DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH ==== Consumer Complaint No | : | 103 of 2011 | Date of Institution | : | 23.2.2011 | Date of Decision | : | 05.09.2011 |
Anil Kumar s/o late Sh. Gian Chand 41 years, resident of H. No. 1355, Sector 68 SAS Nagar, Mohali, Punjab. …..Complainant V E R S U S 1. Life Insurance Corporation of India Divisional Office, Jeevan Prakash Sector 17-B, Chandigarh. 2. The New India Assurance Co. Ltd., Divisional Office-1 (350100) , SCO 36-37, Sector 17-A, Chandigarh. 1600017. ……Opposite Parties CORAM: SH.P.D.GOEL PRESIDENT SH.RAJINDER SINGH GILL MEMBER DR.(MRS) MADANJIT KAUR SAHOTA, MEMBER Argued by: Sh.Arun Kumar Batra, Counsel for complainant Sh.Sandeep Bhardwaj, Counsel for OP-1 Sh.Pavinder Singh Bedi, Counsel for OP-2. --- PER P.D. GOEL, PRESIDENT Briefly Stated the complainant took a medi-claim policy No. 120700/34/09/12/00000329 from OP No.2 through OP No.1. The case of the complainant is that on 8.2.2010, he felt some pain and so he approached to Urology & Surgical Hospital Pvt. Ltd. Sector 40-B, Chandigarh. After a thorough check up, it was diagnosed that he was suffering from Ureteric Calculus and advised for operation. The complainant further stated that he was admitted in the hospital on 12.2.2010 at 7.00 a.m and was operated for Ureteric Calculus and was discharged on 13.2.2010 at about 8.10 a.m. Thereafter, the complainant submitted his claim for reimbursement of the expenses incurred on his treatment with the OP No.1 on 22.2.2010 along with all the requisite documents which was further forwarded to OP No.2 on 24.2.2010. The complainant alleged that OP No.2 vide its letter dated 23.3.2010 repudiated the claim on illegal grounds. Alleging deficiency on the part of OPs for not paying the genuine claim of the complainant this complaint has been filed. 2. OP No.1 filed its reply and took some preliminary objections. It has been pleaded that there is no deficiency or unfair trade practice on the part of OP No.1. The OP No.1 admitted that the complainant is covered under Group Mediclaim Scheme with the OP No.2 but denied payment of premium and receiving of policy. The OP No.1 has also admitted that the complainant has submitted the medical bills for reimbursement of the expenses incurred on his treatment at P.N. Urology and Surgical Hospital, Pvt. Ltd. Sector 40B, Chandigarh from OP No.2. Denying all other allegations of the complaint the, a prayer has been made to dismiss the complaint. 3. OP No.2 in its reply admitted factual matrix of the case. It has been pleaded that the Group Mediclaim Insurance Policy has been issued to OP No.1 by the answering OP, thus there is no relationship of consumer between the complainant and the replying OP. It has been further pleaded that, it is very apparent from preoperative instructions that the dates have been manipulated. Moreover, the timings of P.N. Urology & Surgical Hospital Pvt. Ltd. were 8.00 A.m. to 1.00 pm., whereas the complainant alleged in the complaint that he was admitted at 7.00 a.m.. Further in the card, date of admission and date of operation is mentioned but the date of discharge has not been mentioned, hence the complainant failed to prove the 24 hours hospitalization and also no follow up treatment had been prescribed in the discharge card on 13.2.2010. All other allegations of the complaint has been denied and prayer for dismissal of the compliant has been made. 4. Parties led evidence in support of their contentions. 5. We have heard counsel for the parties and have also perused the record. 6. Admittedly, the complainant is covered under the Group Mediclaim Insurance Policy with OP-2. it is also admitted that the complainant has submitted bill for self treatment at Urology & Surgical Hospital Pvt. Ltd. Sector 40-B, Chandigarh. The OP-2 has raised the plea that the dates and timings in the record of Urology & Surgical Hospital Pvt. Ltd. Sector 40-B, Chandigarh has been manipulated by the complainant as the timings of Urology & Surgical Hospital Pvt. Ltd. Sector 40-B, Chandigarh are 8:00 a.m. to 1:00 P.M. whereas in the complaint it has been averred that the complainant was admitted in the hospital at 7.00 a.m. The date of discharge has not been mentioned in the record. So the complainant has failed to prove the 24 hours hospitalization and as such the claim is not payable. 7. Annexure C-7 is the letter dated 31.03.2010 of LIC at page 34 produced by the complainant and along with at page 35 the repudiation letter dated 23.3.2010 has been annexed. The claim has been repudiated by OP-2 on the ground that as per the discharge card submitted by the complainant, the date of admission is 12.02.2010 and date of discharge is 13.02.2010, both are written with different pen and no time was mentioned about admission and discharge. The learned counsel for the complainant made a reference to the Annexure C-4 at page 24 to prove that there was 24 hours hospitalization of the complainant and the claim has been wrongly repudiated on this count. 8. Annexure C-4 is a discharge summary of Urology & Surgical Hospital Pvt. Ltd. Sector 40-B, Chandigarh, wherein, the date of admission has been recorded as 12.12.2010 at 7.00 a.m. along with date of discharge as 13.02.2010 at 8:10 a.m. Similarly, vide Annexure C-8 at page 37, the doctor of Urology & Surgical Hospital Pvt. Ltd. Sector 40-B, Chandigarh has issued a certificate that Sh.Anil Kumar son of Sh.Gian Kumar was admitted on 12.02.2010 at 7.00 a.m. and was discharged on 13.02.2010 at 8.10 a.m. which proves the 24 hours hospitalization of the complainant. Therefore, it is held without any hesitation that the Op-2 vide letter dated 23.03.2010 has wrongly repudiated the claim on the ground that there was no hospitalization for 24 hours as provided in the terms and conditions of the insurance policy. 9. The defence of the OP-2 that the timings of Urology & Surgical Hospital Pvt. Ltd. Sector 40-B, Chandigarh qua Annexure B at page 15 are 8:00 a.m. to 1:00 P.M. (with appointment) and 5.00 a.m. to 7.30 p.m. and the fact that in the discharge card, the date of discharge has not been mentioned looses its weight in view of the fact that in the discharge summary (Annexure C-4) and the certificate of doctor referred to above proves that the complainant got admitted on 12.02.2010 at 7.00 a.m. and was discharged on 13.02.2010 at 8.10 a.m. 10. The objection of the OP-2 in the repudiation letter referred to above that date of admission and date of discharge are written with different pen without any time of admission and discharge and in the discharge summary, the date of discharge is also manually written whereas the entire discharge summary is computerized is also without any logic and merit in view of the findings arrived in para 8 (supra). 11. However, the complainant has failed to make out any case of deficiency in service against OP-1 and so the complaint qua OP-1 stands dismissed. 12. As a result of the above discussion, this complaint is accepted and OP-2 is directed to pay the claim amount of Rs.29,343/- (Annexure C-6 at Page 31) to the complainant along with interest @ 12% p.a. from the date of repudiation of the letter i.e. 23.03.2010 till its realization along with Rs.10,000/- as costs of litigation within one month from the date of receipt of the certified copy. 13. Certified copies of this order be sent to the parties free of charge. The file be consigned. | Sd/- | Sd/- | Sd/- | 05.09.2011 | [Madanjit Kaur Sahota] | [Rajinder Singh Gill] | [P.D.Goel] | | Member | Member | President |
| | MR. RAJINDER SINGH GILL, MEMBER | HONABLE MR. P. D. Goel, PRESIDENT | DR. MRS MADANJIT KAUR SAHOTA, MEMBER | | 
