Chandigarh

DF-I

CC/204/2022

Nirmal Kumar Bhalla - 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/204/2022
Date of Institution	:	15/02/2022
Date of Decision	:	01/08/2023

 

Nirmal Kumar Bhalla 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.
2. Manager, New India Assurance Co. Ltd., Sector 17, Chandigarh.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

                               

ARGUED BY	:	Complainant in person
	:	Sh. Sukhdarshan Singh, Counsel for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Nirmal Kumar 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 the complainant had purchased a mediclaim policy namely New India Flexi Floater Group Mediclaim Policy (hereinafter referred to as “subject policy”) for himself, his wife and son valid w.e.f. 20.11.2021 to 19.11.2022 by paying premium of ₹29,185/-. On 2.11.2021, the complainant visited Max Hospital for his check up and he was diagnosed with hernia and was suggested operation. The complainant was asked by the treating doctor namely Dr. Anupam Goyal for certain tests.  The mediclaim section of the hospital had given estimate of ₹1,20,250/- for this operation including all tests in the hospital. However, as the complainant got most of the tests conducted from the Charitable Diagnostic Centre, very small amount was spent for the same.   Thereafter, the complainant was admitted in the Max Hospital, Mohali on 16.11.2021 where surgery for hernia was performed and he was discharged on the next day i.e. 17.11.2021. Thereafter, the hospital had raised actual bill of ₹74,988/- and the same was submitted by the complainant with the OPs.  However, the OPs have only released an amount of ₹61,200/- out of the total amount of ₹74,988/- as a result of which the complainant was compelled to pay an amount of ₹13,788/- from his own pocket. Later on, the complainant had also submitted pre hospitalisation charges amounting to ₹4,588/- and post- hospitalisation charges amounting to ₹1,170/- alongwith balance pending amount of ₹13,788/- and the total of the same comes to ₹19,547/- with the OPs.  However, out of the aforesaid total amount of ₹19,547/-, OPs have only released an amount of ₹5,106/- and in this manner the OPs have wrongly withheld an amount of ₹14,441/-.  The aforesaid act of the OPs amount to deficiency in service and unfair trade practice. Thereafter the OPs were served with a legal notice, but, with no result.  OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version in which they admitted that the complainant has purchased the subject policy from the OPs covering the sum insured of ₹5 lacs.  However, it is alleged that the complainant has filed the present consumer complaint by twisting the facts and tried to get undue benefits for which he is not entitled to.  The OPs have already paid the amount to the complainant strictly as per the terms and conditions of the policy.  The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the complainant in person, learned counsel for the OPs and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant was insured with the subject policy at the relevant time when surgery for hernia was performed at Max Hospital, Mohali and he remained admitted w.e.f. 16.11.2021 to 17.11.2021, as is also evident from the discharge summary (available at page 29 of the consumer complaint) and also that the OPs have only released an amount of ₹61,200/ + ₹5,106/- out of the total amount raised by the hospital for pre- hospitalisation and for the surgery of the complainant and post-hospitalisation charges and amount of ₹14,441/- was not paid by the OPs to the complainant, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the claim of the complainant to the tune of ₹14,441/- and the complainant is entitled for the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs are justified in repudiating the partial claim of the complainant and the consumer complaint is liable to be dismissed, as is the defence of the OPs.
   2. Perusal of the actual bill issued by the treating hospital (available at page 25 of the consumer complaint) clearly indicates that the hospital had raised a bill of ₹74,988.32 to the complainant, out of which he had already deposited an amount of ₹10,000/- and thereafter the OPs have only paid an amount of ₹61,200/- and the remaining amount of ₹3,788.32 was again paid by the complainant at the time of clearance of the said bill. In this manner, one thing is clear that the OPs have not paid an amount of ₹13,788/- to the treating hospital, rather the same was paid by the complainant from his own pocket. 
   3. The complainant has also proved on record the bills for pre-hospitalisation charges to the tune of ₹4,588/- and for post-hospitalisation charges to the tune of ₹1,170/- and when the complainant had lodged further claim of ₹19,547/- with the OPs, they have only paid an amount of ₹5,106/- making further clear that the OPs have not paid an amount of ₹14,441/-, which was actually paid by the complainant to the hospital.
   4. It has been contended on behalf of the complainant that as it stands proved on record that the complainant had only lodged claim with the OPs qua the amount which was actually spent by him for his hernia treatment, out of which the OPs have only paid an amount of ₹61,200/- by not paying an amount of ₹14,441/- and further since the OPs have failed to prove on record the reason for deduction of the said amount, the said act of the OPs amounts to deficiency in service  and the consumer complaint be allowed as prayed for.
   5. On the other hand, it has been contended on behalf of the OPs that as the aforesaid amount was deducted by the OPs on account of room charges, which the complainant has wrongly claimed, and the OPs have paid the amount to the complainant strictly as per the terms and conditions of the policy, the consumer complaint of the complainant is liable to be dismissed.  
   6. However, there is no force in the contention of the OPs as the inpatient bill (summary), available at page 25 of the consumer complaint, clearly indicates that the hospital had shown the room rent as zero, making further clear that the complainant has not claimed any room rent from the OPs as the same was not even charged by the hospital.  Hence, it stands proved on record that the OPs have wrongly deducted an amount of ₹14,441/- from the claim and thereby partially repudiated the claim of the complainant, which amounts to deficiency in service and unfair trade practice on their part.
   7. In view of the aforesaid discussion, it is safe to hold that the complainant has successfully proved the cause of action set up in the consumer complaint 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 ₹14,441/- 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			Sd/- [Pawanjit Singh] President
			Sd/- [Suresh Kumar Sardana] Member