District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 113/2021.
Date of Institution:02.03.2021.
Date of Order: 16.5.2023.
Gopi Chand S/o Shri Bal Chand, R/o H.NO. 70, Prajapati Chaupal, VPO Mehmadpur, Ballabgarh, Distt. Faridabad (Hr.).
…….Complainant……..
Versus
Divisional Manager, Oriental Mediclaim Policy, 5B/4BP, 2nd floor, Neelam Railway Road, NIT, Faridabad.
…Opposite party
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Tek Chand Sharma , counsel for the complainant.
Sh. Jatinder Singh , counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant got medi claim policy as "PNB Oriental Mediclaim Policy- 2017: Group Health Insurance Product (Policy for Bank Account holders of PNB only) UIN:
OICHLGP18074V011718 from the opposite party vide policy No 272400/48/2021/8520 on 15.10.2020 after deposited premium of Rs. 3112/- through NEFT, which was Medi Claim Policy covering the risk of all family members of the complainant which was continuously renewed from 16.10.2017 without any break after depositing the premium amount. The said policy was issued by the respondent/opposite party on 22.10.2020 reasons best known to the respondent/opposite party. On 21.10.2020 at 10,.40 P.M. due to road side accident the complainant was taken to Sarvodaya Hospital, Sector 8, Faridabad where on 21.10.2020 first Aid was given to the complainant and on 22.10.2020 OPD test was done by the concerned Doctors of that Hospital, and on 23.10.2020 the complainant was admitted as indoor patient after done Corona test and on 24.10.2020 conducted surgery of his nose in Sarvodaya Hospital, Sector 8, Faridabad and he was discharged on 25.10.2020 as per bill raised by above said Hospital of Rs. 45,824/- as expenses incurred upon his treatment, but only Rs. 19,370/- after got approved were paid by the respondent/opposite party and remaining balance amount was paid by the complainant himself under compulsion. The above said act and conduct of the respondent/opposite party was not just and fair, when the complainant at the time of obtaining the policy on 15.10.2020 the complainant deposited premium of Rs. 3112/- by way NEFT, but the respondent/opposite party intentionally and in illegal manner did not provide the policy on 15.10.2020 to the complainant and in this regard the complainant has to deposit unnecessary Rs. 26,454/- besides the complainant has suffered mental tension, agony in accidental situation, whereas the respondent/opposite party is bound to pay entire amount of Rs. 45,424/- incurred upon the treatment of the complainant. It was the headache of the respondent/opposite party should issue the policy on 22.10.2020 in place of 15.10.2020 because the complainant had already
been deposited the premium amount of Rs. 31127 by way of NEFT, the bank Statement of account of the complainant was also lying with the complainant and the same would be produced as was when required by the opposite party. The above said act and conduct of negligency was fore on the part of the respondent/opposite party, then on the request made by the complainant, to deposit the entire bill issued by Hospital, incurred on the treatment of the complainant as per the terms and condition of Policy issued by the respondent/opposite party, but the request of the complainant was ignored by the respondent/opposite party. Therefore the said act was not correct and in this regard the complainant under compulsion has to deposit the balance amount of Rs. 26,454/-, whereas the respondent/opposite party should deposit the entire amount of Rs. 45,424/-, but only a meager amount of Rs. 19370/- was deposited by the respondent/opposite party which was not just and fair. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the balance payment of Rs.26,454/- (i.e the balance amount which was paid by the complainant on account of his treatment) alongwith interest @ 18% p.a. from the date of its due till realization of whole amount immediately, on the basis of mediclaim policy.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 5500 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had no locus standi to file the present complaint against the opposite party in any manner, whatsoever, as from the bare perusal of the
insurance policy No. 272400/48/2021/8520 covering the insurance risk from 22.10.2020 to 21.10.2021, this Hon’ble Commission would come to the conclusion that the earlier insurance policy No. 272400/48/2020/7857 was covering the risk from 16.10.2019 to 15.10.2020, meaning thereby that the complainant remained uninsured for the period 00.00 hours of 16.10.2020 to 10:00 hours of 22.10.2020. The complainant has actively concealed the material facts from this Hon’ble Court in respect of the manner of injury sustained. The complainant had mentioned in the present complaint that the complainant met with a road side accident on 21.10.2020 at 10:40 PM, whereas from the perusal of the medical record submitted by the complainant on the Commission’s record show that the complainant sustained injury on his nose by a stone resulting from the physical assault, for which the complainant was medico legally examined vide MLR No. SN/211020/2330 dated 21.10.2020 by Sarath Narayan, Emergency Medical Officer, Sarvodaya Hospital and Research Centre,, Sector-8, Faridabad. The complainant was attended by the attending doctors of Sarvodaya Hospital in emergency on 21.10.2020 at 11:30p.m. and was discharged on 22.10.2020 at .30p.m as mentioned in Emergency & Trauma – Discharge summary, From the perusal of Annexure R-3, this Hon’ble Commission would see that the complainant was advised for his admission in ward but the patient preferred not to get treated in Sarvodaya Hospital and was discharged as a case of LAMA (Left Against Medical Advise). It was worth mentioning that the complainant got admitted in Saravodaya Hospital& Research Centre, sector-8, Faridabad for treatment on 23.10.2020 and was discharged on 25.10.2020. Under processing the mediclaim of the complainant, the opposite party approved an amount of Rs.19,370/- being found payable and was released accordingly. Now the complainant cannot claim the
amount of Rs.26,454/- , what to talk of the interest and the alleged amount of Rs.50,000/- compensation and Rs.5500/- as litigation expenses. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party–M/s. Oriental Insurance Company Ltd. with the prayer to: a) make the balance payment of Rs.26,454/- (i.e the balance amount which was paid by the complainant on account of his treatment) alongwith interest @ 18% p.a. from the date of its due till realization of whole amount immediately, on the basis of mediclaim policy. b)pay Rs. 50,000/- as compensation for causing mental agony and harassment .c) pay Rs. 5500 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Gopi Chand, Ex.C-1 – postal receipt, Ex.C-2 – legal notice,, Ex.C-3 – Adhaar card, Ex.C-4 - Customer Account Ledger Report, Ex,C-4 & 5– policy, Ex.C-6 to 12 – Tests, EX.C-13 to 16 - Bill of supply, Ex.C-17 - Covid-19 repot,, Ex.C-18 to 20– Receipts, Ex.C-21 to 23 – invoice, Ex.C-24 &25– OPD sheets, Ex.C-26 – Bill of supply, Ex.C-27 – report,, Ex.C-28 – MLC,, Ex.C-29 – Bill of supply, Ex.C-30 – OPD sheet,, Ex.C-31 – Discharge summary, Ex.C-32 – Summary of key investigations during hospitalization, Ex.C-33 - Discharge slip, Ex.C-34 – Claim Form
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – Ramesh Kumar,
Senior Divisional Manager, M/s. Oriental Insurance Company Limited, 5B/4BP, Railway Road, NIT, Faridabad, Ex.R-1 – insurance policy, Ex.R-2 – report, Ex.R-3 – Discharge summary, Ex.R-4 – bill of supply,
6. In this case, the complaint was filed by the complainant with the prayer to make the balance payment of Rs.26,454/- (i.e the balance amount which was paid by the complainant on account of his treatment) alongwith interest @ 18% p.a. from the date of its due till realization of whole amount immediately, on the basis of mediclaim policy.
7. The complainant got medi claim policy as "PNB Oriental Mediclaim Policy- 2017: Group Health Insurance Product (Policy for Bank Account holders of PNB only) UIN: OICHLGP18074V011718 from the opposite party vide policy No 272400/48/2021/8520 on 15.10.2020 after deposited premium of Rs. 3112/- through NEFT, which was Medi Claim Policy covering the risk of all family members of the complainant which was continuously renewed from 16.10.2017 without any break after depositing the premium amount. The said policy was issued by the respondent/opposite party on 22.10.2020 reasons best known to the respondent/opposite party. The complainant admitted in Sarvodaya Hospital, Sector-8, Faridabad on 21.10.2020 t and discharged on 25.10.2020, as per bill raised by above said Hospital of Rs. 45,824/- as expenses incurred upon his treatment, but only Rs. 19,370/- after got approved were paid by the respondent/opposite party and remaining balance amount was paid by the complainant himself under compulsion.. As per the evidence of opposite party vide Ex.R4 & Ex.C15 & 16 are the same. But the opposite party did not file the bill of supply in their evidence.
8. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant for the balance payment as per the T & C of the policy within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. There are no order as to costs. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 16.05.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
