Chandigarh

DF-I

CC/596/2022

Aditya Bhalla (Minor) - Complainant(s)

Versus

HealthIndia Insurance TPA Services Pvt. Ltd. - Opp.Party(s)

In Person

01 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

Consumer Complaint No.	:	CC/596/2022
Date of Institution	:	09/06/2022
Date of Decision	:	01/08/2023

Aditya Bhalla (minor) through Nirmal Kumar Bhalla (father) resident of house No.345, MDC, Sector 4, Panchkula – 134109, Haryana.

… Complainant

V E R S U S

1. Healthindia Insurance TPA Services Private Limited, Neelkanth Corporate Park, Gala No.:406 TO 412, 4^th Floor, Kirol Road/Village, Vidyavihar Society, Vidyavihar West, Mumbai, Mumbai.
2. Manager, New India Assurance Co. Ltd., SCO No.37-38, Sector 17, Chandigarh.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Nirmal Kumar Bhalla, father complainant
	:	Sh. Sukhdarshan Singh, Counsel for OPs (defence of OPs already struck off)

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Aditya Bhalla, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that Nirmal Kumar Bhalla, father of complainant had purchased New India Flexi Floater Group Mediclaim Policy (hereinafter referred to as “subject policy”) from the OPs covering himself, his wife and minor son, Aditya Bhalla i.e. the complainant and had paid premium of ₹29,185/-. The subject policy was valid w.e.f. 20.11.2021 to 19.11.2022. As the complainant was suffering from high fever, he was taken to Max Hospital at Mohali on 8.3.2022 where he was admitted and was discharged on 14.3.2022.  TPA was informed well in time by the hospital authorities for the cashless approval as per mediclaim policy. Thereafter the hospital authority raised a bill of ₹1,14,898.71, but, the TPA had approved an amount of ₹1,03,835/- only and deducted the remaining amount, without assigning any reason, as a result of which the complainant had to pay the deducted amount of ₹11,065/- to the said hospital from his own.  The complainant had lodged genuine claim with the OPs, but, the same has not been fully settled by them despite repeated requests, which amounts to deficiency in service and unfair trade practice on their part. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. Upon service, OPs appeared through their counsel, but, since reply was not filed within the stipulated period, therefore, their defence was struck off vide order dated 25.11.2022.

2. In order to prove his case, complainant tendered/proved evidence by way of affidavit and supporting documents.
3. We have heard the father of complainant, learned counsel for OPs and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the complainant that Nirmal Kumar Bhalla, father of the complainant had purchased the subject policy (Annexure C-7) from the OPs covering himself, his wife and minor son i.e. the complainant, and due to the ailment of the complainant, he was treated upon at the Max Hospital where he remained admitted w.e.f. 8.3.2022 and was discharge on 14.3.2022 and the said hospital had raised a bill of ₹1,14,898.71, out of which the TPA had only approved bill of ₹1,03,835/- by deducting an amount of ₹11,065/-, without assigning any reason, as a result of which the father of complainant was compelled to pay the deducted amount to the hospital from his own, the case is reduced to a narrow compass as it is to be determined if the aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant.
   2. Perusal of copy of the subject policy (Annexure C-7) clearly indicates that the same covered the complainant, his father, Nirmal Kumar Bhalla and mother, Smt.Sunita Bhalla for the sum insured of ₹5.00 lacs.  It has further come on record that the complainant was admitted at the Max Hospital and the said hospital had raised a bill of ₹1,14,798.71 out of which the OPs had only approved the amount to the extent of ₹1,04,798.71 and thereby made deduction of ₹11,065/- from the actual bill. Copy of bill (Annexure C-5) further indicates that the patient had deposited an amount of ₹11,065/- with the hospital and after giving discount of ₹8,118/- by the hospital, OP company had only paid an amount of ₹95,716/- making further clear that the amount of ₹11,065/-, which was paid by the complainant to the hospital, has not been reimbursed by the OPs making it further clear that the OPs have wrongly deducted an amount of ₹11,065/-, which the complainant had already paid to the hospital. 
   3. Moreover, when the entire evidence led by the complainant has not been rebutted by the OPs by leading any cogent evidence, it is safe to hold that the complainant has successfully proved the deficiency in service and unfair trade practice on the part of the OPs and the present consumer complaint deserves to succeed.
4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹11,065/- to the complainant alongwith interest @ 9% per annum from the date of filing of the instant consumer complaint, till realization of the same.
2. to pay an amount of ₹7,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹7,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/08/2023 hg			[Pawanjit Singh] President
			[Suresh Kumar Sardana] Member