Delhi

East Delhi

CC/611/2016

ASHMA BEGUM - Complainant(s)

Versus

MAX SUPER HOSPITALITY - Opp.Party(s)

28 Aug 2019

ORDER

           DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092                                                                                                                                                                                              

 

                                                                                                   Consumer complaint no        611/2016

                                                                                                   Date of Institution               29/11/2016

                                                                                                   Order reserved on               28/08/2019        

                                                                                                   Date of Order                       02/09/2019                                                                                     

 

In matter of

Mrs  Ashma Begum  

w/o- Mr Gaffar Khan  

R/o- E15, Gali no. 3, Shastri Park, Delhi 110053……...…………….Complainant

                                                                    Vs

United India Insurance Co. Ltd.

10, Raj Block, Naveen Shahdara, Delhi 110032………….…………..Opponent

 

 

Complainant’s Advocate                Rahul Tomar  

Opponent Advocate                       Mr. N K Parikh    

 

Quorum                                            Sukhdev Singh      President

                                                           Dr P N Tiwari        Member

Order by Dr P N Tiwari  Member

 

Brief –Complainant filed this case u/s 12 of the Consumer Protection Act, 1986for claiming additional sum assured against OP under tailor made Group Insurance mediclaim policy which was given by OP for one spouse of retiree of MTNL for a sum assured One Lac.

Facts of the case

Complainant was issued Tailor made Group Mediclaim cashless Policy by OP for the benefits of one of the retiree/spouse of MTNL for a sum assured One Lac under policy no. 22800/28/14/P1051139100 having tenure from 01/10/204 to 30/09/2015 with terms and conditions (Ex Anne. A).

It was stated that wife of deceased husband/ retiree as a complainant here had backache since long so got admitted  at Max Hospital on 07/08/2015 and after operation for Lumber Spondylosis, was discharged on 13/08/2015 as per discharge summary. Cashless was given for  Rs 90,000/-against hospital bill of Rs 2,62,042/-.

Max Hospital demanded balance payment which was paid by the complainant. Complainant later submitted claim for the balance amount which was denied by OP. It was stated that due to unethical practice adopted by Max Hospital, complainant had to pay balance amount Rs 1,72,042/- for which she suffered financial loss, mental agony and harassment. Hence, filed this complaint and claimed balance amount a sum of Rs 1,72,042/- with 24% interest per annum and Rs 5000/- as compensation for harassment and Rs 5000/- for litigation charges.  

 

As OP1/Max Hospital was not a necessary party to this complaint, so OP1 was deleted from the array of party. Hence on amended memo of the party, notice was issued to OP2 (now called as OP) who submitted written statement and denied all the allegations of deficiency on their part and stated that complainant had neither stated correct facts about the case nor filed related documents before the Forum for taking claim illegally. It was stated that the present complaint had no territorial jurisdiction, but as the complaint was admitted so OP had submitted their reply. OP stated that husband of complainant was a employee of MTNL and had died prior to the inception of this policy, but mediclaim ID card was issued by the TPA (Medi-Assist) as per Annexures A,B & C containing detailed circular, detailed group mediclaim policy for MTNL and policy terms and conditions.  

It was stated by OP that sum assured was One lac under cashless policy so on the request of Max Hospital, cashless for Rs 90,000/-was given against hospital bill for Rs 2,62,042/-(Anne.D).OP timely intimated complainant for denial of balance payment as claimed amount was not payable as per policy terms and conditions and sum assured (One Lac).

 

Complainant submitted her evidences, but did not file rejoinder. In her evidence on her own affidavit denied replies submitted by OP as wrong and incorrect. It was stated that all evidences were submitted with her complaint as her policy was a cashless and due to unethical practice adopted by OPs, claim was not passed. She also submitted that OP did not consider her policy terms and conditions in paying balance amount. Hence her claim was genuine and prayed for direction to OP to pay the balance amount.

OP submitted their evidences on affidavit through Mr. V. K. Suri, Sr. Div. Manager with OP and stated that repudiation of claim for additional amount was beyond sum assured so was rightly rejected as per the Tailor-made Group Mediclaim policy where sum assured was one lac for retired employees of MTNL under cashless policy. Under the policy either retired person or his/her spouse would get sum assured maximum to Rs 90,000/-but balance amount Rs 10,000/- would be paid after complainant submit Pre and Post Hospitalization treatment, but here in this case insured/complainant had not submitted a single treatment document to claim balance sum assured amount Rs 10,000/-. Hence, complainant had not followed claim process as per the policy terms and conditions.  

Arguments were heard from both the Ld. counsel and after perusal of records, order was reserved.

We have gone through all the facts and evidences on record. It was clear that the complainant had cashless tailor made group mediclaim policy issued to the retired employees of MTNL and had sum assured to Rs one lac. As per terms and condition of the policy, cashless was given to Max Hospital for Rs 90,000/-, but to claim balance amount Rs 10,000/-, complainant had not submitted any documents pertaining to pre & post hospitalization treatment claim and come to the opinion that complaint has no merit, but in the interest of justice and as per the terms and conditions of the said policy, we direct the complainant to submit all the pre and post hospitalization treatment documents with OP within 30 days after receiving order and OP is directed to clear claim in accordance of the terms and conditions within 45 days. There shall be no order to cost.

Copy of this order be sent to the parties as per the sec. 18(6) of the Consumer Protection Regulations, 2005 ( in short the CPR)  and file be consigned to Record Room under Section 20(1) of the CPR.

 

  (Dr) P N Tiwari  Member                                                                        Sukhdev Singh  President