ORDER

07.07.2023

MS. NIPUR CHANDNA, MEMBER

1. A complaint under Section 12 of Consumer Protect Act 1986 filed by Sh. Dhanshi Ram (hereinafter referred to as complainant). The complainant is seeking refund of Rs.1,06,584/- alongwith interest and compensation, for harassment from OP Insurance Co.  The complainant has filed the present complaint alleging the deficiency in service on the part of OP.  The brief facts of the case are that the complainant is  the mediclaim policy holder of OP insurance company vide policy bearing No. 4128i/iH/78836089/00/000 w.e.f. 02.04.2013 to 01.04.2014.

2. It is alleged by the complainant that the wife of the complainant Smt. Teja Devi was having some respiratory problem, as such complainant approached Dr.Brijmohan on 11.04.2013 who done her Echo and angiography and further suggested for admission at Jaipur Golden Hospital. On 11.04.2013 complainant’s wife was admitted in Jaipur Golden Hospital under the treatment of Dr. A.K Sood. It is alleged by the complainant that after admission complainant approached OP Ins. Co. for claim but OP InsuranceCo. denied the same mentioning the reason that the policy in question is recently being started on 02.04.2013. The wife of the complainant remained admitted in the hospital till 19.04.2013 and the complainant was forced to pay a sum of Rs.1,56,750/- against her treatment.
3. It is alleged by the complainant that in June 2019 his wife had same problem and as such she was admitted to Saroj Hospital on 19.06.2013, where a surgery was done by Dr. Sanjeev Aggarwal and IVC filter was fitted and finally she was discharged on 20.06.2013. The complainant again approached OP for the reimbursement of the claim but no response was received and OP company repudiated the claim on the ground of pre-existing disease. Being aggrieved by repudiation complainant approached Insurance Ombudsman on 21.04.2014. The insurance ombudsman vide its letter dated 29.05.2015 gave the direction to the OP ins. co. to settle the claim of the complainant. Against the direction, the OP approved a sum of Rs.55,000/- and credtied the same in the account of complainant on 30.07.2015 against the total sum of Rs.1,06,584/-. It is alleged by complainant that OP had arbitarily deducted the sum of Rs.51,584/- from the total claim amount under the pretext of settlement. On various occasion complainant approached OP for reconsideration of his claim but all in vain. Being aggrieved by the conduct of OP complainant approached this commission for redressal of his grievance.

4. Notice of the complaint was sent to OP. OP contested the complaint and filed its WS. We have perused the WS filed by OP and it is found that in the WS the OP had mentioned the details of the admission of Ankit Rawat son of the complainant and remained silent about the settlement of the claim of the complainant regarding the treatment of his wife allegedly raised in the present complaint. The annexure attached with the WS is power of attorney, policy document and terms and conditions, copy of claim settlement letter and assessment sheet pertaining to the treatment undergone by Ankit Rawat son of the complainant.

5. Complainant filed his evidence by way of affidavit and has also placed on record the claim settlement letter and assessment sheet pertaining to the treatment undergone by Teja Devi wife of the complainant. copy of the award dated 28.05.2015 of Insurance Ombudsman, copy of the medical bills and record in support of his contention.

6. OP filed evidence by way of affidavit of Vikash Goyal legal manager of OP Insurance Co. corraborating the contents of the written statement filed by OP.

7. Both the parties also filed their written arguments. Despite opportunity OP counsel failed to address the argument. We have heard the argument addressed at the bar by the complainant and have perused the record.

8. The sole question for our consideration in the present complaint case is whether the OP was justified in partly allowing the claim of the complainant. We have gone through the settlement letter and assessment sheet of OP Ins. Co. filed on record by the complainant alongwith his complaint. The reason given by the OP Ins. Co. regarding the deduction was of sublimit exhaust. The OP Ins. Co. failed to place on record any document to substantiate the  grounds of deductions justifying the deductions. Even the OP Ins. Co. had failed to incorporate the correct facts of the complainant claim in its WS. The OP Ins. Co. had provided the details of earlier admission of the complainant’s son in the hospital and the details of the claim dealt by it and remained totally mum on the deductions carried out against the reimbursement of the claim of the complainant’s wife.

9. In such circumstances, having no other option we are compelled to believe on the contention of the complainant that the deductions in the reimbursement claim was arbitary and unjustified.

10. The complainant in the present complaint has mentioned about the admission of his wife in two hospital, one at Jaipur Golden Hospital on 11.04.2013, where the complainant had incurred the medical expenses to the tune of Rs.1,56,750/- and secondly with Saroj Hospital on 19.06.2013 where the complainant had incurred the medical expenses to the tune of Rs.1,06,584/-. The complainant failed to place on record any documentary evidence pertaining to the earlier reimbursement claim of Rs.1,56,750/- with the OP, hence we are unable to entertain the same. As per the assessment sheet the complainant received a sum of Rs.55,000/- against the second claim, the OP Insurance Co. failed to justify the deductions carried out by it in the said claim by way of any documentary evidence, hence in our view the deduction is an arbitary which gave rise to deficiency in service on the part of OP.
11. In view of the above discussion, we therefore hold OP Insurance Co guilty of deficiency in service and direct it as under:

            i) Pay to complainant a sum of Rs.51,584/- alongwith interest @6% per      annum from the date of filing of complaint i.e. 02.05.2016 till realization.

ii) Pay to complainant a sum of Rs.10,000/- as compensation for mental agony and harassment which will include the cost of litigation also.

12. OP is directed to comply the order within 30 days from the date of receipt of this order failing which OP is liable to pay to the complainant interest @9% per annum from the date of non-compliance  till realization.
13. Copy of the order be sent to the parties free of cost. The orders be uploaded on www.confonet.nic.in.File be consigned to Record Room.

Announced in open Forum on   07.07.2023.

SANJAY KUMAR                 NIPUR CHANDNA                          RAJESH            

PRESIDENT                                    MEMBER                               MEMBER