Haryana

Ambala

CC/96/2021

Dr Rita Jaspal - Complainant(s)

Versus

The Oriental Insurance Co Ltd - Opp.Party(s)

Balbir Singh Jaspal

01 Mar 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	96 of 2021
Date of Institution	:	18.02.2021
Date of decision	:	01.03.2023

Dr. Rita Jaspal wife of Dr. Dalbir Singh Jaspal, resident of H.No. 69, Model Town, Ambala City.

          ……. Complainant.

Versus

1. The Oriental Insurance Company Ltd., 2 nd Floor, Jeevan Jyoti Building, Jawaharlal Nehru Marg, Jagadhri Road, Ambala Cantt. 133001 through its Divisional Manager.
2. Park Mediclaim TPA Pvt. Ltd. through its Manager, 702, Vikrant Towers, Rajindra Palace, New Delhi-110008.

….…. Opposite Party

Before:        Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Ms. Pearl Jaspal, Advocate counsel for the complainant.      

                     Ms. Suraj Rashmi Sharma, Advocate, counsel for OP No.1.   

                     OP No.2 already ex parte.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

(i)      To pay Rs.40,000/ along with interest @ 18% P.A. from the    date of deposit till its realization.

(ii)     To pay Rs.50,000/- as compensation for harassment and          mental agony.

                   (iii)    To pay Rs.22,000/-, as litigation expenses.

OR

Grant any other relief which this Hon’ble Commission may deems fit.

2.             Brief facts of the case are that the complainant took Mediclaim Policy bearing no. 261101/48/2019/560 from OP No.1 which was valid for the period from 16.8.2018 to 15.8.2019. At the time of giving the said policy, it was assured by the OPs that cashless medical benefits will be provided to the complainant. The complainant was admitted at Fortis Hospital, Mohali, for B/L Knee Replacement on 22.10.2018. She was operated on 23.10.2018 and was discharged on 29.10.2018. Total bill of Rs.3.20,039/- was raised by the Fortis Hospital, Mohali, towards the said treatment. However, the OPs flatly denied to pay Rs.40,000/- raised on account of navigation charges, over and above the package charges, which is totally illegal, unwarranted and against the policy norms. The scope of the services was inclusive of hospitalization and other charges for the period of policy. The complainant duly submitted all the bills and claimed treatment expenditure which was delayed on one pretext or other by the OPs. The complainant was forced to pay Rs.40,000/- on account of navigation charges under code HSN-999311 dated 23.10.2018, which was denied by the OPs  on cashless basis for the reasons best known to them. The complainant had sent e-mail to the OPs in the mater but in spite of that they failed to resolve the issue thereby causing her harassment and mental agony. Hence this complaint.
3.           Upon notice, OP No.1 appeared and filed written version and raised preliminary objections with regard to maintainability, not come with clean hands and suppressed the true and material facts and estoppal etc. On merits, the OP No.1 admitted the factual matrix of the case with regard to issuance of insurance policy in question, in favour of the complainant, as stated in the complaint, it has been stated that the complainant is barred by estoppel from instituting this complaint as she herself gave undertaking dated 22.10.2018 to Park Mediclaim Insurance TPA that she will not claim Rs.20,000 per knee for navigation charges from the insurance company which is also not payable under the scope of the policy. Rest of the averments of the complainant were denied by the OP No.1 and prayed for dismissal of the present complaint.
4.           Upon notice, none appeared on behalf of the OP No.2, before this Commission, therefore, it was proceeded against ex-parte vide order dated 22.09.2021.
5.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure CA alongwith documents as Annexure C-1 to C-13 and closed the evidence on behalf of the complainant. Learned counsel for the OP No.1 tendered affidavit of Renu Dhingra, Divisional Manager, Divisional Office Oriental Insurance Company, Ambala Cantt. as Annexure OP1/A alongwith documents Annexure OP-1 to OP-5 and closed evidence on behalf of OP No.1.
6.           We have heard the learned counsel for the complainant and learned counsel for OP No.1 and have also carefully gone through the case file.
7.           Learned counsel for the complainant submitted that  though the OPs were under obligation under the policy in question, to pay the navigation charges, referred to above, which were incurred during treatment taken by the complainant in the Fortis Hospital, yet, by not paying the same, the OPs are deficient in providing service.
8.           On the other hand, learned counsel for the OP No.1 submitted that since the complainant herself has given undertaking dated 22.10.2018, Annexure OP1/3 to Park Mediclaim Insurance TPA to the effect that she will not claim Rs.20,000 per knee for navigation charges from the insurance company which is also not payable under the scope of the policy, as such, she is not entitled to the said navigation charges.
9.           Since the facts with regard to issuance of policy in question, in  favour of the complainant; treatment taken by her qua her knee replacement in the Fortis Hospital during subsistence of the said policy; part payment of claim amount except navigation charges are not in dispute, as such, the moot question which falls for consideration is as to whether the complainant is entitled to get the said navigation charges or not. It is significant to mention here that perusal of undertaking dated 22.10.2018, Annexure OP-1/3 clearly goes to show that the complainant and her attendant Dr. D.S. Jaspal have given an undertaking to the TPA at the Fortis Hospital to the effect that she will not claim Rs.20,000 per knee (Rs.40,000/) for navigation charges from the insurance company under the policy in question. Relevant part of the said undertaking is reproduced hereunder:-

“…In this case counseled for Rs.20000 per knee for navigation charges other than the normal package and I declare that I will not claim this amount from insurance also….’

10.           The complainant has not disputed this undertaking. Also, there is no contrary evidence on record, to falsify the contents of the said undertaking. Under these circumstances, it is held that since the complainant herself has undertaken at the Fortis Hospital, by way of executing document dated 22.10.2018, Annexure OP-1/3 to the effect that she will not claim Rs.20,000 per knee (Rs.40,000/-) for navigation charges from the insurance company under the policy in question, as such, now she cannot wriggle out of the same. Thus, the OPs in no way can be held to be deficient in providing service or guilty of adoption of unfair trade practice  by not making payment of Rs.40,000/- to the complainant towards navigation charges.
11.           In view of the aforesaid discussion, we are of the considered opinion that the complaint filed by the complainant is devoid of merits, consequently we dismiss the same. Parties are left to bear their own costs.  Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced:- 01.03.2023.

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President