Chandigarh

StateCommission

A/116/2020

Rajinder Pal - Complainant(s)

Versus

Iffco Tokio General Insurance Company Ltd. - Opp.Party(s)

Vishal Madaan Adv.

31 Mar 2021

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

UNION TERRITORY, CHANDIGARH

 

Appeal No.	116 of 2020
Date of Institution	31.08.2020
Date of Decision	31.03.2021

 

Rajinder Pal Son of Lt. Sh. Gian Parkash, R/o # 1193/A, Near Mata Mansa Mati Mandir, Raipur Rani, District Panchkula.

…..Appellant/Complainant

Versus

1. IFFCO TOKIO General Insurance Company Limited, Plot No.2 B & C, 4^thFloor, IFFCO Complex, Sector 28-A, Madhya Marg, Chandigarh. Pin 160002, through its Branch Manager.
2. IFFCO TOKIO General Insurance Company Limited, IFFCO SADAN, C1, Distt. Centre, Saket, New Delhi – 110017, through its Managing Director & CEO.

                                   …..Respondents/OppositeParties

BEFORE:  JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                 MRS. PADMA PANDEY, MEMBER

               

 

Argued by:  Sh. Vishal Madaan, Advocate for the appellant.

                  Ms. Swati Batra, Advocate for the respondents.

                       

PER PADMA PANDEY, MEMBER

              This appeal is directed against an order dated 17.07.2020, rendered by District Consumer Disputes Redressal Forum-I, UT, Chandigarh (hereinafter to be called as the District Forum only), vide which, it dismissed the complaint, with no order as to cost, filed by the complainant (now appellant).

2. In brief, the facts of the caseare that 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.  It was stated that 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. It was further stated that the Complainant after due intimation to the Opposite Parties had got himself admitted to the Fortis Hospital, Mohali for diagnosis of Coronary Artery Disease on 11.02.2018 and discharged on 18.02.2018. It was further stated that the Fortis Hospital raised the bill of Rs.2,48,900/- and 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. It was further stated that the Complainant approached the Opposite Parties to know the reason of deduction in medical bill and upon this he was told that the 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. It was further stated that the complainant apprised the Opposite Parties that he had not opted for the Private Room and was admitted in General Ward, therefore, the capping of Rs.2500/- and deduction proportionately was illogical and unfair, but to no effect. It was further stated that the aforesaid act of the Opposite Parties, amounted to deficiency in service and unfair trade practice.
3.        The Opposite Parties filed their joint written reply and admitted the factual matrix of the case and stated that the they had received a cashless request from Fortis Hospital, Mohali with respect to the complainant for claimed amount of Rs.2,48,900/- and 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. It was further stated that the Hospital was informed that the deducted amount be collected from the complainant, therefore, amount of Rs.1,12,789/- was paid by the complainant. It was further stated that inadvertently, there was some calculation mistake on the part of the answering Opposite Parties and 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/-. It was further stated thatthe package of Rs.6500/- was availed by the complainant against room charges, and thus, actual deducted amount should be Rs.1,54,265/-. It was further stated that 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 complainant. It was further stated that there was no deficiency, in rendering service, and remaining averments, were denied, being wrong, on the part of the Opposite Parties.
4. In the rejoinder filed by the complainant, hereiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of the Opposite Parties.

5. The Parties led evidence, in support of their case.
6. After hearing the Complainant in person and Counsel for the Opposite Parties,and, on going through the evidence, and record of the case, the District Forum, dismissed the complaint, as stated above. 
7. Feeling aggrieved, the instant appeal, has been filed by the appellant/complainant, against the order dated 17.07.2020.
8. We have heard the Counsels for the Parties, and have gone through the evidence, and record of the case, carefully.
9. After giving our thoughtful consideration, to the rival contentions, raised by the Partiesand the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed for the reasons to be recorded hereinafter.
10. From the document, we find that, out of the claimed amount of the appellant of Rs.2,48,900/-, the respondents had processed and approved the same to the tune of Rs.1,36,111/- after deducting an amount of Rs.1,12,789/-. It is observed from the Policy vide Annexure C-1 (Pages 26 and 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 the percent) of the sum insured on per day basis or actual, whichever is less”. The term and conditions of the Policy, in question, were accepted by the appellant, at the time of purchasing the Family Health Protection Policy for himself and his wife. The Forum has rightly observed that an amount of Rs.1,12,789/- was correctly deducted as per the terms and conditions of the policy, which was accepted by the complainant, and therefore, it is held that no deficiency in service and unfair trade practice was caused to the appellant. This Commission therefore upholds the above decision of the Forum and hence, the aforesaid appeal is liable to be dismissed.
11. The District Forum, was, thus right, in holding that the Opposite Parties were neither deficient, in rendering service, nor indulged into unfair trade practice. The order of the District Forum, being legal and valid, is liable to be upheld.
12. No other point, was urged, by the Counsel for the Parties.
13. For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, with no order as to costs. The order of the District Forum is upheld.
14. Certified copies of this order be sent to the parties, free of charge.
15. The file be consigned to Record Room, after completion.

 

Pronounced.

31.3.2021                  

                    

 

                                                       Sd/-

                         [JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

                                                                Sd/-

[PADMA PANDEY]

MEMBER

 

Gp

 

                                STATE COMMISSION

APPEAL No.116 of 2020

(Rajinder Pal Vs. IFFCO TOKIO General Insurance Co. Ltd.)

 

Argued by:

 

Sh. Vishal Madaan, Advocate for the appellant.

Ms. Swati Batra, Advocate for the respondents.

 

Dated  the 31^stday of March, 2021

                       

            Vide our detailed order of the even date, recorded separately, the appeal filed by the appellant has been dismissed, with no order as to cost and the order passed by the District Forum has been upheld.

 

       Sd/-                                   Sd/-                           

(PADMA PANDEY)	(JUSTICE RAJ SHEKHAR ATTRI)
MEMBER	PRESIDENT

 

GP