Judgment:
S.A. Siddiqui, Member (Judicial):
1) Complainant/ Appellant has filed this appeal under section 15 of the C.P. Act, 1986 (hereinafter called the Act) against judgment and order dt. 07.03.2012 passed by DCDRF (Central) Maharana Pratab Bus Terminal, Kashmiri Gate, Delhi. In complaint case no. 307/10 Sh. Satya Prakash Vs ICICI Lombard General Insurance Company Ltd.
2) Complainant/ Appellant secured a Health Insurance policy no. 40341/fpp/02853238/01/000, Vide Card No. IHPN-05229030/01 for Rs.2,00,000/- The period of Insurance was 21.11.2009 to 20.11.2011. On 23.02.2010 with complainant felt heart problem, he therefore approached Sir Ganga Ram Hospital for treatment. He made efforts to get cash less Medical facility from the Insurance Company but could not get proper response. Ultimately he was admitted in the hospital on 01.03.2010. He underwent Heart-Surgery in the Hospital and was discharged on 09.03.2010. Before discharge he made payment of Rs.1,86,488/- on 17.03.2010. He again felt some problem and was again admitted in Sir Ganga Ram Hospital. He was again operated and remained hospitalized from 17.03.2010 to 22.03.2010. He again made payment of Rs.1,30,401/-.
3) It was the case of the complainant that due to wrongful denial of the cashless facility by the Insurance Company, he suffered financially and was also subjected to physical and mental harassment. He therefore filed a complaint claiming reimbursement of Medical expenses along with compensation.
4) The OP/ Respondent filed its reply maintaining that no cause of action ever arose to the complainant and that the complaint was filed on false allegations and deserves dismissal. No harassment was caused to the complainant. It was reported by TPA that complainant was given œanti coagulants? which could not have been given without medical prescription. The complainant and the hospital did not give satisfactory response to the queries raised by the OP/ TPA and therefore complainant case was closed. The OP/ Respondent further maintained that cashless facility was never denied. The claim of the complainant was closed due to non receipt of reply to the query. It was further submitted on behalf of OP/ Respondent that complainant did not file any invoice or discharge summary and therefore payment was denied. However the cash less facility was not declined. The complainant did not lodge any claim with Insurance Company or the TPA and therefore no occasion arose to process the claim or to repudiate the same.
5) The complainant filed rejoinder reiteratering the facts alleged in the complaint.
6) Parties led evidence. The evidence was evaluated by the Ld. District Forum which noted that the Hospital provide all the necessary information to the Insurance Company to make available the cash less Insurance facility to the complainant. There was nothing on record to suggest that Insurance Company or its TPA informed the complainant or the Hospital that cash facility could not be extended. The Insurance Company for reasons best known to it, decided to remain silent about the request of extension of the cash less facility. Therefore by implications, it amounts to denial of cash less facility without any valid reasons and therefore the Insurance Company was found guilty of committing deficiency in service.
7) Ld. District Forum further noted that the complainant too was negligent as there was nothing on record to suggest that after discharge and making payment of Hospital charges, the complainant lodged any claim with the Insurance Company are TPA for reimbursement of the expenses or payment of the Insurance amount. In view of the above facts and circumstances, the Ld. District Forum rejected the first relief i.e. payment of Insurance claim or Rs.2,00,000/- but allowed compensation of Rs.40,000/- along with Rs.10,000, cost of litigation in view of the deficiency committed by the Insurance Company for not extending the cash less Medical facility to the complainant without valid reasons.
8) However, the complainant was not satisfied with the impugned judgment and order dt. 07.03.2012 and filed present appeal on the following main grounds besides the others are:
i) That the impugned order dt. 07.03.2012 suffer from illegality in as much as the Ld. District Forum recorded the finding of deficiency of service on the part of the Insurance Company yet failed to award Insurance claim of Rs.2,00,000/-.
ii) OP/ Respondent failed to process the genuine claim of the complainant despite giving prior information to it for providing cash less facility for treatment.
iii) That the Ld. District Forum failed to consider that the complaint itself could have been treated as lodgment of claim for reimbursement of Medical expenses. But the Insurance Company intentionally maintained silence due to malafide reasons.
9) The OP/ Respondent filed reply to the appeal. It was maintained that there was no evidence on record to show that complainant after his discharge from the Hospital lodged the claim with Insurance Company or its TPA. The claim should have been preferred with all necessary documents. Therefore it could not be examined and processed.
10) It was further maintained that since no proper claim was preferred, the same was never repudiated. Initial request lodged with the TPA mentioned four days history of leg pain while the subsequent documents, received on query as well as claim history with TTK showed the history of similar complaints since 2008. No documents related to the treatment in 2008 were made available by the complainant though the patient was treated with an anticoagulants. There was no satisfactory response to the repeated querries made by the TPA from the complainant. As a matter of fact cash less facility was never denied. The Insurance claim of the complainant was closed on account of non receipt of reply to the quarries.
11) We have heard Sh. D.R. Kaushik Ld. Counsel for the Appellant and Sh. Anuj Chauhan Ld. Counsel for the Respondent. We have also gone through the case law Suraj Mal Ram Niwas Oil Mills Vs. United India Insurance Company Ltd. and ANR civil Appeal in 1375/03 decided on 08.10.2010 by Honble Supreme Court of India filed by OP/ Respondent. The purchase of Insurance policy no. 40341/fpp/02853238/000, Vide Card No. IHPN-05229030/01 for Rs.2,00,000/- for the period 21.11.2009 to 20.11.2011 has not been denied. It has further not been denied that the complainant made a payment of Rs.1,86,487 for the Hospital for treatment during the period 01.03.2010 to 09.03.2010 and further paid a sum of Rs.1,30,401/- for Hospitalization and treatment from 17.03.2010 to 22.03.2010. It is also not disputed that the complainant approached Sir Ganga Ram Hospital on 23.02.2010 on account of feeling some kind of heart problem. Through Hospital he applied for cashless Medical facility in Sir Ganga Ram Hospital. He was treated by Dr. Tarun Grover, through his letter dt. 23.02.2010 wrote to the ICICI Lombard Health care for extension of the cash less Medical facility to the complainant. Dr. Tarun Grover informed the Company about ID proof- Driving License of the complainant. It was further informed that the Doctor was first consulted in the Hospital on 22.02.2010 with the complaint of severe pain in left leg for the last 3-4 days. Clinically diagnosed to have acute thrombotic occlusion of left lower limb, the pain in left leg in 2008 which was gradually resolved by conservative management (anticoagulant) so active intervention was abandoned.
12) Through letter dt. 26.02.2010 in reply to query of the Insurance Company received through letter dt. 25.02.210, the OP/ Respondent was informed that consultation papers/ treatment details from 2008, when the patient was first diagnosed with left leg pain, were not available. Again in response to another query of the Insurance Company, through letter dt. 26.02.2010, Dr. Tarun Grover, consultant, deptt. of vascular and indo vascular surgery, Sir Ganga Ram Hospital replied that patient was recommended for Hospitalization and also filled the Insurance Forum in 2008, but before admission, he showed improvement in symptoms and therefore he was not admitted in the Hospital in the year 2008. The Hospital again replied the OP/ Respondent regarding its query through letter dt. 05.03.2010.
13) Needless to say that the Hospital provided all necessary information to the Insurance Company to make available cash less facility to make to the complainant. But Insurance a made stoic Company silence for the reasons best known to it. Therefore by implication it amounted to denial of cash less facility which turn proves deficiency on the part of the Insurance Company.
14) We have also gone through the class IV of the policy documents regarding that policy related terms and conditions of the complainant complied with the terms and conditions of the policy. Sir Ganga Ram Hospital, Dr. Tarun Tondon replied all the queries made by the Insurance Company/ its TPA to despite of this the conduct of the Insurance Company to maintained silence among complete deficiency of service.
15) It is also a fact that complainant was hospitalized twice in Sir Ganga Ram Hospital and made payment of Rs.1,86,488/- respectively. But after discharge the complainant in complete disregard with the class IV point iv of the policy documents was duly applied for reimbursement of the expenses/ award of claim amount. The complainant must suffer for his fault and non compliance with the terms and conditions of the policy.
16) Therefore where in complete agreement with the financial regarded by the Ld. District Forum that the complainant was no entitle for reimbursement of the Medical expenses incurred by him to the extent of Rs.2,00,000/-. But he was uncertainly entitled for compensation of cost of litigation as he was subjected to harassment and suffered financially as well as physically and mentally. However we also file with the compensation and the cost awarded by the Ld. District Forum is not complete consonance with the facts and circumstances of the case therefore we have decided to enhance it in the interest of justice.
17) Accordingly the appeal is partly allowed the impugned judgment and order dt. 07.03.2012 is set aside of the following modified orders passed. The OP/ Respondent is directed to pay a sum of Rs.50,000/- towards mental pain, agony and harassment etc. The OP/ Respondent is further directed to pay a sum of Rs.20,000/- towards cost of litigation. The payment shall be made within a period of 30 days from the date of receipt of the copy of the judgment. The complaint no. 307/2010 stands partly decrial accordingly.
18) A copy of this order be provided free of cost as per rule. Copy of the judgment be sent to the District Forum concerned for compliance and placing the same on the original complaint file. Record of the appeal is consigned to record room thereafter.