Delhi

New Delhi

CC/622/2011

Sunil Matta - Complainant(s)

Versus

M/S. New India Assurance Company Ltd. - Opp.Party(s)

17 Jul 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI (DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.CC/622/11                            Dated:

In the matter of:

1. Sh. Sunil Matta,
2. Shri Baldev Lal,

Both at R/o: 3/69, Old Rajinder Nagar,

New Delhi-110060

……..COMPLAINANTS

       

VERSUS

1. The New India Assurance Co. Ltd.,

Regional Office at:

Jeevan Bharti Building,

124, Connaught Circus, New Delhi-110001

 

2. Divisional Office 712500,

2^nd floor, Mount Casa Blanca Building,

(Old no.701-702) 260, Anna Salai,

Near Anand Theatre, Chennai-600006

                         ………. OPPOSITE PARTIES

 

ORDER

President:  C.K Chaturvedi

The complainant was beneficiary of a good health policy under OP insurance company as a benefit of Citi Bank card Member Account Holder, in respect of self and family members based on contract of insurance coverage. The benefits in respect of the insured persons were subject to terms & conditions & exclusions under the respective policies.

Besides complainant, his father Baldev Lal and mother Swarn Matta were the insured under the policy from 01.02.10 to 31.01.11. The certificate of insurance is A1/A, filed with evidence of OP. The said certificate mention overleaf highlights of the terms & conditions of the good health policy clause 3A, mention the limits for hospitalization benefits expenses, which are attracted in this case.

The case of the complainant is in respect of deficiency on the part of OP in not fully reimbursing the treatment expenses of Rs.2,15,887/- but limiting the reimbursement to Rs.1,09,400/-. It allegedly deducted Rs.1,06,488/- as per terms of the policy. The complainant protested to this and stated that his father was treated in emergency conditions in Sri Ganga Ram Hospital on complaint of chest pain and extreme weakness in lower limbs, being unable to stand. He was admitted in shared room having two beds. After MRI, he was diagnosed to be suffering from GBS (Gullian Barre Syndrome) a rare disease, which stands with paralysis of lower body area that moves towards upper limb and face. The doctor advised that it was spreading very fast and advised medicine Gamma IV (Intra Venus Medication) which alone cost Rs.1.68 lakhs, during hospitalization period and bill was of Rs.2,15,887/-.

The OP in its reply has justified the deduction on the basis of terms and conditions of policy provide limits. In view of this it is necessary to have look at Annexure 2, page 28 of the complaint, which is the final bill mentioning all charges as under, and the limits table

 

 

 

 

 

 

 

In terms of the table of benefits, the insured was admissible for Rs.60,000/- i.e. up to 30% of claim under clause (I) & (II) and (III). He was entitled to Rs.60,000/- for consultations and Rs.80,000/- for medicines.

The complainant has attached the certificate & policy terms with his complaint. That shows he was fully aware of the terms & limits. The OP has acted as per terms of limits, and therefore, we do not find any deficiency on its part. The complaint is dismissed.

File be consigned to record room.

Copy of the order be sent to the parties free of cost.

 

 

Pronounced in open Court on 17.07.2015.

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 

 (RITU GARODIA)

MEMBER