Chandigarh

DF-I

CC/140/2019

Rajinder Pal - Complainant(s)

Versus

IFFCO TOKIO General Insurance Company Limited - Opp.Party(s)

Vishal Madaan Adv.

17 Jul 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Consumer Complaint  No	:	CC/140/2019
Date  of  Institution	:	08/03/2019
Date   of   Decision	:	17/07/2020

 

 

 

 

 

Rajinder Pal S/o Lt. Sh. Gian Parkash, R/o H.No.1193/A, Near Mata Mansa Mati Mandir, Raipur Rani, District Panchkula.

……… Complainant

 

Versus

 

[1]  IFFCO TOKIO General Insurance Co. Limited, Plot No.2 B & C, 4^th Floor, IFFCO Complex, Sector 28-A, Madhya Marg, Chandigarh – 160002, through its Branch Manager.

 

[2]  IFFCO TOKIO General Insurance Co. Limited, IFFCO Sadan, C-1, District Centre, Saket, New Delhi – 110017, through its Managing Director & CEO.

 

……. Opposite Parties

 

BEFORE:   RATTAN SINGH THAKUR     PRESIDENT

SMT.SURJEET KAUR             MEMBER

DR.S.K. SARDANA              MEMBER

                               

 

For Complainant	:	Sh. Vishal Madaan, Advocate.
For Opposite Parties	:	Ms. Swati Batra, Advocate.

 

PER SURJEET KAUR, MEMBER

 

 

          Adumbrated in brief, the facts necessary for the disposal of the instant Consumer Complaint are, the Complainant purchased a Family Health Protection Policy for himself and for his wife bearing Policy No.52872619 and got the same renewed from time to time.  Lastly, the Policy was valid from 30.11.2017 to 29.11.2018 covering total floater sum insured of Rs.4,40,000/- to the Complainant and his wife. The Complainant after due intimation to the Opposite Parties had admitted to the Fortis Hospital, Mohali for diagnosis of Coronary Artery Disease on 11.02.2018 and discharged on 18.02.2018. The Fortis Hospital raised the bill of Rs.2,48,900/-. The Opposite Parties had passed the claim of Rs.1,36,111/- out of the aforesaid bill raised by the Hospital and rest of the bill amount of Rs.1,12,789/- was paid by the Complainant. The Complainant approached the Opposite Parties to know the reason of deduction in medical bill. Upon this he was told that Opposite Parties had approved Rs.2500/- per day towards room charges to the Complainant; whereas, the Complainant had taken the General Ward which costs Rs.3800/- per day and accordingly, the Opposite Parties had proportionately deducted the claim of the Complainant from other treatment charges. The Complainant apprised the Opposite Parties that he had not opted the Private Room and was admitted in General Ward therefore the capping of 2500/- and deduction proportionately was illogical and unfair but all the submission and reasoning of the Complainant were fell on the deaf ears. With the cup of woes brimming, the Complainant has filed the instant Consumer Complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.

 

2.      Notice of the complaint was sent to Opposite Parties seeking their version of the case.

 

3.      Opposite Parties contested the claim of the Complainant and filed their joint written statement, inter alia, admitting the basic facts of the case. It has been pleaded that the answering Opposite Parties had received a cashless request from Fortis Hospital, Mohali with respect to the Complainant for claimed amount of Rs.2,48,900/-. On receipt of the said request, the claim was processed and approved for Rs.1,36,111/- and deducted Rs.1,12,789/- on the basis that the insured had availed Rs.4500/- per day against room charges instead of room limit of Rs.2500/- per day including nursing as per policy terms and conditions. Accordingly, the Hospital was informed that the deducted amount be collected from the Complainant. Hence, amount of Rs.1,12,789/- was paid by the Complainant. However, inadvertently there was some calculation mistake on the part of the answering Opposite Parties. According to the packages and tariff submitted by the Hospital, it was observed that the Complainant had availed single room package for CABG (Coronary Artery Bypass Graft) which amounts to Rs.2,45,000/-. Hence, with respect to this package Rs.6500/- was availed by the Complainant against room charges. Therefore, actual deducted amount should be Rs.1,54,265/-. Since the answering Opposite Parties had paid an extra amount of Rs.41,476/- to the Hospital due to calculation mistake, it needs to be recovered from the insured (Complainant). Thus, denying all other allegations and stating that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.

 

4.      Rejoinder was filed and averments made in the Consumer Complaint were reiterated.

 

5.      Parties were permitted to place their respective evidence on record in support of their contentions.

 

6.      We have heard the learned counsel for the Parties, through video conferencing, and also perused the record with utmost care and circumspection.

 

7.      In the present case, the claimed amount of the Complainant is Rs.2,48,900/- and the Opposite Parties has processed and approved the same to the tune of Rs.1,36,111/- and ultimately, deducted Rs.1,12,789/-.

 

8.      In the Policy (Annexure C-1, Page 26 & 27) under the head of Main Coverage Clause 1(b)II it is mentioned that “In respect of cities other than Class “A” cities, a limit of 1.25% (one and one fourth of a percent) of the sum insured on per day basis or actual, whichever is less”. As per the case of the Complainant, he paid Rs.4,000/- per day as room rent and opted for General Ward, but still the fact remains that the terms and conditions of the policy in question were accepted by the Complainant at the time of purchasing the Family Health Protection Policy for himself and his wife. Hence, in our considered opinion the claim of Rs.1,12,789/- was correctly deducted as per terms and conditions of the policy and there is no deficiency of service and unfair trade practice caused to the Complainant as his claim was processed and duly approved as per terms and conditions of the policy.  

 

9.      For the reasons recorded above, we do not find even a shred of evidence to prove any deficiency in service or unfair trade practice on the part of Opposite Parties. Consequently, the Consumer Complaint fails and the same is dismissed, leaving the parties to bear their own costs.

 

10.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.
11.  

17^th July, 2020                                                           

Sd/-

(RATTAN SINGH THAKUR)

PRESIDENT

 

 

Sd/-

 (SURJEET KAUR)

       MEMBER

 

 

Sd/-

 (DR.S.K. SARDANA)

       MEMBER

 

“Dutt”