Punjab

Ludhiana

CC/19/375

sunil Mahajan - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

Inderjeet Singh adv.

26 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 375 dated 05.08.2019.                                                        Date of decision: 26.07.2022.

 

Sunil Mahajan aged about 49 years son of Sh. Kuldip Raj, resident of B-XXXVI-379, Street No.6, Vikas Nagar, Ludhiana.                                                                                                                               ..…Complainant 

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1. United India Insurance Co. Ltd., 818, Industrial Area-B, Above Allahabad Bank, Near Partap Chowk, Ludhiana, through its Manager.
2. M/s. Raksha TPA Pvt. Ld., 15/5, Mathura Road, Faridbad-121003.
3. Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana.                                                                                 …..Opposite parties 

Complaint under Section 12 of the Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Inderjit Singh Luthra, Advocate.

For OP1                         :         Sh. Rajeev Abhi, Advocate.

For OP2 and OP3          :         Complaint against OP2 and OP3 not admitted                                             vide order dated 16.08.2019.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                In nutshell, the case of the complainant is that the complainant purchased Family Medicare Policy vide policy No.2010032818P105603328 which covered the complainant, his wife Monica Mahajan and two children Ridhi and Master Varun for an amount of Rs.4,50,000/-. A premium of Rs.19,207/- was paid. The policy was valid from 21.07.2018 to 20.07.2019. Originally the policy was obtained many years ago and the complainant has been paying premiums regularly.

2.                It is further alleged that on 30.09.2018, the wife of the complainant namely Monica Mahajan was hospitalized with Dayanand Medical College and Hospital, Ludhiana. She was discharged on 03.10.2018. Immediately after the admission, request for cashless treatment was sent to OP1 which was not approved and the cashless facility was not provided. As the cashless treatment was not allowed, the complainant paid the hospital expenses of Rs.22,520/- from his own pocket to OP3. Thereafter, the claim was lodged with OP1 as per terms and conditions of the policy. However, the OP1 instead of reimbursing Rs.22,520/-, Op1 reimbursed a sum of Rs.14,223/- on 12.03.2019 and refused to pay the remaining part of the claim. This amounts to deficiency of service on the part of the OPs. In the end, it has been requested that the OPs be directed to pay the remaining amount of Rs.8297/-  along with interest @18% per annum and the OPs be further made to pay a compensation of Rs.1,00,000/- and litigation expenses of Rs.35,000/-.

3.                The complaint as against OP2 and OP3 was not admitted vide order dated 16.08.2019.

4.                The complaint has been resisted by OP1. In the written statement filed on behalf of the OP1, it has been, inter alia, pleaded that the complaint is not maintainable. According to OP1, after the claim for reimbursement of the medical expenses for hospitalization of Monika Mahajan wife of the complainant was lodged for a sum of Rs.22,520/-, an amount of Rs.14,223/- was approved and paid to Dayanand Medical College and Hospital, Ludhiana vide NEFT reference No.CITIN9937621418 on 11.03.2019 after deducting an amount of Rs.8297/- as per the detail given in the claim settlement voucher dated 18.03.2019. The aforesaid payment was accepted by the complainant voluntarily and unconditionally without any protest. It has further been pleaded that an amount of Rs.8297/- was deducted out of the claim of Rs.22,520/- as per terms and conditions of the policy. An amount of Rs.1650/- was no payable being over stay charges. A sum of Rs.910/- was deducted under the head of dietician fee as Rs.110/- were not payable and a sum of Rs.800/- was not payable as per his overstay charges. Similarly, Rs.3,500/- was not payable as per overstay charged under the head of hospital services. Another sum of Rs.510/- for misc. charges and Rs.300/- for pulse oxymeter charges was deducted which was also not payable as per the policy trms and conditions. The admission fee of Rs.300/- was also not payable and out of sum of Rs.1000/- the claim for RMO/Nursing charges of Rs.400/- was not payable and only a sum of Rs.600/- was payable under the said head. Apart from that discount of Rs.727/- given by the hospital was also deducted. Thus, the deduction of Rs.8297/- has been legally made in accordance with terms and conditions of the policy and there has been no deficiency of service on the part of OP1. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                In evidence, the complainant has submitted his affidavit as Ex. CA along with documents Ex. C1 to Ex. C5 and closed the evidence.

5.                On the other hand, the counsel for the OP1 tendered affidavit Ex. RA of Sh. Inderjit Singh, Divisional Manager of OP1 as well as affidavit Ex. RB of Sh. Dinesh Kumar, A.M. of M/s. Raksha Health Insurance TPA Pvt. Ld. along with documents Ex. R1 to Ex. R20 and closed the evidence.

6.                We have heard the counsel for the parties and have gone through the record carefully.

7.                It is not disputed that Monika Mahajan wife of the complainant was hospitalized from 30.09.2018 to 03.10.2018. As per the discharge summary Ex. C2, she was diagnosed  acute febrile illness with thrombocytopenia. As per the discharge summary, the patient was hospitalized only for three days. In the claim settlement voucher Ex. R2, a sum of Rs.1650/- against room expenses, Rs.800/- doctor fees, Rs.3500/- as hospital services and Rs.400/- against RMO/nursing charges in all Rs.6350/-  has been deducted on account of overstay of the hospital. There is no record as to how OP1 has considered the stay in the hospital from 30.09.2018 to 03.10.2018 as overstay. It is a matter of common knowledge that the patient is discharged when the doctor on the hospital authorities come to a conclusion that the patient is in a  stable condition and he/she is fit to discharge and the patient has no discretion whatsoever. Therefore, the deduction of aforesaid amount of Rs.6350/- on account of overstay of the patient in the hospital does not appear to be justified. In our considered view, it would be just and proper if OP is directed to pay Rs.6350/- along with composite costs and compensation of Rs.3500/-.

8.                As a result of above discussion, the complaint is partly allowed with direction to OP1 to reimburse Rs.6350/- to the complainant within a period of 30 days from the date of receipt of copy of order. OP1 is further directed  to pay composite cost of Rs.3500/- (Rupees Three Thousand Five Hundred only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order.  Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

9.                Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:26.07.2022.

Gobind Ram.

Sunil Mahajan Vs United India Insurance Co.                CC/19/375

Present:       Sh. Inderjit Singh Luthra, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OP1.

                   Complaint against OP2 and OP3 not admitted vide order dated                             16.08.2019.

                  

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to OP1 to reimburse Rs.6350/- to the complainant within a period of 30 days from the date of receipt of copy of order. OP1 is further directed  to pay composite cost of Rs.3500/- (Rupees Three Thousand Five Hundred only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order.  Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:26.07.2022.

Gobind Ram.