Delhi

West Delhi

CC/12/161

Savita Singhal - Complainant(s)

Versus

Bajaj allianz - Opp.Party(s)

14 Mar 2017

ORDER

    CONSUMER DISPUTES REDRESSAL FORUM (WEST)

                                        GOVERNMENT OF NCT OF DELHI

  150-151, Community Centre, C-Block, JanakPuri, New Delhi – 110058

 

                                                                                                        Date of institution: 06.03.2012

Complaint Case. No.161/12                                                             Date of order:14.03.2017

IN  MATTER OF

Savita Singhal, R/o. 39/15 Old Rajinder Nagar, New Delhi-110060              Complainant

 

VERSUS

Bajaj Allianz General Insurance Company  Ltd. at-1, DLF Industrial Plot, Second Floor, Moti Nagar, Delhi-110015.                                                                                                 Opposite party

ORDER

R.S. BAGRI, PRESIDENT

1.        Savita Singhal named above hereinafter referred as the complainant has brought the present complaint under Section 12 of the Consumer Protection Act against Bajaj Allianz General Insurance Company  Ltd. hereinafter in short referred as the opposite party for directions to the opposite party to pay sum of Rs.26,300/-part of the medi claim with interest and Rs.50,000/- compensation on account of deficiency in service on the part of the opposite party.

2.        The brief facts of the complaint as stated are that the complainant on payment of Rs.4,514/- of premium took medi claim policy no.OG-09-1104-6003-00033559 for the period 25.03.09 to 24.03.10. The complainant again on payment of Rs.4,514/- as premium took Comprehensive Health  Cover bearing policy no.OG-10-1104-6003-00010757 for the period 25.03.10 to 24.03.11. That on expiry of the insurance cover the complainant on payment of Rs.11,215/- again took comprehensive health cover bearing policy no.OG-11-1104-6003-00000587 with insured sum of Rs.1,00,000/-  and bonus of Rs.10,000/ for the period 25.03.11 to 24.03.12.

3.        That the complainant felt some problem in her right eye. She was taken to Sharp Sight Centre. Where Dr. Kamal B. Kapur after examination diagnosed senile cataract. The doctor advised surgery. She was admitted on 30.11.11 and after successful  micro incision cataract surgery with mil lens in her right eye was discharged. The complainant showed her identification card issued by the opposite party to the Sharp Sight Centre for availing cashless facility. The cashless facility was declined by Sharp Sight Centre. She was told that the complainant after payment of the whole bill the amount can be claimed from the opposite party after lodging claim with them. The complainant incurred expenses of Rs.38,300/- on the operation.

4.        That on 02.12.11 the complainant lodged claim with the opposite party with all supporting documents. The opposite party reiumbursed sum of Rs.12,000/- only out of total expenses of Rs.38,300/- and refused to pay the remaining amount of Rs.26,300/-. The complainant contacted the opposite party. Who told that she will get Rs.12,000/- only and refused to entertain her. Therefore, on 27.12.12 she sent a legal notice to the opposite party requesting to reiumburse the remaining sum of Rs.26,300/- but to no effect. Hence, the present complaint for directions to the opposite party to reimburse remaining sum of Rs.26,300/- of the medical expenses incurred by her with interest and pay a sum of Rs.50,000/- towards physical and mental agony, harassment and financial losses on account of deficiency in service on the part of the opposite party.

5.        After notice the opposite party appeared and filed reply while contesting the complaint and raising preliminary objections of maintainability of the complaint in the present forum, the complaint is false and frivolous and misleading facts are alleged, the complaint is gross abuse of process of law and this forum and there is no deficiency in service on the part of the opposite party and prayed for dismissal of the complaint.

6.        However, on merits, the opposite party admitted that the complainant was ensured for medi claim with the opposite party. She was operated senile cataract in her right eye. The complainant submitted medical claim of Rs.38,300/. But as per Clause 6(g) of the terms and conditions of the medi claim policy liability of the opposite party in making payment in respect of surgery for cataract is restricted to 10% of the limit of indemnity subject to minimum of Rs.12,000/- of the actual incurred amount which is lower and maximum of Rs.35,000/-. The claim of the complainant was for Rs.38,300/-, therefore, the complainant was paid Rs.12,000/- as per the insured contract the sum ensured  being Rs.1,00,000/- only. Therefore, the claim was rightly settled. There is no deficiency in service on the part of the opposite party. The complaint may be dismissed with costs.

7.        The complainant filed replication to the reply of the opposite party while controverting the stand taken by the opposite party and reiterated her stand and once again prayed for  directions to the opposite party.

8.        When Savita Singhal, the complainant, was asked to lead evidence in support of her claim, she filed affidavit narrating facts of the complaint and replication. She also relied upon annexure-C/1 policy no.OG-11-1104-6003-00000587  for Rs.4,514/- dated 25.03.11 with receipt of payment of premium for Rs.11,215/- dated 22.03.11, annexure-C/2 discharge summary from Sharp Sight Centre dated 30.11.11, annexure-C/3 receipt of payment of Rs.38,300/- dated 30.11.11, annexure-C/4 claim form dated 02.12.11, annexure-C/5 intimation dated 05.12.11, annexure-C/6 invoice no.02111128004 dated 30.11.11, annexure-C/7 statement  of account  and annexure-C/8 legal notice dated 27.12.11.

9.        When the opposite party was asked to lead evidence in support of their defence, they relied upon affidavit  of Ramnique Sacher narrating facts of the reply. The opposite parties  in support of their defence have also relied upon all the documents produced by the complainant and terms and conditions of  insurance cover.

10.      The parties also filed written submission in support of their respective case. We have heard counsel for the parties and have gone through the material on record carefully and thoroughly.

11.      After having heard and going through the material on record it is common case of the  parties that the complainant had taken medi claim policy with ensured sum of Rs.1,00,000/- from the opposite party. She was operated for  senile cataract in her right eye. She spent Rs.38,300/- on her treatment. She filed claim of Rs.38,300/- with the opposite party under the medi claim policy. But the opposite party reimbursed sum of Rs.12,000/-  only out of total expenses of Rs.38,600/- on the ground that as per Clause 6(g) of the insurance policy obligation of the opposite party to make payment in respect of surgeries for cataract (after expiry of two years period referred to in exclusion C-2) is restricted to 10% of the limit of indemnity for each and every claim subject to minimum of Rs.12,000/- or actually incurred amount whichever is lower and maximum of Rs.35,000/-.

12.      Before proceeding further it is worthwhile to reproduce clause 6(g) of the insurance policy. Which runs as under:-

“Our obligation to make payment in respect of surgeries for cataracts (after the expiry of the 2 years period referred to in Exclusion C2) above, shall be restricted to 10% of the limit of indemnity for each and every claim, subject to a minimum of Rs.12,000/-(or the actual incurred amount whichever is lower) and maximum of Rs.35,000/- for each of you.  (h) We shall make payment in Indian Rupees only.”

13.      Hon’ble National Commission in case law reported as Om Prakash Versus National Insurance Co. Ltd. 2012 (III) CPJ59 has held that insurance policy is a contract  and the parties are bound by the terms and conditions of the insurance policy. Similar view is taken by the Hon’ble Supreme Court in case law reported as Suraj Mal Ram Niwas Oil Mills (P.) Ltd. Versus United India Insurance Company & Anr.2010 (IV) CPJ38. In view of findings and observations of the Hon’ble National Commission in Om Prakash’s case (Supra)  and Hon’ble Supreme Court on Suraj Mal Ram Niwas Oil Mills (P.) Ltd.’s case (Supra). We have no hesitation concluding that the insurance policy and insurance cover note is a contract between the complainant ensured and the opposite party insurance company and as per Clause 6 (g) of the terms and conditions of the insurance cover the complainant is entitled for reiumbursed of Rs.12,000/- only against medical expanses of Rs.38,300/-. Therefore the opposite parties rightly reiumbursed a sum of Rs.12,000/- only and declined to reiumburse remaining sum of Rs.26,300/-. Hence, there is no unfair trade practice or deficiency in service on the part of the opposite party. So the complaint fails and is here by dismissed.

Order pronounced on : 14.03.2017

• Copy of order be sent to the concerned parties free of cost.
• Thereafter, file be consigned to record.

                  

 

 

(PUNEET LAMBA)                                      (URMILA GUPTA)                                      ( R.S.  BAGRI )

     MEMBER                                                      MEMBER                                                   PRESIDENT