Delhi

New Delhi

CC/485/2018

SMT. BANARSO DEVI - Complainant(s)

Versus

M/S. UNITED INDIA INSURANCE CO. LTD. - Opp.Party(s)

23 Oct 2019

ORDER

 

 

CONSUMER FISPUTES REDRESSAL FORUM-VI

(DISTRICT NEW DELHI,  M-BLOCK, 1^ST FLOOR,

VIKAS BHAWAN, I.P. ESTATE. NEW DELHI-1100001.

 

 

R.B..No.485/2018

Old Case No.547/2016

 

Mrs. Banarso Devi,

61 A, Rama Road,

Delhi-05

(Through Sh. Rajinder Aggarwal

S/o Mrs. Banarso Devi)

                                             …..Complainant

Vs.

 

1.   United India Insurance Co. Ltd.,

2, LSC, C.Lal Chowk,

Okhla Industrial Area, Ph.2,

New Delhi-110020. 

 

2.       Heritage Health TPA Pvt. Ltd.,

411, Laxmi Deep Building,

Laxmi Nagar District Centre,

Delhi-92.                                                  

    ….Opposite Parties

 

NIPUR CHANDNA, MEMBER

 

O R D E R

 

 

The complainant has filed the present complaint against the O.Ps under section 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant, aged 83 years is covered under individual Health Insurance policy No.0406032814P105019017 for the period from 17.9.14 to 16.9.15 along with renewal cover note, charging premium of Rs.18450/- for cover under Senior Citizen without any Cap Code 20. The above policy was renewal of policy No.0406034813-9700000877 for the period  from 17.9.13 to 16.9.14 along with renewal notice demanding a premium of Rs.18450/and endorsement No.040603/48/13/97/82000052 thereon showing that the complainant was covered under Senior Citizen Non Capping. 

2.     The complainant has never made any request for any change in the coverage of policy issued by OP-1 during the period from 2008 to 2015. The complainant was admitted in Sir Ganga Hospital, Delhi for treatment of left formoral fracture from 28.2.15 to 9.3.15. The request was sent to the TPA vide email dt. 8.3.2015 to send the cashless authorization for a sum of Rs.2,20,000/- against the treatment.  But the OP-2 vide its letter dt. 9.3.2015 sent a approval of Rs.1,21,375/- against the final bill of Rs.2,17,471/-.  It is stated by OP-2 that there was a capping on room rent and as such the room rent was paid at the rate of Rs.3250/- per day whereas the policy in question was for a senior citizen and there is no such capping as stated by OP-2.  The complainant paid a sum of Rs.96,096/- to the hospital at the time of discharge and lodged a claim with the OP vide his letter dt. 26.3.2016 for reimbursement. The complainant also sent reminder dt. 8.4.2016 for settlement of his claim.  The OP-1 vide its letter dt. 19.4.2016 rejected the claim arbitrarily, hence this complaint.

3.     Initially, complaint has been contested by OP-1.  OP-1 filed its written statement in which it denied any deficiency in services on its part. It is further stated by the OP that the claim of the complainant was rightly settled for a sum of Rs,1,21,375/-.  The sum insured of the complainant is only Rs.3,25,000/- and as per the provision of the policy, the patient is entitled for room rent of Rs.3250/- i.e. 1% of the sum insured per day. As such the claim was rightly dealt with and prayed for the dismissal of the complaint.

4.     Both the parties have  filed their evidence by way of affidavit.  However, due to non-appearance, OP-1 was proceeded ex-parte vide order dt. 6.6.2018.  On 5.7.2018, the application filed by the complainant for placing of record additional evidence was allowed  and accordingly, the additional affidavit of the complainant along with copy of endorsement scheduled taken on record.

5.     We have heard argument advance at the Bar and have perused the record.

6.     The sole question for our consideration is whether OP was justified in repudiating the claim of the complainant under the pretext of capping.  Answer to it is – Negative. 

7.     The complainant has placed on record the copy of endorsement scheduled, the contents of which is reproduced is as under:

REASON FOR ENDORSEMENT : IT IS HEREBY AGREED AND DECLARED THAT THE INSURED IS COVERED UNDER THE SENIOR CITIZEN POLICY, SINCE 17.9.2021 AND WAS COVERED UNDER THE CODE-20.  BY MISTAKE CODE WAS CHANGED TO “97” WHEREAS IT SHOULD HAVE BEEN CODE “20” HENCE FOR MRS. BANARSO DEVI “NO CAPPING” “ SENIOR CITIZEN” CONDITION SHALL BE APPLICABLE.

 

8.     Perusal of the aforesaid endorsement makes it clear that the claim of the complainant fall under Code-20 since 2001  and as such no capping is applicable as alleged by OP-1.  In the aforesaid endorsement OP-1 itself admitted that there was a mistaken on its part while issueing the policy in question regarding the code through which the claim of the complainant will be dealt. 

9.     In view of the above discussion, we are of the considered view that the repudiation of the balance claim by OP-1 is on false and frivolous grounds of capping which was never applicable on the complainant, hence the rejection of balance claim of the complainant by OP is unjustified and arbitrary, amounting to deficiency in services.  We, therefore, hold the OP-1 guilty of deficiency in service and direct it as under:

i. Pay to the complainant a sum of Rs.96,096/-  along with 9% interest from the date of filing of complaint i.e 10.10.2016 till payment.

 

2. Pay to the complainant a sum of Rs.10,000/- towards compensation on account of harassment, mental agony which will also include the cost of litigation cost.

 

The order shall be complied within 30 days of the receipt of the copy of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post.

Announced in open Forum on 23/10/2019.

 

 

 

(ARUN KUMAR ARYA)

PRESIDENT

                                    ( NIPUR CHANDNA )                                     (  H.M. VYAS )

                                          MEMBER                                                        MEMBER