| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No.197 of 10.6.2022 Decided on : 30-04-2024 Ishwinder Pal Singh aged about 40 years S/o Sukhminder Singh R/o H.No.19713-A, Street No.10A, Ajit Road, Bathinda. ........Complainant Versus ManipalCigna ProHealth Insurance Company Ltd., (Formerly known as Cigna TTK Health Insurance Co.), Regd. Office at 401/402, 4th Floor, Raheja Titanium, Off. Western Express Highway, Goregaon (East), Mumbai-400063, through its Managing Director/Chairman. ManipalCigna ProHealth Insurance Company Ltd., Ist Floor, Sandhu Tower-1, Gurdev Nagar, Ferozepur Road, Ludhiana-141001, through its Authorized Signatory.
.......Opposite parties Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Smt.Priti Malhotra, President Smt.Sharda Attri, Member Present : For the complainant : Sh.Arvinder Singh, Advocate. For opposite parties : Sh.Vinod Garg, Advocate. ORDER Priti Malhotra, President The complainant Ishwinder Pal Singh (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against ManipalCigna ProHealth Insurance Company Ltd., and others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that he obtained health insurance policy bearing No.PROHLV050014207 valid from 9.2.2021 to 8.2.2022 under 'ProHealth-Protect Plan (Family Floater)' from opposite parties and deposited the requisite premium for a sum assured of Rs.5,50,000/- in which his family including Ishwinder Pal Singh himself, wife Prabhleen Kaur, son Jasalam Singh aged about 8 years and daughter Mehnaaz Kaur aged about 2 years are covered. The terms and conditions of the policy were never supplied by opposite parties. It is alleged that the complainant and his wife Prabhleen Kaur had fallen ill due to dengue fever and infection and remained admitted in the hospital of Dr.Mohinder Singh Hospital on 17.10.2021 and got treatment. The complainant spent a total sum of Rs.11,647/- for his own treatment and Rs.41,142/- for the treatment of his wife. In this regard, he lodged insurance claims bearing No.26728039 and 26727893 with opposite parties. He completed all the requisite formalities including original bills and medical treatment record regarding the treatment of the complainant and his wife duly countersigned by Dr.Mohinder Singh, but opposite parties reimbursed only Rs.9247/- against claim No.26728039 for Rs.11,647/- and Rs.29,902/- against the claim No.26727893 for Rs.41,142/-. In this way, they deducted a sum of Rs.2400/- against claim No.26728039 and Rs.11,240/- against claim No.26727893 without any reasonable cause and excuse. It is further alleged that the complainant repeatedly contacted opposite parties and requested them to pay the balance amount of approx. Rs.13,640/- against both the claims, but to no effect rather they failed to give him any satisfactory reply. He also sent e-mail to opposite parties on 5.2.2022, but they have failed to respond till date. He also got issued a legal notice to opposite parties through his counsel on 17.3.2022, but to no avail. On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay him balance amount of medical reimbursement claim of Rs.13,640/- alongwith interest @2% per month w.e.f the date of lodging the claim till payment and Rs.50,000/- as compensation and Rs.22,000/- as litigation expenses. Upon notice, opposite parties appeared through counsel and contested the complaint by filing written version and raising legal objections that the intricate questions of law and facts are involved in the complaint. They require voluminous documents and evidence for determination. It is not possible in the summary procedure under 'Act' and appropriate remedy, if any, lies only in the civil court. The complainant has concealed the material facts and documents from this Forum and opposite parties. As such, he is not entitled to any relief. The complainant has concealed the fact that opposite parties have already made payment of Rs.9247/- and Rs.29,902/- i.e. amount admissible and payable as per terms and conditions of the policy and no more amount is payable. The claim No.26727893 was submitted for Rs.29,902/- only and not for Rs.41,142/- as alleged in this complaint. The terms and conditions of the policy have to be construed/ interpreted strictly in determining the rights and liabilities of the parties. Opposite parties have also referred the judgments of Supreme Court in 2009 (4) CLT 313 (SC), 2009(2) CLT 15 (SC) and 2007 (2) CLT 186 (SC). It is further pleaded that the complainant had raised 2 reimbursement claims for his wife’s hospitalization claims. The complainant through claim form dated 20.11.2021 raised a reimbursement claim (bearing claim No.26727893) for his wife Prabhleen Kaur hospitalization at Dr.Mohinder Singh hospital from 17.10.2021 to 23.10.2021 amounting to Rs.29,902/- alongwith the supporting medical documents and bills. Opposite parties upon due assessment of claim documents and medical bills had settled the claim for Rs.29,902/- as per the policy terms and conditions. The settlement of claim was done through transaction No.135701738GN00025 dated 23.12.2021 and was intimated to the complainant vide settlement letter dated 24.12.2021. Further legal objections are that the complainant raised another claim bearing claim No.26728039 for his hospitalization at Dr.Mohinder Singh hospital from 17.10.2021 to 19.10.2021 claiming Rs.11,447/- for hospitalization. Opposite party upon due assessment of the claim and as per the policy terms and conditions settled the claim for Rs.9247/-. The hospitalization period of one day is considered to be 24 hrs. hospitalization and going by the same. The complainant was hospitalized for 2 days (i.e. from 17th Oct to 18th Oct and 18th to 19th Oct) and was accordingly discharged on 19th Oct, 21. Hence, the room charges (Rs.2000/- per day) and Nursing Charges (Rs.200/- per day) were deducted while disbursement of the claim. Accordingly, the settlement of claim was done through transaction No.136501562GN00131 dated 31.12.2021 and informed the complainant vide settlement letter dated 3rd January 2022. The complainant is not the consumer of opposite parties and complaint is bad for non-joinder of necessary party as the complainant has filed the complaint for himself as well as for treatment of his wife Prabhleen Kaur whereas he has no locus-standi or cause-of-action to file the complaint on behalf of his wife. The complaint is not maintainable in its present form and is liable to be dismissed. On merits, opposite parties have reiterated their stand as taken in the legal objection as detailed above and controverted all other averments of the complainant and prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 10.6.2022, (Ex.C1) and documents, (Ex.C2 to Ex.C61). In order to rebut the evidence of complainant, opposite parties have tendered into evidence affidavit of Lakshey Janeja dated 2.1.2024, (Ex.OP1/7) and documents, (Ex.OP1/1 to Ex.OP1/6). We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for parties have reiterated their stand as taken in their respective pleadings as detailed above. We have given careful consideration to these submissions. Admitted facts are that the complainant purchased one health insurance policy bearing No.PROHLV050014207 valid from 9.2.2021 to 8.2.2022 under 'ProHealth-Protect Plan (Family Floater)' from opposite parties for sum assured of Rs.5,50,000/-. It covers family of the complainant including Ishwinder Pal Singh himself, wife Prabhleen Kaur, son Jasalam Singh and daughter Mehnaaz Kaur. A perusal of record reveals that no doubt, opposite parties have settled both the claims of the complainant as per their terms and conditions, but counsel for complainant pressed for the claim of Rs.11,000/-. As per allegations of the complainant, opposite parties failed to consider the claim of Rs.11,000/-. Since the claim of the complainant has already been paid being it genuine, so, the non-consideration for missing out bill amounting to Rs.11,000/-, (Ex.C31) is deficiency in services as opposite parties are also liable to pay this amount. Therefore, the complainant is also entitled for bill amount of Rs.11,000/- from opposite parties incurred by him for the treatment of his wife. In view of what has been discussed above, present complaint is partly allowed without any order as to cost. Opposite parties are directed to pay the claim of the complainant regarding bill/receipt of Rs.11,000/-, (Ex.C31) as per their terms and conditions to the complainant. The compliance of this order be made within 45 days from the date of receipt of copy of this order. In case of non-compliance of the order within the stipulated period, thereafter opposite parties will be liable to pay cost of Rs.2000/- to the complainant. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced 30-04-2024 - (Priti Malhotra)
President (Sharda Attri) Member
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