Chandigarh

DF-I

CC/81/2023

JASPAL KAUR - Complainant(s)

Versus

M/S ORIENTAL INSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

05 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/81/2023
Date of Institution	:	17.2.2023
Date of Decision	:	5/03/2024

 

Jaspal Kaur aged about 70 years wife of Sh. Gurbax Singh, resident of House No. 714, Sector 22-A, Chandigarh.

 

...Complainant

 

VERSUS

 

1. M/s Oriental Insurance Company Limited, 1^st  Floor, SCO No. 47, Chandigarh-160047.

 

2. Vidal Health Insurance TPA (Previously known as Vipul Medcorp) 515, Udyog Vihar, Phase-V, Gurgaon 122016.

...Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Devinder Kumar, Advocate for complainant
	:	Sh. Vijay Kumar Garg, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties  (hereinafter referred to as the OPs). The brief facts of the case are as under :-

1. It transpires from the averments as projected in the consumer complaint that the complainant and her husband have been taking medicalim insurance policy (hereinafter to be referred as subject policy) from OP No.1 since 2015  and kept the same renewed  annually on payment of premium and the  subject policy  Annexure C-1 was renewed  from the OPs which was valid w.e.f. 15.1.2022 to 14.1.2023 with sum insured of Rs.3,00,000/- each on payment  of premium amount of Rs.37,548/- . The copy of terms and conditions of the policy is annexed as Annexure C-2. On 11.11.2022 the complainant visited Dr. Aggarwal Eye Hospital  for a routine check up of vision and she was diagnosed  OU NPDR and cataract surgery  was conducted and copy of discharge summary  is annexed as Annexure C-3 and C-4. Thereafter the treating hospital  raised the bill of Rs.1,30,000/- vide Annexure C-5. Accordingly the complainant lodged the claim of Rs.1,32,000/- for the said treatment with OP No.1 alongwith original bills and other requisite documents  who further forwarded the same to OP No.2. However, OP No.2 vide email dated 23.12.2022 Annexure C-6  informed the agent of the complainant  that on instructions of OP No.1, the claim is settled for Rs.24,000/- only out of the total claim of Rs.1,32,000/-. It was also intimated through the said email that the amount of Rs.24,000/- has been assessed only after deduction on account of “GIPSA PACKAGE FOR MICS”. However, neither such deduction clause has been inserted in the terms and conditions annexed with the policy nor the same were conveyed to the complainant till date even after receipt of the first policy in the year 2015 and in this mannerthe OPs have wrongly and illegally deducted the aforesaid amount on flimsy ground. Moreover, the exclusion clause provided waiting period  of the policy   for the expenses of the cataract  after 2 years of inception of the policy and since the complainant is holding the subject policy since 2015, even on that account the claim of the complainant could not have been settled partially. The complainant was covered with the sum insured of Rs.3,00,000/- and she has lodged claim of Rs.1,32,900/- only but the OPs wrongly settled the claim partially. The aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of  maintainability, cause of action suppression of fact  non joinder of necessary party and also that the complainant is not a consumer.  However, it is admitted that the complainant lodged claim of Rs.1,32,900/- and the claim of the complainant was settled for a sum of Rs.24,000/- as per negotiated GIPSA PPN Package for cataract surgery as  the treating hospital was also under the network  of GIPSA PPN. It is further alleged that the complainant was explained by the hospital about the negotiated GIPSA PPN package at the rate of Rs.24000/- for cataract surgery through phaco procedure , thus, the complainant is not entitled for the entire claim amount of Rs.1,32,000/-. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments on record.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant and her husband have obtained mediclaim insurance policy from OP No.1 since January 2015 and got the same renewed annually and the subject policy was got renewed by them which was valid w.e.f. 15.1.2022 to 14.1.2023, with sum insured of Rs.3,00,000/- each  as is also evident from Annexure C-1 the copy of policy schedule and as per terms and conditions of the subject policy the cataract surgery was also covered after 2 years of the inception of the policy and the complainant got the cataract surgery done from Dr. Agarwal Eye Hospital  on 11.11.2022 as is also evident from discharge summary Annexure C-4 and the treating hospital raised bill of Rs.1,32,000/- which was paid by the complainant from her own pocket and thereafter raised the claim of the same with OP No.1 which was partially allowed by OP No.1 by making deductions  on the ground that an amount of Rs.24,000/- was only permissible as per “GIPSA PACKAGE FOR MICS, the case is reduced to a narrow compass as it is to be determined if  the OPs are unjustified in partially allowing the claim of the complainant and the complainant is entitled for relief as prayed for as is the case of the complainant or if the OPs are justified in partially allowing the claim of the complainant as per  terms and conditions of the subject policy as well as “GIPSA PACKAGE FOR MICS and the complaint is liable to be dismissed as is the defence of the OPs.
   2. Perusal of Annexure C-1 the copy of policy schedule as well as Annexure C-2 terms and conditions  of the subject policy indicate that the subject policy was valid wi.e.f. 15.1.2022 to 14.1.2023  covering the complainant and her husband with sum insured of Rs.3,00,000/- each. However, a meticulous perusal of the policy Annexure C-1 and the terms and conditions Annexure C-2 reveal that the subject policy do not find any reference that if the claim of the insured will be processed/approved/settled  as per “GIPSA PACKAGE FOR MICS”.
   3. As per defence of the OPs the complainant was explained by the treating hospital about the negotiated GIPSA PPN package  at the rate of 24000/- for cataract surgery through phaco procedure  but  the OPs failed to adduce on record any iota of evidence to prove their version that the complainant was explained about negotiated GIPSA PPN package. Moreover, the subject policy as well its terms conditions are silent about such special clause. Thus, the OPs have wrongly applied the “GIPSA PACKAGE FOR MICS”  while assessing the claim of the complainant by unilaterally making deductions as per “GIPSA PACKAGE FOR MICS” which was not a part of subject policy or terms and conditions of the same.
   4. Perusal of Annexure C-6 clearly indicates that the OPs have partially allowed the claim of the complainant to the tune of Rs.24,000/- making deductions as per “GIPSA PACKAGE FOR MICS”, which as discussed above is wrongly applied by the OPs, hence, it is safe to hold that the OPs have wrongly made the deductions while assessing the claim of the complainant and the said act of the OPs amounts to deficiency in service and unfair trade practice.  
   5. So far as the quantum of relief is concerned as it stands proved on record vide bill Annexure C-5 the treating hospital raised bill of Rs.1,30,000/-  and the complainant failed to prove on record another bill of Rs.2900/-  which has also been included by the complainant in claim lodged before the OPs, hence, it is safe to hold that the complainant incurred Rs.1,30,000/- for her treatment. Since the OPs have only settled partial claim to the tune of Rs.24,000/-, thus, the complainant is entitled for  balance claim of Rs.1,06,000/- from 12.2.2023 the date when she was conveyed about the partial settlement of her claim.
4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹1,06,000/- to the complainant alongwith interest @ 9% per annum from 12.2.2023 till onwards.
2. to pay an amount of ₹10,000/-to the complainant as compensation for causing mental agony and harassment to her;
3. to pay ₹10,000/- to the complainant/s as costs of litigation.

5. This order be complied with by the OPs within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 5/03/2024 mp			Sd/- [Pawanjit Singh] President
			Sd/-
			[Suresh Kumar Sardana] Member