District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No. 670/2021.

 Date of Institution:28.12.2021.

Date of Order:24.05.2023.

Karan Chaudhary son of Shri Anil Chaudhary, resident of House No. 518, Sector-29, Faridabad, Haryana, age 26 years, Mobile No. 8802252020, Adhar No. 3226 2372 4416.

                                                          …….Complainant……..

                                                Versus

1.                M/s. National Insurance Company Limited, branch Office-SCO 96, Ist floor, Sector-16 Market, Old Faridabad – 121007 through its principal officer/Authorised Signatory.

2.                M/s. Safeway TPA Services Pvt. Ltd., 815, Vishwa Sadan, District Center, Janakpuri, New Delhi – 110 058 through its Principal Officer/Authorised Signatory.

                                                                              …Opposite parties

Complaint under section-12 of Consumer Protection Act, 1986

Now  amended  Section 34 of Consumer protection Act 2019.

BEFORE:            Amit Arora……………..President

Mukesh Sharma…………Member.

Indira Bhadana………….Member.

PRESENT:                   Sh. Pankaj Panwar , counsel for the complainant.

                             Sh.  Anuj Gupta , counsel for opposite party No.1.

                             Opposite party No.2 ex-parte vide order dated 3005.2022.

ORDER:  

                   The facts in brief of the complaint are that the father of the complainant i.e Anil Chaudhary had taken a mediclaim insurance policy bearing No. 361102/50/20/10004863 for a sum assured amount of Rs.5,00,000/- from opposite party No.1 .  During the validity of said policy, the complainant suffered from Left Parietal Meningioma and underwent Gamma Knife  Radiosurgery and was admitted with M/s. Rancan Gamma Knife Centre, Vimhans, Delhi on 20.03.2021 and discharged on 21.03.2021.  The total expenditure on the treatment of the complainant namely Karan Chaudhary coasted Rs.3,11,930/- approximately except the expenditure on special diets and transportation.  As per the terms and conditions of the above said insurance policy, the said expenditure of Rs.3,11,930/- were to be borne by the insurance company i.e. opposite party No.1.   The complainant applied for the re-imbursement of said amount of Rs.3,11,930/- with opposite party No.2 through the authorized TPA within time and Rs.2,01,177/- was sanctioned and transferred in the joint account of complainant as well as his father.  There was no reason or legal aspect for which re-imbursement of Rs.3,11,930/- amount of Rs.1,10,753/- could be denied but for the utter shock and surprised to the complainant, the opposite parties refused to re-imburse an amount of Rs.1,10,753/-/ without any reason or cause. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite parties to:

a)                make the balance re-imbursement amount of Rs.1,10,753/-.

 b)                pay Rs. 50,000/- as compensation for causing mental agony and harassment .

2.                Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that  Anil Chaudhary got himself, his wife and his two sons including complainant insured with the answering opposite party under National Parivar Mediclaim policy bearing policy No. 361102502010004863 w.e.f 15.10.2020 to 14.10.2021 for floater sum insured of Rs.5,00,000/- subject to its terms and conditions in corporate therein.    After receiving the claim form of the complainant same was processed by the team of opposite party No.2, the permissible and admissible amount of Rs.2,01,177/- was approved and paid by the opposite party No.2 on behalf of answering opposite party.  The reason and amount which was disallowed by the opposite party No.2 was detailed below:

Clause 5.5.8  of the National Parivar Mediclaim Policy, reads as under:-

Admittedly complainant underwent GAMMA Knife Radiosurgery, which was an advancement in the field of radiation, It was very precise form of radiation therapy that focuses intense beams of gamma rays with pinpoint accuracy to trt lesions in the brain. Gamma Knife radiosurgery, like other forms of stereotactic (SRS), was not surgery in the traditional sense because threw was no incision instead, Gamma Knife radiosurgery uses specialized equipment to focus about 200 tiny beams of radiation on a tumor or other target with submillimeter accuracy.  Therefore, as per the policy T & C, charges incurred on account of advanced surgeries were to be restricted upto the conventional charges, so charges for the Conventional IMRT had been approved and paid by the opposite party No.2 on behalf of answering opposite party to the complainant.  In view of the aforesaid terms and conditions as well as detail of deductions stated above, the complainant was not entitled for any further amount reason being the admissible amount had already been paid by opposite party No.2 on behalf of answering opposite party. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                Notice issued to opposite party No.2 on dated 27.4.2022 not received back either served or unserved.  Case called several times since morning but none appeared on behalf of opposite party No.2.  Mandatory period of 30 days expired.  Hence, opposite party No.2 was hereby proceeded against ex-parte vide order dated 30.05.2022.

4.                The parties led evidence in support of their respective versions.

5.                We have heard learned counsel for the parties and have gone through the record on the file.

6.                In this case the complaint was filed by the complainant against opposite parties–National Insurance Co. Ltd. with the prayer to: a)  make the balance re-imbursement amount of Rs.1,10,753/-.  b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .

                    To establish his case the complainant  has led in his evidence,  Ex.CW1/A – affidavit of Karan Chaudhary, Ex.C-1 – insurance policy, Ex.C-2 -  premium certificate,Ex.C-3 – insurance policy valid from 15.10.2019 to 14.10.2019, Ex.C-4 –MRI Brain with contrast,, Ex.C-5 -  Bill of supply, Ex.C-6 – Cash receipt, Ex.C-7 – cash bill, Ex.C-8 -  Claim Settlement Voucher, Ex.C-9 – OPD Bill cum receipt,, Ex.C-10 Invoice cum receipt, Ex.C-11 – IPD receipt, Ex.C-12 – Discharge summary, Ex.C-13 – Snapshot, Ex.C-14 – patient bill,, Ex.C-15 – Details of medicines & consumables, Ex.C-16 – letter dated 07.09.2021, Ex.C-17 -  letter dated 23.09.2021, Ex.C-18 – Adhaar card,

          On the other hand counsel for the opposite party No.1 strongly agitated and opposed.  As per the evidence of the opposite party  No.1 Ex.RW1/A - affidavit of  Rameshwar, Asstt. Manger cum Duly Constituted Attorney of National Insurance Ltd., D.O-1, NIT, Faridabad, Ex.R-1 – insurance policy, Ex.R-2 – terms and conditions, Ex.R-3 -  the mentioned clause of National Mediclaim policy has been applicable at the time of settlement of claim which was opted by the insured.

7.                In this complaint, the complaint was filed by the complainant with the prayer to make the balance re-imbursement amount of Rs.1,10,753/-.

8.                In this case, earlier opposite party has paid an amount of Rs.2,01,177/-  to the complainant.  As per calculation given in the written statement opposite

party No.1 has disallowed  an amount of Rs,89,769/- . The details are as under:

9.                After going through the evidence led by the complainant as well as opposite party,  the deduction  done by the opposite party is on higher side and the complainant is paying  the premium to the insurance company. In our opinion the deduction is on higher side as per table mentioned above. Hence, the complaint is allowed.  Opposite party No.1 is directed to pay 50% of the disallowed amount i.e Rs.89769/- as per the detailed  mentioned above. Opposite party No.1 is also directed to pay Rs.2200/- as compensation for causing mental agony  & harassment alognwithRs.2200/- as litigation expenses to the complainant.  Compliance of this

order  be made within 30 days from the date of receipt of copy of this order.   Copy of this order be sent to the parties concerned free of costs.  File be consigned to the record room.

Announced on:  24.05.2023                                 (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.

                                                (Indira Bhadana)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.