TTK Health Care (TPA) & ICICI Lombard have been jointly ordered to pay medical expenditure of Rs. 46,895/- along with interest @ 9% p.a. and Rs.20,000/- as compensation including litigation cost. The order is as follows:
CONSUMER DISPUTES REDRESSAL FORUM-VI
(DISTT. NEW DELHI),
‘M’ BLOCK, 1STFLOOR, VIKAS BHAWAN, I.P.ESTATE, NEW DELHI-110001.
Case No.C.C./693/11 Dated: 24 September 2013
In the matter of:
Sh. Dasrath Raj Kapila
New Delhi …COMPLAINANT
1. M/s. TTK Health Care Pvt. Ltd.,
2. M/s. ICICI Lombard General Insurance
New Delhi-110 025.
3. M/s. ICICI Lombard General Insurance
Andhra Pradesh … OPPOSITE PARTIES
Member : Asha Kumar
Briefly allegations are that complainant obtained a mediclaim cashless policy bearing No.4034/HIR/04020945/01/000 valid from 19.9.2010 to 18.9.2011 and paid a premium of Rs.20,183/-. The complainant got admitted in National Heart Institute on 15.1.2011 for some liver problem and was discharged on 19.1.2011. The complainant gave cashless card to the hospital authorities to send the estimate to OP for approval. But the OP declined facility of the cashless claim on the ground that treatment towards alcohol influence ailments not covered under the policy. The complainant paid Rs.46,895/- to the hospital towards treatment charges. In the para 8 of complaint complainant mentioned as he is teetotaler and have never consumed alcohol and the problem in liver arose due to Diabetic condition which was already disclosed at the time of taking the policy. A letter issued by National Heart Institute dated 19.1.2011 that the damage to the liver was due to Diabetic and not due to alcohol intake. Hence the present complaint wherein complainant prayed for Rs.46,895/- towards medical expenses incurred in hospital along with 18% interest. He further prayed for Rs.50,000/- towards compensation and litigation cost etc.,
Notice was served upon the OP. None appeared on behalf of OP proceeded exparte on 24.4.2012. Case was fixed for settlement for many dates on the request of OP. But nothing came out.
Heard documents on record perused.
All the allegations made by complainant remained unrebutted because OP does not choose to content the claim and later on proceeded exparte on 24.4.2012. We have no other option but to believe on the allegations made by complainant.
We have gone through the policy and the documents placed on record along with letter of hospital dated 19.1.2011. It is clearly mentioned that the damage in the liver is due to Diabetic condition and not due to alcohol intake and it was already disclosed at the time of taking the policy that complainant is diabetic. The plea taken by OP is unjustified. The cashless facility was not provided to complainant as promised by OP and failed to settle the payment of complainant despite the letter of the hospital provided. There is deficiency on the part of the OP. We hold OP guilty of deficiency in service and direct OP to pay Rs.46,895/- along with interest @ 9% p.a. from the date of payment in the hospital till date of payment. We further award Rs.20,000/- as compensation including litigation cost.
The order shall be complied within 30 days from the receipt of the copy of the order; otherwise action can be taken under Section 25 / 27 of the Consumer Protection Act.
Copy of the order be sent to the parties free of cost.
Pronounced in open Court on 24 September 2013.
(S.R.CHAUDHARY) (ASHA KUMAR)