PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                                                 CONSUMER COMPLAINT NO. 62/2023

Present-Dr. Ramakanta Satapathy, President,

  Sri. SadanandaTripathy, Member,

Sanjaya Kumar Patra,

C/O-Pramod Kumar Naik,

At-Rugudi Banda, Dhankauda, Via-Remed,

Sambalpur-768006.                                                   ………………......Complainant.

Vrs.

1. The New India Assurance Co. Ltd.

Rourkela Branch Office, Kachery Road,

Uditnagar, Rourkela, Sundargarh-769012.

2. Paramount Health Services & Insurance TPA Pvt Limited

Bhubaneswar Branch Head, 271(P), Bapuji Nagar, Near JhranaSahi, Sisubhawan Squire, Bhubaneswar-751009.

3. Paramount Health Services & Insurance TPA Pvt Limited

Plot No. A-442, Road No. 28, M.I.D.C. Industrial Area, Ram Nagar, Near VitthalRukhmaniMandir, Wagate Estate, Thane West-400604.

•                   ……………......Opp.Parties

Counsels:

1. For the Complainant         :- Sri. R.Gupta & Associates
2. For the O.P.No.1                :- Sri. B.K.Purohit
3. For the O.P.No.2 & 3         :- Ex-parte

Date of Filing:25.04.2023,  Date of Hearing :02.07.2024,  Date of Judgement :27.08.2024

Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The case of the Complainant is that the Complainant availed New India Floater Mediclaim policy and Janata Mediclaim policy vide Policy No. 5550134212800000002 and 55050134212800000001 respectively for the period 18.06.2022 to 17.06.2023 and 15.05.2022 to 14.05.2023. The Complainant paid premium of Rs. 24,962/- and Rs. 4684/- respectively. The policies are continuing since 2020-21.

On 19.01.2023 the Complainant visited Trilochan Netralaya, Sambalpur and diagnosed left side eye cataract. The Hospital is attached with O.Ps and cashless facility is available. On 20.01.2023 Complainant submitted insurance paper and estimate of Rs, 40,000/- made and proposal submitted before O.P.No.2 & 3 vide claim No. 5883679. The O.P.No.2 & 3 without proper verification and consultation with O.P.No.1 rejected the claim on the ground “As per available insurance coverage details insured is covered under the present policy since 18.06.2021patient admitted with complaints of left eye cataract. Considering the duration, past history and relation of presenting conditions falls within 2 years waiting period of the policy. In case of any authentic documentation which is evident to prove completition of 2 years coverage, please revert with the same for review and consideration.”

The Complainant operated the left eye in Networking Hospital of O.Ps and submitted bills within time. The insurance papers were in micro letters. The O.P.No.2 & 3 without proper verification issued a deficiency letter dated 23.02.2023 which were submitted earlier. Again on 24.02.2023 the papers were submitted. The O.Ps settled the claim amount at Rs. 10,800/- out of Rs. 37,540/- against policy No. 550501/34/22/28/000008. The rest Rs. 26,740/- was deducted intentionally and documents submitted not properly verified by O.Ps. The O.Ps adopted unfair trade practice and deducted Rs. 25,590/-. The O.Ps not followed policy condition No. 5.F and 3.1 of the New India floater Mediclaim policy.

Being aggrieved complaint has been filed.

2. The O.P.No.1 admitted the insurance of policies. For cataract 10% capping system in there. In floater policy the insured has continuous coverage in excess of 24 months with the insurer expenses on treatment of the cataract are not payable. As per clause No. 3.1 even after 24 months of continuous coverage the cataract will not be covered, if it arose from a pre-existing condition until 48 months of continuous coverage have elapsed since inception of first policy with the company. For cataract maximum charges incurred during hospitalisation is Rs. 10,800/-.

Rs. 10,800/- under the Janata Mediclaim Policy Settled as cashless was denied under New India floater Mediclaim policy and waiting period is 24 months for contract. Insured was covered for sum of Rs. 50,000/- and for capping 10% only eligible for Rs. 5000/-. The insurance preferred to pay Rs. 10,800/- under Janata Mediclaim policy.

There is no deficiency on the part of O.Ps. The TPA is an independent agency appointed by IRDA. The amount paid to the Complainant is proper and complaint is liable to be dismissed.

3. The O.P.No.2 & 3 are set ex-parte.
4. Perused the documents filed by both the parties. The Complainant filed following documents:

1. Policy No. 55050134222800000002 for 2022-23 18.06.2022 to 17.06.2022 period covered.
2. Policy No. 55050134220600000001 for the period 15.05.2022 to 14.05.2023.
3. Policy No. 55050134212800000014 for 2021-22 for 18.06.2021 to 17.06.2022.
4. Policy Janata Mediclaim for 2022-21 15.05.2020 to 14.05.2021 period.

The Janata Mediclaim policy of the Complainant is running regularly from 15.05.2020 onwards. Likewise the floater policy is running since 24.04.2020. The Complainant was denied cashless on 20.01.2023 vide FIR No. 5883679 cashless claim. On 24.02.2023 documents against claim No. TP 006555050122900653263 vide letter dated 04.03.2023 the O.Ps settled only Rs. 10,800/- against claim amount Rs. 37,540/-. The O.Ps issued deficiency letter dated 23.02.2023. Floater scheme policy has been filed.

The O.Ps filed:

1. Floater Mediclaim policy No. 5505013422280000002 for the period 18.06.2021 to 17.06.2022.
2. Janata Mediclaim policy No. 55050134220600000001 for the period 15.05.2022 to 14.05.2023.

5. Perused the documents filed by the parties. The Complainant availed floater policy of mediclaim for the period 18.06.2021 to 17.06.2022 and 18.06.2022 to 17.06.2023. Janata Mediclaim policy was availed for the period 15.05.2020 to 14.05.2021& 15.05.2021 to 14.05.2022. It is the admission o f both the parties that the insured was admitted on 24.01.2023 and discharged on 25.01.2023 under Trilochan Netralaya. As per New Indian floater Mediclaim policy clause No.9 point 3.1 the policy only covers in excess of twenty four months insurance coverage with the insurer. In the present case. The floater scheme is not applicable as the date of admission is less than 24 months. Accordingly, the Complainant is only entitled for the benfit under the Janata mediclaim policy. As per schedule 2.10 the maximum charges inclusive of Room/ICU/OT charges/Surgeons, Anaesthetist, doctors fees/Medicines, internal appliances and other charges during hospitalisation for cataract with imported foldable lens is Rs. 10,800/-. Under the New India floater mediclaim policy the capping is 10% i.e. sum assured Rs. 50,000/-x10%= Rs. 5000/-. The Complainant is only entile for Rs. 5000/- under the floater scheme. The O.Ps preferred to provide the larger benefit i.e. Rs. 10,800/- under Janata Mediclaim policy. The amount has been credited to the Complainant is not denied.

Taking into consideration the circumstances of the complaint, the claim of the Complainant is not acceptable. This Commission observed that there is no deficiency on the part of O.Ps for settlement of claim. Accordingly, the case is dismissed. No cost and compensation.

Order pronounced in the open court on 27^th day of August, 2024.

Supply free copies to the parties.