DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

 

Complaint Case No : CC/217/2019

Date of Institution : 06.12.2019

Date of Decision : 07.07.2020

Narinder Kumar Jindal s/o Sh. Hukam Chand resident of # B-IV/147, Sindhwani Street, Old Cinema Road, Barnala, District Barnala, Punjab.                          …Complainant

Versus

1. National Insurance Company Limited, PUDA Market, Opposite Maharaja Aggarsain Chowk, Near Gaddakhana, Near Alal Mart, Barnala-148101 through its Branch Manager.

2. M/s Raksha TPA Pvt. Ltd., SCO-39, 1st Floor, Sector-26, Madhya Marg, Above Barbeque Nation, Chandigarh-160019 through its Branch Manager. 

…Opposite Parties

Complaint under Consumer Protection Act, 1986.

Present: Sh. RK Singla counsel for the complainant.

Sh. NK Singla counsel for opposite party No. 1.

Opposite party No. 2 exparte. 

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

(ORDER BY KULJIT SINGH, PRESIDENT):

    The complainant namely Narinder Kumar Jindal has filed the present complaint under the Consumer Protection Act, 1986 (in short the Act) against National Insurance Company Limited, Barnala and another. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that he purchased one cashless Parivar Mediclaim insurance policy from the opposite party No. 1 for the period from 6.4.2018 to 5.4.2019 bearing policy No. 4042011501810000003 and opposite party No. 2 is the TPA of opposite party No. 1. 

3. It is further alleged that the complainant suffered with Urine Problem, Cough, Breathlessness etc so on the advice of doctors of Dayanand Medical College and Hospital, Ludhiana got admitted in the said hospital for treatment and informed the opposite parties regarding the same and remained admitted in the hospital from 11.1.2019 to 18.1.2019. Further, the hospital raised treatment bill for Rs. 66,694/-. The complainant approached the opposite parties and asked them to pay hospital bill as he is holding cashless policy. On this the opposite parties told the complainant to pay the bill amount himself and they will reimburse the whole amount later on and complainant paid the treatment bill to the said hospital. 

4. It is further alleged that after that the complainant submitted claim form alongwith original bills to the opposite parties for the settlement of claim. The opposite parties avoided the complainant and ultimately transferred an amount of Rs. 7,363/- in the account of the complainant without any information to the complainant. When he came to know about the transfer of this amount he approached the opposite parties and demanded the balance amount but they told that it is full and final payment of his claim but failed to mention any reason for less payment. The complainant accepted this amount under protest. It is further submitted that thereafter the complainant admitted in the said hospital for the treatment of same disease for the period from 28.1.2019 to 15.2.2019, 7.3.2019 to 16.3.2019 and 19.3.2019 to 4.4.2019 and opposite parties paid all the three bills directly to the hospital being cashless policy. The act of the opposite parties amounts to deficiency of service on their part. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay a sum of Rs. 59,331/- the balance amount alongwith interest at the rate of 18% per annum from the date of payment i.e. 18.1.2019 till realization. 

2) To pay Rs. 22,000/- as litigation expenses. 

3) To pay Rs. 3,00,000/- as compensation for mental agony and harassment.  

4)   Any other relief which this Forum deems fit. 

5. Upon notice of this complaint, the opposite party No. 1 filed written version taking legal objections on the grounds of not maintainable, concealment of material facts, not come to the Forum with clean hand, estoppal and being false and frivolous. 

6. On merits, it is admitted that complainant remained admitted in DMCH, Ludhiana from 11.1.2019 to 18.1.2019 with the history of cough, breathlessness and was diagnosed for DM-2, HTN, Right Solitary Kidney with PUJ obstruction (Partial) with hydronephrosis i.e. acquired absence of kidney. The said hospital raised inpatient final bill dated 18.1.2019 for an amount of Rs. 57,251/- and Rs. 9,443/- were for the medicine bills. As per terms and conditions of the policy total expenses incurred for any one illness is limited to 50% of the sum insured i.e. Rs. 2,50,000/-. Rs. 7,363/- out of the claim amount of Rs. 66,694/- were transferred in the account of the complainant on 7.11.2019 being full and final payment after deducting Rs. 59,331/- as the illness limited was exhausted due to payment of Rs. 2,42,637/- directly to the DMCH, Ludhiana by the opposite parties on 5.9.2019 for the treatment of the complainant for the same disease and detail is mentioned in Claim Settlement Voucher. Further, the amount was transferred in the account of the complainant with due information. Rest of the averments of the complaint are denied and lastly prayed for the dismissal of present complaint with costs.

7. The opposite party No. 2 not appeared before this Forum despite service so the opposite party No. 2 was proceeded against exparte vide order dated 24.1.2020. 

8. In support of his complaint, the complainant tendered into evidence his own affidavit Ex.C-1, copy of insurance policy Ex.C-2, copy of discharge summary Ex.C-3, copy of final bill Ex.C-4, copy of medicine bills  Ex.C-5, copy of letter dated 29.5.2019 Ex.C-6, copy of statement of account  Ex.C-7, copy of discharge summary dated 15.2.2019 Ex.C-8, copy of letter dated 24.9.2019 Ex.C-9, copy of discharge summary dated 4.4.2019 Ex.C-10, copy of application dated 29.11.2019 Ex.C-11 and closed the  evidence.   

9. To rebut the case of the complainant, the opposite party No. 1 tendered into evidence copy of insurance policy Ex.OP-1/1, copy of terms and conditions Ex.OP-1/2, copy of email of Raksha TPA Ex.OP-1/3, copy of claim settlement voucher Ex.OP-1/4, copy of detail of payment Ex.OP-1/5, affidavit of Kuldeep Raj Ex.OP-1/6 and closed the evidence. 

10. We have heard the learned counsel for the parties and have gone through the record. Written arguments also filed by the opposite party No. 1. 

11. It is not denied by the opposite party No. 1 that the complainant purchased one cashless Parivar Mediclaim insurance policy Ex.C-2 from opposite party No. 1 which was valid from 6.4.2018 to 5.4.2019 for an amount of Rs. 5,00,000/- for the family of the complainant consisting of complainant, his wife and his son. It is admitted by the opposite party No. 1 that the complainant remained admitted in DMCH, Ludhiana from 11.1.2019 to 8.1.2019 vide discharge summary Ex.C-3 within the validity period of the insurance policy with history of cough, breathlessness and diagnosed for DM-2, HTN, Right Solitary Kidney with PUJ obstruction (Partial) with Hydronephrosis i.e. acquired absence of kidney. It is not denied by the opposite party No. 1 that the said hospital raised inpatient final bill dated 18.1.2019 for an amount of Rs. 57,251/- and Rs. 9,443/- for the medicine bills. 

12. But the main objection of the opposite party No. 1 to pay this amount is that as per terms and conditions of the insurance policy Ex.OP-1/2 total expenses incurred for any one illness is limited to 50% of the sum insured i.e. Rs. 2,50,000/- in the present complainant as the sum insured is Rs. 5,00,000/- as per the insurance policy Ex.C-2. The complainant claimed Rs. 66,694/- for the treatment and medicines from 11.1.2019 to  18.1.2019. But as the complainant already have taken the treatment of Rs. 2,42,637/- in DMCH, Ludhiana which were directly paid to the said hospital on 5.9.2019 by the opposite party No. 1 so remaining amount of Rs. 7,363/- was paid to the complainant on 7.11.2019 as per the above mentioned terms and conditions of the insurance policy. The deduction of Rs. 59,331/- was made from the amount of Rs. 66,694/- claimed by the complainant, due to limit already exhausted by the complainant on his treatment for the same disease in the same hospital, which is clearly mentioned in Claim Settlement Voucher Ex.OP-1/4. 

13. We have also perused the copy of terms and conditions of the insurance policy Ex.OP-1/2 in which at title Sublimit point (a) it is mentioned that total expenses incurred for any one illness is limited to 50% of the sum insured which is Rs. 2,50,000/- in the present complaint. The complainant admitted in his complaint and affidavit Ex.C-1 that he was admitted in the DMCH Hospital, Ludhiana for the treatment of same disease for the period from 28.1.2019 to 15.2.2019 vide discharge summary Ex.C-8,  7.3.2019 to 16.3.2019 and 19.3.2019 to 4.4.2019 vide discharge summary Ex.C-10 and all the three bills directly paid by the opposite party No. 1 to the hospital being it was a cashless policy. From copy of payment details Ex.OP-1/5 it is proved on the file that opposite party No. 1 paid Rs. 88,263/- to the DMC Ludhiana on 28.1.2019, Rs. 1,01,246/- to DMC Ludhiana on 5.9.2019, Rs. 53,128/- to DMC Ludhiana on 5.9.2019 and Rs. 7,363/- on 11.11.2019 to the complainant totaling Rs. 2,50,000/- for the treatment of the complainant for the same disease as admitted by the complainant in his complaint. In our view also the insurance policy amount limit exhausted as per terms and conditions of the policy Ex.OP-1/2 and complainant is not entitled for the remaining amount of Rs. 59,331/- and by not paying the same is not at all any deficiency in service or unfair trade practice on the part of the opposite party No. 1. 

14. In view of the above discussion there is no merit in the present complaint and same is dismissed. However, taking a lenient view no order as to costs or compensation upon the complainant. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.

ANNOUNCED IN THE OPEN FORUM:

        7th Day of July 2020

 

 

 

            (Kuljit Singh)

            President

              

(Tejinder Singh Bhangu)

Member