Haryana

StateCommission

A/735/2018

UNITED INDIA INSURANCE CO. - Complainant(s)

Versus

ASHWANI NANDA AND ANOTHER - Opp.Party(s)

D.P. GUPTA

05 Aug 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                      First Appeal No.735 of 2018

                                                 Date of Institution: 05.06.2018

                                                               Date of Decision: 05.08.2022

 

United India Insurance Company Limited, Jagadhri Road, Near Telephone Exchange, Yamuna Nagar through Sh.Parveen Gupta, Deputy manager, United India Insurance Company Limited, Regional office SCO No.123-124, Sector 17-B, Chandigarh.

…..Appellant

Versus

1.      Ashwani Nanda S/o Sh.Mulakh Raj Nanda

2.      Smt. Kamal Nanda W/o Sh.Ashwani Nanda

Both R/o H.No.353-L, Model Town, Yamuna Nagar, Tehsil Jagadhri, Distt. Yamuna Nagar.

3.      M/s E-Meditek Solutions Ltd. PlotNo.577, Udyog Vihar, Phase-5, Gurgaon through its authorized signatory.

…..Respondents

CORAM:    Mr.S.P.Sood, Judicial  Member

                    Mr. Suresh Chander Kaushik, Member

                   

Present:-    Mr. D.P.Gupta, Advocate for the appellant.

                   Mr. Munish Mittal, Advocate for the respondent Nos.1 and 2.

                   Respondent No.3 already proceeded ex parte.

 

                                                 ORDER

S P SOOD, JUDICIAL MEMBER:

          The present appeal No.735 of 2018 has been filed against the order dated 03.04.2018 of the District Consumer Disputes Redressal Forum, Yamuna Nagar at Jagadhri (In short  Now “District Commission”) in complaint case No.453 of 2015, which was allowed.

2.       The brief facts of the case are that complainant No.1-Ashwani Nanda had purchased a medi-claim policy from the OP No.1. He was insured for Rs.3,00,000/-. The complainant No.2 also insured for same amount.   The OP NO.1 charged a premium of Rs.12,250/- for complainant No.1 and Rs.9900/- for complainant No.2. These policies were valid from 27.02.2015 to 26.02.2016.  Prior to this policy in question, they had also obtained another medi claim policy from OP No.1 since 2004 successively from OPs after  satisfying themselves used to issue the said policy.  In the month of May 2015, the complainant No-.2 faced sever obstructive sleep Apnea as she felt problem in breathing while in sleep and  was got admitted in Fortis Hospital, Mohali. She remained admitted in the said hospital from 13.05.2015 to 20.05.2015, and spent Rs.2,21,737/- on her treatment. On the recommendation of the treating doctor, she purchased a machine worth Rs.83,000/- from Gurnam Health Care vide bill dated 18.05.2015  and complainant No.2 also spent Rs.17,553/- on her treatment. This is how total expenses spent by complainants were Rs.3,22,299/-.  As per the terms and conditions of the policy, the OPs were liable to pay the entire amount.  Under the compelling circumstances, the complainants deposited a sum of Rs.2,50,000/- in installments.  OP No.2 paid only a sum of Rs.1,80,904/- to the hospital out of the total bill amount of Rs.2,21,737/- and thereafter the hospital authorities issued a cheque of Rs2,09,367/- to the complainant (which includes Rs.1,80,904/- paid  by TPA and Rs.28,463/- in excess amount paid by them to the hospital).  In the month of October 2015, OPs have also paid the amount of Rs.17,553/- .  OP No.2 did not pay balance amount of Rs.40,833/- and Rs.83,000/- inspite of repeated request.  Thus there was deficiency in service on the part of the OPs.

3.      In its written version, OP raised preliminary objections with regard to locus standi, maintainability of complaint, accruing cause of action.  As per the terms and conditions of the policy, the amount released to the hospital immediately by the TPA.  The amount of machine purchased by them is not covered under the policy.  
The room rent payable according to the insured amount i.e. 1% and some bills like tonics etc. were not covered under the policy. Thus there was no deficiency in service on the part of the O.Ps and requested to dismiss the complaint.

4.      After hearing both the parties, the learned District Commission, Yamuna Nagar has allowed the complaint vide order dated 03.04.2018, which is as under:-

“We allow the present complaint  with the following directions:

1. The OPs are directed to make the payment to the complainants of the room rent at the rate of 2% of the sum insured for the hospitalization period.
2. The OPs are also directed to reimburse the amount of expenses of Rs.83,000/- incurred by the complainant on account of purchase of Comfort Gel Full Face Mask Machine.  The complainant No.2 is also entitled to the charges of doctor’s visit at the rate of Rs.850/- per day, if already not paid to her.  However, it is clarified that the awarded amount shall not exceed to the sum assured of Rs. 3,00,000/- including  the payment already made to the complainants.  Let the order be complied with within 45days from the date of preparation of copy of this order, failing which the complainant  shall be entitled to the simple interest @ 6% per annum from the date of preparation of order till its realization.”

5.      Feeling aggrieved therefrom, O.P.-appellant has preferred this appeal.

6.      This arguments have been advanced by Sh.D.P.Gupta, learned counsel for the appellants as well as Sh.Munish Mittal, learned counsel for the respondent Nos.1 and 2. With their kind assistance the entire records as well as the original record of the District Commission including whatever the evidence has been led on behalf of  both the parties had also been properly perused and examined.

7.      Learned counsel for the appellant vehemently argued that  learned District Forum has wrongly awarded the expenses for purchase of comfort gel full face mask machine.  The expenses for the said machine falls within the exclusion clause 4.16 of the insurance policy.  The cost of such type of machine was not payable, which was only recommended by the treating doctor.  As per the terms and condition of the policy, the room rent @ 2% only for the period  the patient was admitted in IC unit and not otherwise.  The complainant was not entitled for charges of doctors visit @ Rs.850/- per visit. As per the terms and conditions of the policy, the appropriate amount  is released to the complainant. The complainant be not entitled for the remaining claim amount as prayed for.

8.      Learned counsel for the respondent Nos.1 and 2 vehemently argued that during the subsistence of the medi-claim policy, the complainant N0.2 admitted in Fortis Hospital, Mohali from 13.05.2015 to 20.05.2015  for obstructive sleep apnea.  On the recommendation of the treating doctor, the complainant No.2 purchased a machine for an amount of Rs.83,000/- from Gurnam Health Care vide bill dated 18.05.2015. The opposite parties did not pay the full amount of medical reimbursement, which they are entitled to.

9.        The relevant provision of insurance policy has already been reproduced in the impugned order. There is no need to reproduce again. As per clause (b) of Section 1.2 of the medi-claim insurance policy, the complainants are entitled to the room rent for the hospitalization period @ 2% and as per exclusion clause 4.16, the complainants are also entitled for Rs.83,000/-  spent by them for the purchase of comfort Gel full Face mask machine.   
The treating doctor has recommended the machine for treatment of the patient.  Accordingly, as per  clause 1.2, the complainants are also eligible for charging Rs.83,000/-  from the OPs. The OPs illegally deducted the balance amount of the complainant. The learned District forum rightly allowed the claim of the complainant. The learned District Commission had committed no illegality while passing the order dated 03.04.2018.  The appeal is also devoid of merits and stands dismissed.

10.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant No.1-Ashwani Nanda against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

11.              Applications pending, if any stand disposed of in terms of the aforesaid judgment.

12.              A copy of this judgement be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgement be uploaded forthwith on the website of the commission for the perusal of the parties.

13.              File be consigned to record room alongwith a copy of this judgement.

 

 

05th August, 2022              Suresh Chander Kaushik            S. P. Sood                                                                Member                                             Judicial Member    

S.K

(Pvt. Secy.)