DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/150

Date of Institution   : 23.02.2018/29.11.2021

Date of Decision    : 04.07.2022

Ms. Jagjit Kaur daughter of Sh. Tarlok Singh resident of 1799, Patti Hardass DI, Amritsar.     

                …Complainant Versus

HDFC Standard Life Insurance Company Limited through its Chairman/Managing Director/Principle Officer through its Branch Office District Shopping Complex, Ranjit Avenue, Amritsar. 

                  …Opposite Party

 

Complaint Under Section 12 and 13 of Consumer Protection Act, 1986. As Amended Upto Date.

 

Present: Sh. Deepinder Singh Adv counsel for complainant.

Sh. S.K. Vyas Adv counsel for opposite party.

 

Quorum:-

1. Sh. Ashish Kumar Grover : President

2.Sh. Navdeep Kumar Garg : Member 

 

(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):

1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 12 & 13 of the Consumer Protection Act, 1986 (as amended upto date) against HDFC Standard Life Insurance Company Limited (hereinafter referred as opposite party)

2. Brief facts of the case are that the complainant got Health Benefit mediclaim insurance for herself from the opposite party covering the risk period 17.7.2017 to 16.7.2022. It is alleged that the complainant unfortunately fell ill on 10.11.2017 and was taken to CORPORATE HOSPITAL, AMRITSAR and admitted from 10.11.2017 to 15.11.2017 and the treatment cost of the said hospital came to Rs. 63,237/- and the opposite party was immediately informed about the said hospitalization as the said policy was issued on cashless basis and the complainant was insured for sum of Rs. 3 lacs. It is further alleged that the opposite party instead of making the said payment transferred the amount of Rs. 15,000/- in the account of the complainant. Thereafter, the complainant visited the opposite party number of times for the payment of balance amount of Rs. 48,237/-, but the opposite party did not pay the balance amount till the filing of the present complaint. The above said act of the opposite party amounts to deficiency in service and unfair trade practice on its part. Hence, the present complaint is filed for seeking the following reliefs.- 

i) To pay the amount of Rs. 48,237/- alongwith interest @ 12% per annum from 15.11.2017 till the realization. 

ii) To pay Rs. 30,000/-  as compensation on account of mental agony and harassment alongwith litigation expenses.    

3. Upon notice of this complaint, the opposite party appeared and filed written version by taking preliminary objections interalia on the ground of concealment of material facts. On merits, it is alleged that the claim has been correctly paid to the complainant as per terms and conditions of the insurance policy purchased by the complainant. As per records the complainant had taken insurance plan as critical + DHCB which means daily benefit & critical illness is covered and as per the said plan the insured covered for the sum of Rs. 3.00 lacs thus eligibility is Rs. 3,000/- per day. It is further alleged that as per terms and conditions of the policy cash benefit is payable after deducting first 24 hours stay i.e. deducting 1 day from number of days incurred for hospitalization. But as per the information given by the complainant she was admitted in the hospital on 10.11.2017 and discharged on 15.11.2017 and thus billed for 6 days and after deducting 1 day as per terms and conditions of the policy the amount payable came to Rs. 15,000/- i.e. Rs. 3,000/- per day x 5 days. Thus, there is no deduction of Rs. 48,237/- as alleged rather the amount has been paid as per policy terms and conditions. All other allegations are denied by the opposite party and prayed for the dismissal of complaint. 

4. In support of her case the complainant tendered into evidence her own affidavit Ex.C1, copy of the hospital bill Ex.C-2, copy of the payment receipt Ex.C-3 and closed the evidence. 

5. To rebut the case of the complainant the opposite party at the time of filing written version filed affidavit of Sh. Arpit Higgin, Manager Legal Ex.O.P1/A alongwith documents Ex,O.P1 to Ex.O.P3. 

6. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties.  

7. It is not in dispute that the complainant got insurance policy for herself from the opposite party covering the risk period 17.7.2017 to 16.7.2022 and the complainant was insured for a sum of Rs. 3.00 lacs. It is also not in dispute that the complainant was admitted in CORPORATE HOSPITAL, AMRITSAR on 10.11.2017 and was discharged on 15.11.2017. The main point in dispute in the present case as argued by the Ld. Counsel for the complainant is that the complainant on her treatment has spent Rs. 63,237/- (Ex.C-2) in the above said hospital and the opposite party has paid only Rs. 15,000/- to the complainant (Ex.C-3) and illegally deducted Rs. 48,237/-. On the other hand, Ld. Counsel for opposite party argued that the claim has been correctly paid to the complainant as per terms and conditions of the insurance policy. Ld. Counsel for opposite party further argued that as per records the complainant had taken insurance plan as critical + DHCB which means daily benefit & critical illness is covered and as per the said plan the insured covered for the sum of Rs. 3.00 lacs thus eligibility is Rs. 3,000/- per day. It is further argued by the Ld. Counsel for the opposite party that as per terms and conditions of the policy cash benefit is payable after deducting first 24 hours stay i.e. deducting 1 day from number of days incurred for hospitalization and the complainant was admitted in the hospital on 10.11.2017 and discharged on 15.11.2017 and thus billed for 6 days and after deducting 1 day as per terms and conditions of the policy the amount payable came to Rs. 15,000/- (i.e. Rs. 3,000/- per day x 5 days), therefore, there is no deduction of Rs. 48,237/- as alleged by the complainant, rather the amount has been paid as per policy terms and conditions. In order to support its version the opposite party has placed on record the copy of insurance policy Ex.O.P3 vide which it is mentioned as under;-

“Daily Hospital Cash Benefit Option (DHCB):

1% of Sum Insured for a maximum period of 20 days per year if admitted in Non ICU room and 2% of Sum Insured for a maximum period of 10 days per year if admitted in ICU room.

The benefit will be payable as a lump sum amount at the end of stay in the Hospital for each continuous hospitalization for more than 24 hours as a result of injury, sickness or disease. The benefit amount payable will be calculated as mentioned below: Daily Hospital Cash Benefit (as per option)”.

8. So, from the perusal of the record it is proved that the opposite party has rightly paid the claim amount of Rs. 15,000/- to the complainant as per terms and conditions of the policy Ex.O.P3 and the complainant has admitted that she has received the amount of Rs. 15,000/- from the opposite party and the same is proved from Ex.C-3 i.e. claim settlement statement placed on record by the complainant. 

9. In view of the above discussion, there is no merit in the  present complaint and same is dismissed. However, no order as to costs or compensation. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.  

ANNOUNCED IN THE OPEN COMMISSION:

       4th Day of July, 2022

 

 

            (Ashish Kumar Grover)

            President             

 

(Navdeep Kumar Garg)

Member