Delhi

North East

CC/70/2020

Nihal Singh - Complainant(s)

Versus

M/s Oriental Insurance Company Ltd. - Opp.Party(s)

04 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 70/20

 

 

 

In the matter of:

 

		Shri Nihal Singh S/o Shri Bansi Singh R/o H.No 1449/4, St. No. 9, Durga puri,  New Delhi		Complainant
		Versus
	1.     2.	M/s Oriental Insurance Co. Ltd . C-93, Subhash Road, Naveen Shahdara, Delhi-110032   M/s health Insurance TPA Ltd. Corporate Office at: CPC, 2nd Floor, Majestic Omnia Building, A -110, sector 4, Noida 201301 District Gautam Budh Nagar, UP Through its Manager/Director		Opposite Parties
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		09.12.20 07.02.23 04.09.23

 

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Ms. Adarsh Nain, Member

 

ORDER

Ms. Adarsh Nain, Member

The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the  Complainant has been regularly taking Health insurance policies from M/s Oriental Insurance Company Ltd. i.e. Opposite Party 1 while M/s health Insurance TPA Ltd, the Opposite Party 2 is acting under the instructions of Opposite Party 1. It is stated that the complainant had taken Medi –claim policy from Opposite Party 1 vide policy bearing no. 271702/48/2019/911 valid for period from 14.07.18 to 13.07.19 and 14.07.19 to 13.07.20  and deposited the premium for himself and his wife. On 21.04.19 wife of Complainant got hospitalised, remained there for a period from 21.04.19 to 25.04.19 on account of major operation. The Complainant stated that he had deposited a sum of Rs. 2,72,074/- in hospital as per the direction of hospital i.e. Rs. 2,58,710/- was deposited in hospital and Rs. 13,364/- paid for medicine. The Complainant filed claim before the Opposite Party No.2 and Opposite Party No.2 passed the claim of Rs. 2,13,435/- instead of Rs. 2,72,074/-. The Complainant stated that his wife was fully covered under the mediclaim health insurance policy, hence the Opposite Parties are liable to pay the entire amount of the treatment but the Opposite Parties deducted a sum of Rs. 58,639/-. The Complainant stated that Opposite Party No.2 is TPA and Opposite Party No. 1 is the insurance company, hence the Opposite Parties were jointly and severally liable to pay the balance amount of Rs. 58,639/- to the Complainant. The Complainant stated that he had sent legal notice dated 11.09.19 to Opposite Parties via speed post but Opposite Parties neither paid the insurance amount nor replied to the said notice.  Complainant stated that after receiving notice Opposite Party paid Rs. 20,499/- on 24.10.19 and Rs. 38,140/- is due upon Opposite Parties.  Complainant has prayed for the balance amount of Rs. 38,140/- with 18 % interest. He further prayed for Rs. 1,00,000/- for mental harassment and Rs. 25,000/- towards litigation cost.

Case of the Opposite Party No.1

2. The Opposite Party No.1 contested the case and filed written statement. Opposite Party 1 took the preliminary objection that the policy was subject to terms and conditions. While admitting the policy, the Opposite Party contends that the claim of the complainant was rightly considered by them as per the coverage under the subject policy.  It is submitted that the claim amount has been allowed to the complainant after making necessary deductions under the policy and in accordance with the terms and conditions of the policy; hence, no deficiency has been on their part. Thus the complaint deserves to be dismissed.

Rejoinder to the written statement of Opposite Party No.1

3. The Complainant filed rejoinder to the written statement of Opposite Party No.1 wherein the Complainant has denied the pleas raised by the Opposite Party No.1 and has reiterated the assertion made in the complaint.

Case of the Opposite Party No.2

4. None has appeared on behalf of Opposite Party No.2 despite service of notice on 13.01.21. Therefore, Opposite Party No.2 was proceeded against Ex-parte vide order dated 17.08.22.

Evidence of the Complainant

5. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party No.1

6. In order to prove its case Opposite Party No.1 has filed affidavit of Shri Rajiv Chopra, Sr. Divisional Manager of Opposite Party No.1, wherein the averments made in the written statement of Opposite Party No. 1 have been supported.

Arguments & Conclusion

7. We have heard the Complainant in person and Ld. Counsel for Opposite Party No.1. We have also perused the file.
8. The case of the complainant is that  under mediclaim policy  issued by Opposite Party No. 1, the Complainant filed claim Rs. 2,72,074/- before the Opposite Party No.2 and Opposite Party No.2 first passed the claim of  Rs. 2,13,435/- instead of Rs. 2,72,074/- and Rs. 58,639/- were still due. The Complainant further stated that after receiving notice Opposite Party paid      Rs. 20,499/- on 24.10.19 and Rs. 38,140/- is still due upon Opposite Parties. It has been contended that the Opposite Parties are liable to pay the entire amount of the treatment under the policy. Complainant has prayed for the balance amount of Rs. 38,140/- with 18 % interest. He further prayed for Rs. 1,00,000/- for mental harassment and Rs. 25,000/- towards litigation cost.
9. On the other hand, while admitting the policy, the Opposite Party No.  1 contends that the claim of the Complainant was rightly considered by them as per the coverage under the subject policy.  It is submitted that the claim amount has been allowed to the Complainant after making necessary deductions under the policy and in accordance with the terms and conditions of the policy, hence, no deficiency has been on their part.
10. While perusing the pleadings, it has come to our notice that the in paragraph no.3 of his rejoinder to the reply of Opposite Party No. 1, the Complainant made the contention that the Opposite Party insurance company cannot be allowed to turn around under the garb of any alleged terms and conditions which had never been read over to the complainant. This shows that the Complainant was in receipt of the terms and conditions and the contention of the Complainant cannot be believed that he was unaware of terms and conditions of the policy just because the same was not read over to him. It has been admitted in the complaint that the Complainant was regularly taking policies from the Opposite Party No. 1 for himself and his wife and there is nothing on record to show that the Complainant was not able to understand the terms and conditions. Therefore, it cannot be believed that the Complainant was unaware of those terms and conditions since those were not read over to him.
11. It is evident from the terms and conditions of the subject policy that the Opposite Party No. 1 had considered the claim amount in accordance with those terms and conditions and the Complainant has admittedly received  Rs. 2,13,435/-plus Rs. 20,499/- out of total claim amount of Rs. 2,72,074/-. The remaining amount of Rs. 38,140/ is in dispute.
12. In view of above discussion, we are of the considered view that the remaining amount of Rs. 38,140/- out of total claim amount of Rs. 2,72,074/- has been rightly disallowed by the Opposite Party No. 1 under the terms and conditions of the subject policy, Therefore, we do not find Opposite Parties deficient in their services towards the Complainant.
13. Thus, we dismiss the present complaint accordingly with no order as to costs.
14. Order announced on 04.09.2023.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

 

(Anil Kumar Bamba)           Member

(Adarsh Nain) Member

(Surinder Kumar Sharma) President