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

 

Complaint Case No : RBT/CC/2018/257

Date of Institution   : 06.04.2018/29.11.2021

Date of Decision    : 31.05.2022

Upinder Singh Banga son of Sh. Jagat Singh Banga, resident of 57-Mewa Mandi, Amritsar. 

                …Complainant Versus

1.United India Insurance Co. Ltd., Madan Mohan Malviya Road, Amritsar, through its Divisional Manager/Officer Incharge.

2.Vipul Med Corp Insurance, TPA Pvt. Ltd., S.C.I No. 98, First Floor, Industrial Area, Phase-II, Chandigarh.  

             …Opposite Parties

Complaint Under Section 11 & 12 of Consumer Protection Act, 1986. As Amended Upto Date.

 

Present: Sh. Munish Kohli Adv counsel for complainant.

Sh. Vikas Mahajan Adv counsel for opposite party No. 1.

Opposite party No. 2 exparte.

 

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 11 & 12 of the Consumer Protection Act, 1986 (as amended upto date) against the United India Insurance Co. Ltd., and others (hereinafter referred as opposite parties)

2. Brief facts of the case are that the complainant obtained Mediclaim insurance policy from the opposite parties from time to time against the payment of requisite premium amount as claimed by them from time to time and policy bearing No. 2002002816P100246903 for the period w.e.f. 9.4.2016 to 8.4.2017 and another latest policy bearing No. 2002002817P100780217 for the period w.e.f. 9.4.2017 to 8.4.2018 obtained by the complainant by paying the requisite premium of Rs. 23,053/-. It is alleged that the complainant is getting mediclaim insurance from the opposite parties for the last so many years continuously without any break. At the time of obtaining impugned mediclaim insurance policy the concerned agent of the opposite parties duly assured that in the event of getting of any medical treatment the opposite parties will indemnify the complainant and on the basis of assurance the above said mediclaim policy was obtained the regular premium was paid by the complainant without any lapse covering risk of medical treatment for him as well as his wife Smt. Jagjit Kaur. It is further alleged that during the currency of impugned insurance policy the wife of complainant Smt. Jagjit Kaur suffered pain in abdomen and she was diagnosed AC APPENDICITTS  from Altec Laser & Super Speciality Centre and in respect thereof the medical treatment was obtained by the wife of complainant and an amount of Rs. 64,855/- was spent by the complainant on her treatment. It was a cashless insurance policy and the opposite parties were under obligation to pay the entire amount towards the medical treatment obtained by the wife of the complainant, but the opposite parties have not provided the said cashless facility to the complainant and rather advised the complainant to apply for reimbursement of medical expenses. The complainant applied for the reimbursement of above said medical claim of Rs. 64,855/-, but the opposite parties have only paid an amount of Rs. 25,000/- on 7.6.2017 and deducted an amount of Rs. 39,855/- illegally. The complainant requested the opposite parties to reimburse the above mentioned balance of Rs. 39,855/- spent by the complainant towards medical treatment of his wife. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice on their part. Hence, the present complaint is filed for seeking the following reliefs.- 

i) To pay the impugned claim of Rs. 39,855/- alongwith interest @ 12% per annum w.e.f. 7.6.2017. 

ii) To pay Rs. 25,000/-  as compensation on account of mental agony and harassment and Rs. 11,000/- as litigation expenses.   

3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written statement taking preliminary objections interalia on the grounds of not come to the Forum clean hands, no cause of action, suppressed of material facts etc. It is further alleged that Policy clause 1.1, which provides that the company will pay the amount of such expenses incurred as are medically necessary and reasonable and customary. Further policy clause 3.33 reveals that Reasonable and Customary charges means the charges for service or supplies, which are standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involved. The complainant themselves have not availed the cashless facility at any empaneled hospitals and had preferred the reimbursement mode of claiming treatment expenses to the tune of Rs. 64,855/-. The claim was therefore processed and settled for an amount of Rs. 25,000/- which satisfies the norms of expenses which are medically necessary, reasonable and customary as explained above. On merits, the above said mediclaim insurance policy is admitted. It is admitted that the wife of the complainant was admitted at Altec Laser & Super Specialty Centre from 8.4.2017 to 11.4.2017 and she was diagnosed as a case of Appendicitis for which she underwent Lap Appendectomy during the hospitalization. The complainant lodged claim for reimbursement of Rs. 64,855/- and the claim was processed as per policy terms and conditions and the company settled and paid Rs. 25,000/- on 7.6.2017 vide NEFT Number NEFT-17788871504 under claim file No. 18RB04UIK0163. The details of the packages with other prominent hospitals are as under:-

i.Carewell Heart & Super Specialty Hospital-Rs. 14,000/- for Lap Appendectomy.

ii.Apollo Hospital, Amritsar Rs. 15,000/- for Lap Appendectomy.

iii.Fortis Hospital, Amritsar Rs. 25,000/- for Lap Appendectomy. 

As such, the claim of the complainant regarding remaining amount was refused and repudiated and the complainant was duly informed in this respect. Hence, there is no deficiency in service on its part and prayed for the dismissal of complaint. 

4. Notice was sent to opposite party No. 2 but none appeared on behalf of opposite party No. 2 and was proceeded against exparte vide order dated 23.5.2018.

5. In order to prove the case the complainant tendered into evidence his own affidavit Ex.CW1/A, copy of policy schedule Ex.C-1, copy of the statement of account Ex.C-2, copy of cashless history of member Ex.C-3, copy of letter dated 7.9.2017 Ex.C-4, copy of postal receipt Ex.C-5, copy of letter dated 19.6.2017 Ex.C-6, copy of letter Ex.C-7, copy of discharge summary Ex.C-8 and closed the evidence. 

6. The opposite party No. 1 has produced documents Ex.O.P1 to Ex.O.P9 alongwith the written version and closed the evidence as per order dated 18.2.2019.

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

8. There is dispute regarding the quantum in the present complaint and rest averments made by the complainant are admitted by the opposite party. The dispute regarding the present case is that the wife of the complainant Smt. Jagjit Kaur suffered pain in abdomen and she took treatment from Altec Laser & Super Specialty Centre and spent Rs. 64,855/-. The complainant applied for reimbursement of above said medical claim of Rs. 64,855/-, but the opposite party has paid an amount of Rs. 25,000/- on 7.6.2017 and deducted Rs. 39,855/- unlawfully, illegally and without any basis. The complainant mentioned in the complaint that no terms and conditions were supplied or communicated to the complainant. 

9. On the other hand, the opposite party filed written version and admitted the insurance policy and admitted that wife of the complainant took the treatment from  Altec Laser & Super Specialty Centre and also admitted that the complainant lodged claim for reimbursement of Rs. 64,855/-. The claim was processed as per policy terms and conditions and the company settled and paid the claim for an amount of Rs. 25,000/- on 7.6.2017. The claim was settled as per policy clause 1.1 & 3.33. The opposite party mentioned that package of said treatment in Carewell Heart & Super Specialty Hospital is Rs. 14,000/-, Apollo Hospital, Amritsar is Rs. 15,000/- and Fortis Hospital, Amritsar is Rs. 25,000/- for the above said treatment, which was taken by the wife of the complainant. Therefore, the claim was processed and settled for an amount of Rs. 25,000/- which satisfies the norms of expenses which are medically necessary, reasonable and customary as explained above. 

10. The complainant produced the insurance policy and other documents vide which the wife of the complainant has took treatment and spent Rs. 64,855/- and this fact is also admitted by the opposite party and opposite party admitted that the complainant applied for reimbursement of Rs. 64,855/- and submitted bills. On the other hand the opposite party has failed to produce any evidence to prove that the package in Carewell Heart & Super Specialty Hospital is Rs. 14,000/-, Apollo Hospital, Amritsar is Rs. 15,000/- and Fortis Hospital, Amritsar is Rs. 25,000/- for Lap Appendectomy treatment which was taken by the wife of the complainant. Merely mentioned in written version is not adequate. The complainant has spent Rs. 64,855/-, but the opposite party has only paid Rs. 25,000/- without any reasonable ground. Therefore, there is clear cut deficiency in service on the part of opposite party No. 1 and the present complaint is allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay the remaining amount of Rs. 39,855/- alongwith interest @ 7% per annum from the date of filing the present complaint. The opposite party No. 1 further directed to pay Rs. 10,000/- as  compensation on account of mental tension and Rs. 3,300/- on account of litigation expenses to the complainant. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties free of costs by the District Consumer Commission, Amritsar as per rules. File be sent back to District Consumer Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

       31st Day of May, 2022

 

 

            (Ashish Kumar Grover)

            President             

 

(Navdeep Kumar Garg)

Member