BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 290 of 2018
Date of Institution : 29.11.2018
Date of Decision : 30.05.2019
Kapil Kumar son of Sh. Jagdish Chander, resident of village Nathusari Kalan, District Sirsa.
……Complainant.
Versus
- M.D. India Health Insurance TPA Pvt Ltd., S No.46/1, E-Space, A-2 Building, 4th Floor, Pune Nagar Road, Vadgaonsheri, Pune- 411014.
- Birla Sun Life Insurance, 5th & 6th Floor, G-Crop Tech Park, Ghodbunder Road, Near Ksbunder Road, Near Kasar Wadavali Police Station, Thane- 400601.
- Birla Sun Life Insurance Company Ltd. Opp. Punjab National Bank, Dabwali Road, Sirsa.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH.R.L.AHUJA………………. ……PRESIDENT.
SH.ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. Baljit Kaur, Advocate Legal Aid Counsel for the complainant.
Sh. M.K. Singla, Advocate for opposite parties No.2 and 3.
Opposite party no.1 exparte.
ORDER
The case of the complainant, in brief, is that complainant purchased a policy namely BSLI Hospital Plus Plan from the Birla Sun Life Insurance Company through agent of the company and the policy was issued on 29.2.2016 which is valid for five years i.e. up to 28.2.2021 and the complainant is regularly paying yearly installments. It is further averred that agent of the company had given policy documents to the complainant according to which if the complainant fell ill during the period of policy and if he is admitted in the hospital, then the insurance company will pay the amount of Rs.7500/- per day. That complainant suffered from the problem of ulcerative colitis and he remained admitted in the hospital for 18 days i.e. from 3.5.2018 to 21.5.2018 and he was treated by Dr. Kapil Jain in Shanti Devi Institute, Hisar. However, the insurance company only paid an amount of Rs.37,500/- at the rate of Rs.7500/- for five days and the said claim has been got released through M.D. India Health Insurance TPA Pvt. Ltd. which is not according to the policy and even the said amount has been paid after his several visits and repeated requests. The complainant remained admitted for 18 days in the hospital for treatment and an amount of Rs.1,35,000/- was payable by the ops at the rate of Rs.7500/- per day and in this way an amount of Rs.97,500/- is outstanding against the ops and by not paying the said amount, the ops have harassed the complainant. Hence, this complaint.
2. On notice, opposite party no.1 failed to appear and was proceeded against exparte.
3. Opposite parties no.2 and 3 appeared and filed reply taking certain preliminary objections. It is submitted that the insurance policy is a concluded contract between the parties and the terms and conditions of insurance contract is equally binding upon both the parties to the contract and none of the parties to the contract is permitted to travel beyond the specific terms and conditions of the contract. It is further averred that complainant since the day of availing the insurance cover earlier on two occasions remained ill and for the first time, the complainant remained admitted in the hospital from 24.10.2016 to 29.10.2016 and was taking treatment and the op company after going through the medical records of the complainant has disbursed an amount of Rs.37,500/- (i.e. 7500 per day and five days hospitalization) and again the op company were in receipt of claim intimation wherein the complainant again remained admitted in the hospital from 28.10.2017 to 8.11.2017. The op company after receipt of medical documents has disbursed an amount of Rs.90,000/-. It is further submitted that complainant thereafter again has raised the medical claim and has represented and claimed to take treatment as indoor patient from 3.5.2018 to 21.5.2018. However, the op company after properly scrutinizing the hospitalization documents of the complainant does not found the same feasible to accept in its entirety for the reason that as per the medical documents, complainant was given IV medication till 7.5.2018 i.e. injection nurogard 1 amp in 100 ml NS, injection cort S 100 MG and rests are tables. Later on 11.5.2018 he underwent biopsy, but there was no change in the medicine and he was on oral medication. Even if his CRP count was increased, there was no change in type of administration of medicine. Therefore, the op company restricted the days till 8.5.2018 i.e. for five days and accordingly has made payment. It is further submitted that answering op as per the specific terms and conditions of the policy contract has already released the payment and nothing is due and payable by the op company. Remaining contents of the complaint are denied and prayer for dismissal of complaint made.
4. The parties then led their respective evidence.
5. The perusal of the record reveals that complainant in order to prove his complaint has furnished his affidavit Ex.CW1/A in which he has reiterated all the averments made in the complaint and has also tendered documents Ex.C1 to Ex.C53. On the other hand, ops no.2 and 3 have furnished documents Ex.R1 to Ex.R4.
6. Admittedly, the complainant got insured himself by purchasing a BSLI Hospital Plus Plan on 29.2.2016 which was valid for a period of five years up to 28.2.2021. As per allegations of complainant, he was ill and was admitted in the hospital for the period 3.5.2018 to 21.5.2018 for 18 days, however, he was paid at the rate of Rs.7500/- per day for only five days i.e. Rs.37,500/-, but however, remaining claim for Rs.97,500/- was declined by the ops illegally and arbitrarily. Though, ops no.2 and 3 have taken specific plea that insurance policy is a concluded contract between the parties and the terms and conditions of the insurance contract is equally binding upon both the parties to the contract. In case complainant suffers illness and remains hospitalized, then the op company is under contractual obligation to reimburse the complainant or to make payment of an amount of Rs.7500/- per day to the hospital authorities in terms of policy contract. They have further taken the plea that earlier on two occasions, he remained ill and remained admitted in the hospital from 24.10.2016 to 29.10.2016 and op company after going through the medical records of the complainant has disbursed an amount of Rs.37,500/- i.e. Rs.7500/- per day for five days. Again the company paid claim for the admission of complainant for the period 28.10.2017 to 8.11.2017 for an amount of Rs.90,000/-. Thereafter, again complainant has raised medical claim fom 3.5.2018 to 21.5.2018 on account of treatment as indoor patient, but however, company after properly scrutinizing the hospitalization documents of complainant does not found the same feasible to accept in its entirety for the reason that as per the medical documents complainant was given medication till 7.5.2018 i.e. injection nurogard 1 amp in 100 ml NS, injection cort S 100 mg and rests are tablets. Later on 11.5.2018, he underwent biopsy, but there were no changes in the medicine, he was on oral medication. Even if his CRP count was increased, there was no change in type of administration of medicine. Therefore, the op company restricted the days till 8.5.2018 i.e. for five days and accordingly has made payment. In order to prove their defence plea, the ops no.2 and 3 have not furnished affidavit of any official of insurance company nor they have furnished affidavit of any of the official of TPA who examined the claim documents of complainant and gave his opinion that his entitlement was only for five days. On the other hand, complainant has furnished opinion of the treating doctor dated 26.6.2018 which is Ex.C52 on record by which Dr. Kapil Jain of Shanti Devi Hospital, Hisar has given opinion for his long stay in the hospital. So, it appears from the record that complainant is entitled for reimbursement of the medical claim for hospitalization from 3.5.2018 to 21.5.2018 i.e. for 18 days, but however, ops have paid only for five days out of these 18 days and complainant appears to be entitled for the amount of Rs.97,500/- for remaining 13 days and non payment of the same amounts to deficiency in service on the part of ops.
7. In view of the above, we allow this complaint and direct the opposite parties to pay the balance amount of Rs.97,500/- to the complainant within a period of 30 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @7% per annum on the above said amount from the date of order till actual payment. We further direct the ops to further pay a sum of Rs.5000/- as composite compensation and litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:30.05.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
