BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.105 of 2017

      Date of Instt. 17.04.2017

      Date of Decision: 12.01.2021

Sushil Kumar Kapoor aged 66 years S/o Sh. Roshan Lal Kapoor, R/o H. No.50, Adarsh Nagar, Jalandhar, C/o M/s. Garima Sales Corp., 13-New Vijay Nagar, Jalandhar.

..........Complainant

Versus

M/s New India Assurance Co., 16, Patel Chowk, Jalandhar, through its Branch Manager.

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before:        Sh. Kuljit Singh             (President)

Smt. Jyotsna                   (Member)

Present:       Sh. Balwinder Luthra, Adv. Counsel for the Complainant.

Sh. R. K. Sharma, Adv. Counsel for the OP.

Order

Kuljit Singh (President)

1.                The instant complaint has been filed by the complainant, wherein alleged that the complainant hired the services of OP for getting medi-claim policy for his own as well as of his family and was regularly obtaining the mediclaim policy from OP for the last about 10-15 years and had no taken any claim and is paying its due premium to OP without any interruption. The OP was going on changing schemes/names their mediclaim policies and recently, the complainant got insured himself as well as his family with their policy i.e. New Mediclaim 2012, vide policy No.36100134152500000120 from the period 11.07.2015 to 10.07.2016. As per the said policy, complainant Sh. Sushil Kumar Kapoor alongwith his wife Smt. Seema Kapoor is covered upto the total sum assured of Rs.1,50,000/- + cumulative bonus buffer of Rs.45,000/-. Copy of the policy cover note is attached. That the complainant got operated his wife Smt. Seems Kapoor on 17.03.2016 regarding Knee Replacement Surgery from Aasta Hospital, 14, Sri Guru Ravidass Nagar, Jalandhar and remained in the said hospital till 23.03.2016 and spent an amount of Rs.1,63,568/- upon the surgery, Doctor fee, Nursing Expenses, Medical etc. Copies of the relevant bills are attached. That before the operation, the complainant approached the OP and showed the medical prescription of the Doctor regarding the said surgery and they assured the complainant that their company will reimburse the whole amount of the claim. The complainant after the operation, lodged the claim before OP for the reimbursement of the said amount as per the terms and conditions of the above said policy and OP assured complainant that the whole amount will be reimbursed from their end. That the complainant surprised to see the claim settlement voucher, vide which the OP had deducted an amount of Rs.18,415/- from the said genuine claim of the complainant. Copy of the letter is attached. That the complainant, thereafter approached OP and asked the representative as to why they had deducted the said amount from the claim, but they have not gave any proper genuine reason for not paying the said amount to complainant. Even as per the claim settlement voucher, the main reason behing the non-payment of the claim has been disclosed as “Non-payable as per room rent entitlement capping”, which is not a genuine reason, vide deducting the Doctor Fees, Anesthesia Fees, Surgeon Fees, Nursing Fees etc. That the deduction of the said claim amount of complainant is without any justification or reason, as such, OP provide negligent service and unfair trade practice on their part. That earlier, complainant filed a complaint regarding the present subject matter before this Forum on 06.12.2016 but the same was withdrawn with the permission to file the fresh complaint on 14.12.2016 due to typographical date mistake in Para No.3 of the complaint. That the non-payment of the above said amount of the complainant shows deficiency and negligence in service and unfair trade practice on the part of the OP. That the OP is liable to pay damages to the tune of Rs.50,000/- alongwith the remaining claim amount of Rs.18,415/- alongwith interest upto date to the complainant, hence the present complaint filed.

2.                Notice of the complaint was given to the OP, who filed reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable against the OP, as such the same is liable to be dismissed. That out of the claimed amount of Rs.1,63,568/-, Rs.18,415/- was not payable as per terms and conditions of the insurance policy were deducted by the Raksha TPA Pvt. Ltd., the Third Party Administrator for the settlement of the claims and Rs.1,45,153/- were paid to the complainant on account of reimbursement of expenses of treatment of Seems Kapoor. The details and reasons of deductions has been given in the claims settlement Voucher letter dated 26.08.2016 itself and the complainant was informed accordingly. As the sum assured is Rs.1,50,000/-, the complainant was entitled to only 1% of the sum assured towards the Room Rent. Room Rent as per terms and conditions of the insurance policy means the amount charged by a Hospital for the occupancy of a bed per day basis and shall include associated medical expenses. As the room rent claimed/charged was Rs.2000/- per day against the entitlement of the complainant of Rs.1500/- (1% of the sum assured) as such, the deductions was made accordingly, and similarly the proportionate deductions were also made from the Doctors Fee, Anesthesia Charges, Surgeon Fee, Hospital Services as detailed above. Admission Charges and Nursing Fees were also not payable as per insurance policy, as such, those charges were also deducted. The OP has paid the amount of Rs.1,45,153/- payable as per terms and conditions of the insurance policy. It is further alleged that there is neither any deficiency in service or negligence in service not there is any unfair trade practice on the part of the OP, as making the deductions out of the claimed amount which were not payable as per terms and conditions of the OP does not amounts to any deficiency in service or negligence in service or unfair trade practice as per terms and conditions of the insurance policy. On merits, it is admitted that the complainant availed the services of the OP. It is further submitted that Rs.18,415/- which were not payable as per terms and conditions of the insurance policy were deducted by the Raksha TPA Pvt. Ltd., the Third Party Administrator for the settlement of the claims and Rs.1,45,153/- were paid to the complainant on account of reimbursement of expenses of treatment of Seems Kapoor. The details and reasons of deductions (Total Deductions of Rs.18,415/-) has been given in the claims settlement voucher letter dated 26.08.2016 itself and the complainant was informed accordingly. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 to Ex.C-4 and closed the evidence.

4.                In order to rebut the evidence of the complainant, the counsel for the OP tendered into evidence affidavit of Sh. Jaibir Shanker as Ex.OA alongwith some documents Ex.O-1 to Ex.O-20 and closed the evidence.

5.                We have heard the argument from learned counsel for both the parties and also gone through the case file as well as written arguments submitted by learned counsel for the complainant, very minutely.

6.                Precisely, the case of the complainant is only that the complainant got insured himself as well as his family by taking a policy from OP, which was commenced from 11.07.2015 to 10.07.2016 and as per policy, the complainant alongwith his wife covered upto the total sum assured of Rs.1,50,000/- + cumulative bonus buffer of Rs.45,000/-, copy of the policy is Ex.C-1. The complainant got operated his on 17.03.2016 regarding Knee Replacement Surgery from Asta Hospital, Jalandhar and remained in the said hospital till 23.03.2016 and spent an amount of Rs.1,63,568/- upon the surgery and other expenses, copy of the same is Ex.C-3. After the operation the complainant lodged his claim, but out of the claimed amount of Rs.1,63,568/-, Rs.18,415/- was not payable as the OP deducted Rs.18,415/- as “non-payable as per room rent entitlement capping” and accordingly, the complainant filed the present complainant for reimbursement of the said amount i.e. Rs.18,415/-.

7.                On the other hand, the OP taken a plea in the written reply that the detail and reasons of deductions (Rs.18,415/-) has been given in the claims settlement voucher dated 26.08.2016, which is Ex.C-2, wherein clearly mentioned about the room rent. As the sum assured is Rs.1,50,000/-, the complainant was entitled to only 1% of the sum assured towards the Room Rent. Room Rent as per terms and conditions of the insurance policy means the amount charged by a Hospital for the occupancy of a bed per day basis and shall include associated medical expenses. As the room rent claimed/charged was Rs.2000/- per day against the entitlement of the complainant of Rs.1500/- (1% of the sum assured) as such, the deductions was made accordingly, and similarly the proportionate deductions were also made from the Doctors Fee, Anesthesia Charges, Surgeon Fee, Hospital Services as detailed above. Admission Charges and Nursing Fees were also not payable as per insurance policy, as such, those charges were also deducted. The OP has paid the amount of Rs.1,45,153/- payable as per terms and conditions of the insurance policy.

8.                After considering the over all facts and circumstances, one thing is clear that as per document Ex.C-2 i.e. Claim Settlement Voucher, all deductions are disclosed and clearly mentioned by the OP in ‘Details of Deductions’ and further in document Ex.C-4 at Point No.3 How Much We Will Reimburse in 3.1 (a) ‘Room Rent, boarding and nursing expenses as provided by the Hospital not exceeding 1.0 % of the sum insured per day’, this point is also evident from document Ex.O-2. Apart from that the OP already paid Rs.1,45,153/- to the complainant. So, accordingly, we reached to the conclusion that Rs.18,415/- is legally deducted by the OP and nothing is due towards the OP, so the complaint of the complainant is without merits, the same is dismissed with no order of cost. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.  

9.               Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated                                       Jyotsna                           Kuljit Singh

12.01.2021                              Member                          President