- Copy of correspondence dated 20.7.2013 is exhibited as Ex.CW-1/G
- Copy of OP letter dated 29.07.2013 is exhibited as Ex.CW-1/H.
- The Commission has considered the facts and material on record. It is admitted that the complainant was covered under Individual Health Policy for a sum of Rs.1,50,000/-. It is undisputed that the complainant was admitted in Shanti Mukund hospital from 15.11.2012 to 19.11.2012. It is undisputed that the complainant has filed a claim which was rejected.
- OP-2, TPA, vide letter dated 05.4.2013 repudiated the claim, the said letter is as follows-
“We have processed the above claim in accordance with the terms and conditions, exclusion and limitation of Mediclaim Policy issued to you.
We regret to inform you that, your above claim fails to meet the following criteria and is considered Non-Admissible.
FILE IS SENT TO BODO FOR THEIR FURTHER ACTION.
Please note that you can represent your case within 15 days of our rejection to the Underwriting Office.”
- It is undisputed that the complainant made a representation. OP-2, TPA sent a letter dated 20.7.2013 to OP-1, relevant portion is as follows -
Brief Case History | Patient was admitted as a case of Comm.Fracture Shaft Humerus and CRF with interlocking nail was done. |
Present status of Claim | Claim file is under query.The query raised is as under: - Kindly provide the duly filled Claim –form.
- Details of since when are you covered under the mediclaim policy supported by policy copy.
If we get the reply, the claim can be processed subject to mediclaim policy terms & conditions. |
- OP-2 sent a letter dated 29.7.2013 with similar query to complainant.
- The repudiation letter by OP-2 merely states that the claim has been repudiated under the terms and condition, exclusions and limitation. The said letter also mentions that the claim fails to meet the following criteria. However, no criteria are mentioned in the said letter.
- Thereafter the complainant made a representation. OP-2 sent a letter asking for duly filled claim form and details of medi-claim policy. However, no clarification has been offered to the complainant, nor has any submission by OP to this Commission provided reasons for requesting the claim form and policy documents, especially considering the claim has already undergone processing and been rejected.
- OP-1, the insurance has relied on Clause 5.4 of individual health policy. The said clause required notice of hospitalization with full particulars within 24 hours. OP-1 has stated that claim was filed after one month of discharge. Nonetheless, OP-1 has not specified the date on which the claim was filed. OP-1 has not provided clarification about the cashless claim.
- The Hon’ble Supreme Court in the matter of SGS India Limited vs Dolphin International AIR 2021 SC 4849 has held the following
- The onus of proof that there was deficiency in service is on the complainant. If the complainant is able to discharge its initial onus, the burden would then shift to the Respondent in the complaint.”
- The responsibility of substantiating an allegation rests upon the party making the claim. However, OP has not fulfilled its obligation by neglecting to clarify the date of the claim and demonstrate how it falls outside the coverage outlined in Clause 5.4 of the policy. Moreover, OP has not provided explanations for giving different reasons for the rejections at different point of time. The sections of OP exhibit significant deficiencies.
- Top of Form
- Bottom of Form
- The complainant has filed hospital bills dated 19.11.2012 for Rs.76,762/-. Complainant has filed receipt dated 12.11.2012 from the hospital of consultation for Rs.2700/-. The complainant has filed receipt dated 15.11.2012 from the blood bank for Rs.3500/-. Complainant has also filed a consultation receipt dated 03.12.2012 for Rs.1200/- from Dr. Vivek Aggarwal. Complainant has filed pharmacy invoice as follows
- Bill No. A50926 dated 16.11.2012 for Rs.232/-
- Bill No. A51054 dated 16.11.2012 for Rs.246.50
- Bill No. A5203 dated 19.11.2012 for Rs.1470/-
- Bill No. A5343 dated 26.11.2012 for Rs.1274/-
- Bill No. A23622 dated 04.12.2012 for Rs.900/-
Thus, the total amount paid by complainant is Rs.88,284.50 towards her treatment.
- Hence we find OP-1 guilty in deficiency in service and direct OP-1 to pay:
- Rs.88,284.50/- with 9% interest from date of discharge till realization.
- Rs.25,000/- towards mental harassment and physical inconvenience.
- Rs.5,000/- towards litigation expenses.
- File be consigned to record Room. Order be complied and uploaded within 30 days.
