1. This is a petition filed by one Mr. Surendra Kumar Karwa(hereinafter referred to as the petitioner) against the Branch Manager, United India Insurance Company Ltd. Nagaon Branch and one another (hereinafter referred to as the opposite parties) U/S 12 of the Consumer Protection Act, 1986 praying for recovery of money, compensation and other reliefs.
- Facts and circumstances for filing of the aforesaid petition as narrated by the petitioner are as follows:-
The complainant, namely, Sri Surendra Kumar Karwa opened a Mediclaim policy being policy No.1310012815p102863510 for himself, his wife and son with the United Insurance Company Ltd. Nagaon Branch. The term and condition of the policy was duly followed and also accepted by the opposite parties and accordingly, the opposite parties undertook to render service of the facility of cash-less treatment of the claimant, his wife and son during the validity period. The petitioner also stated that on last 01-02-2016, at night while he along with his wife and son were travelling by bus met with an accident near Bilaspur(Gurgaon)for which his wife, namely, Smti. Manju Devi Karwa sustained injuries badly and then, she was admitted in Medanta Hospital at Gurgaon and treated there. The complainant further stated in his petition that his wife, thereafter, through him lodged her claim before the opposite party No.1 to get the benefit of her medi-claim policy covering the risk of Rs.2,00,000/-and submitted the Hospital bill amounting to Rs.3,50,000/- but the opposite parties surprisingly paid only Rs.1,40,000/- against her medi-cliam policy by deducting an amount of Rs.60,000/- of her legitimate claim amount. The complainant further stated that when his wife sought clarification about the deduction, the opposite parties informed that she was entitled to Rs.2,000/- per day as room rent whereas she opted for room rent of Rs.7,500/- per day and she was not entitled to receive the said extra amount from the opposite parties against her medi-claim policy and not being satisfied though she served legal notice on the opposite parties through her counsel but did not get any response from them to settle her claim. The petitioner alleged that the opposite parties have violated the condition of the policy as well as the term of the contract between the policy holder and the Insurance Company and thereby committed deficiency of service. Hence, this claim petition is before this Commission seeking for relief.
- Opposite parties filed their written version denying all the allegation leveled against them by the complainant. By their written version the opposite parties inter alia pleaded that there is no cause of action for the complainant to file this petition before this commission, that the complaint case is not maintainable, that the petition of the complainant does not attract the provision of Section 12 of the Consumer Protection Act and that there is no deficiency of service on the part of the opposite parties while repudiate further claim of the complainant.
The opposite parties stated further in the written version that after receiving the intimation letter from the complainant, they registered the claim to the Heritage Health TPA Pvt. Ltd, Guwahati for settlement and accordingly, the Heritage Health TPA Pvt. Ltd, Guwahati settled the claim at Rs.1,40,000/- against the insure policy of Rs.2,00,000/- after scrutiny and deduction of the amounts as per term and condition of the medi-claim policy. The opposite parties vide their written version further submitted that the complainant had filed the instant claim only for wrongful gain and he is not entitled for any further amount for his wife against the said medi-claim policy and hence, they did not commit any deficiency of service. Under such circumstances, the opposite parties pray for dismissal of the complaint petition.
4. On basis of pleadings of both the contesting parties the following points have come out for discussion and decision:-
- Whether the complainant suffered mental and financial loss for the act of the opposite parties while deducting Rs.60,000/-from the insured amount of Rs.2,00,000/- which he incurred for treatment of his wife following injuries sustained during an accident to which his wife is entitled to claim against the medi-claim policy No.1310012815p102863510 and whether such act on the opposite parties amounts to deficiency in service?
- Whether the complainant is entitled for the relief as prayed for?
- Both side adduced evidence of one witness each and also exhibited several documents in support of their claim. The witnesses were cross examined by their opponents.
- Written argument filed by both the contesting parties and perused the same. Also heard oral arguments for the parties.
7. Decision and reasons thereof:-
8. For the sake of brevity both the Point (i) & (i) are taken jointly for discussion and decision.:-
The claim of the claimant is that he opened a Mediclaim policy for himself, his wife and his son with the united India Insurance company Ltd. and his wife was treated in Medanta Hospital Gurgaon after meeting an accident and when his wife lodged her claim before the opposite party No1. to get the insured amount of Rs.2,00,000/- against her Hospital expenditure, the opposite parties paid only Rs.1,40,000/- after deducting an amount of Rs.60,00,000/- illegally from her legitimate claim for Rs.2,00,000/- . In support of his claim, the complainant examined himself as P.W.1. In his evidence in affidavit, the P.W.1 stated that he opened a Mediclaim policy being Policy No.1310012815p102863510 for himself, his wife and his son with the United Insurance Company Ltd. Nagaon Branch and the term and condition of the policy was accepted by the opposite parties and thereby they undertook to render service of the facility of cash-less treatment of the claimant, his wife and son during the validity period. He further deposed that on last 01-02-2016, at night while he himself along with his wife and son were travelling by bus met with an accident near Bilaspur(Gurgaon) for which his wife, namely, Smti. Manju Devi Karwa sustained injuries badly and then, she was admitted in Medanta Hospital at Gurgaon and treated there. The complainant as P.W.1 further deposed that his wife, thereafter, through him lodged her claim before the opposite party No.1 to get the benefit of her mediclaim policy covering the risk of Rs.2,00,000/-and submitted all the Hospital bill amounting to Rs.3,50,000/- but the opposite parties surprisingly, paid only Rs.1,60,000/- against her medicliam policy by deducting an amount of Rs.60,000/- of her legitimate claim amount. The P.W.1also deposed that when his wife sought clarification about the deduction, the opposite parties informed that she was entitled to only Rs.2,000/- per day as room rent whereas she opted for room rent of Rs.7,500/- per day to which she was not entitled against her mediclaim policy and not being satisfied with such explanation, though she served legal notice on the opposite parties through her counsel but did not get any positive response from them to settle her claim. The petitioner as P.W.1 further deposed that the opposite parties have violated the condition of policy as well as the term of contract between the policy holder and the Insurance Company and as such, the conduct of opposite parties amount to deficiency in service and he is entitled to receive the amount claimed in his claim petition on behalf of his wife.
The opposite parties claimed that after receiving the intimation letter from the complainant, they registered the claim and forwarded the same to the Heritage Health TPA Pvt. Ltd, Guwahati for settlement and accordingly, the Heritage Health TPA Pvt. Ltd, Guwahati settled the claim of the complainant at Rs.1,40,000/- against the insure policy of Rs.2,00,000/- after scrutiny and deduction of the amounts as per term and condition of the mediclaim policy. In support of their written version, the opposite party examined one Hitesh Sarmah, Branch Manager,United India Insurance Co. Ltd. Nagaon Branch. He as D.W.1 deposed that the insurance coverage of the mediclaim policy Vide Ext.A was Rs.2,00,000/- for both husband and wife and Rs.1,00,000/- for the son. He also deposed that Rs.1,40,000/- was paid against the claim of the complainant and as per clause 1.2 A of Ext.D, Rs.60,000/- was deducted from the insured amount. The admitted fact is that Rs.1,40,000/- was already paid to meet the Hospital expenditure of the wife of the petitioner by the opposite parties against his mediclaim policy.
The opposite parties asserted that the petitioner’s wife is entitled to Rs.2,000/- per day as room rent whereas she opted for room rent of Rs.7,500/- per day to which she was not entitled against their medi-claim policy and the deduction was as per terms and condition of the policy after proper scrutiny of the hospital bill. The petitioner in course of evidence, exhibited the mediclaim policy vide Ext.1 which the opposite parties exhibited vide Ext.A and the relevant entry regarding house rent to be paid to the insurance holder vide Ext. D. The opposite party claimed and adduced evidence that the complainant for treatment of his wife is entitled to receive room rent @ 1% per day of the assured sum and accordingly, Rs.60,000/- was deducted from the assured sum as per clause 1.2(A) of Ext.D.
The relevant entry of Ext. D vide clause 1.2(A) read as follows:-
1.2(A). Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing Home upto 1% of sum isured per day, this also includes Nursing Care, RMO charges, IV fluids/blood Transfusion, Injection, administration charges and similar expenses.
The admitted position is that the complainant already received Rs.1,40,000/- for treatment of his wife against the said mediclaim policy. In their written version the opposite parties claimed that the amount of Rs.60,000/- was deducted for room rent from the assured sum as per policy clause 1.2 B, 1.2 C and 1.2D. The D.W.1 Sri Hitesh Sarma who was the branch Manager of United India Insurance. Co.Ltd. in his evidence stated that the deduction was as per clause 1.2 A of Ext. D.
Thus, from the analysis of clause 1.2 A of Ext. D., it is seen that the petitioner is entitled for Rs.2000/- per day as room rent for treatment of his wife. His wife stayed at the Hospital from 02-02-2016 to 10-02-2016 in total 9 days. As per clause 1.2 A of Ext. D, it is clear that the petitioner’s wife is entitled for room Rs.2,000/- per day calculating at the @1% of assured sum per day. Hence, she is entitled for 18,000/- as room rent. On the contrary the petitioner claimed Rs.67,500/- for staying at the Hospital @ Rs.7,500/- Thus deduction of Rs.49,500/-(Rs.5,500/- per day) is permissible as per clause 1.2 A of policy clause of Ext.1. However, regarding deduction of remaining amount of Rs.10,500/- from the insured amount of Rs.2,00,000/-, there is no explanation from the opposite parties. Thus, it is clear that the petitioner is entitled to recover Rs.10,500/- from the opposite parties for treatment of his wife against his medi-claim policy. Thus, there was a deficiency of service on the part of opposite party No.1 and 2 while deducting Rs.10,500/- from the assured sum of the medi-claim policy of the wife of the petitioner. Hence, this commission is of view that the complainant is entitled to recover Rs.10,500/- from the opposite parties for treatment of his wife against his medi-claim policy.
In result both the points for discussion and decision are answered accordingly.
O R D E R
9. In view of the above discussion, it is found that the complainant has succeeded to establish that there was a deficiency of service on the part of opposite party No.1 and 2.
Accordingly, the prayer made by the complainant U/S 12 of the Consumer protection is partly allowed on contest. Issue direction to the opposite party No.1 and 2 to pay the wife of the complainant immediately Rs.10,500/- (Rupees Ten Thousand & Five Hundred) only against the Mediclaim Policy bearing No. 1310012815p102863510 with interest @ 12% per annum from date filing the petition till payment along with another amount of Rs.10,000/- (Rupees Ten Thousand) only as compensation.
Inform all the parties concern.
Furnish copy free of cost to the parties.
