Delhi

New Delhi

CC/990/2012

Shukla Kapur - Complainant(s)

Versus

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

22 Jul 2016

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

 NEW DELHI-110001

Case No.C.C./990/2012                                 Dated:

IN THE MATTER OF:

MRS. SHUKLA KAPUR

W/o Mr. R.K. Kapur,

A-73, Avenue-I,

Saket,

New Delhi-110017

 

        ……..COMPLAINANT

VERSUS

 

1.     THE NEW INDIA ASSURANCE

COMPANY LTD.,

Delhi-Regional Office,

Jeevan Bharti Building,

124, Connaught Circus,

New Delhi

      .... OPPOSITE PARTY-I

 

2.     TTK HEALTHCARE SERVICES PVT. LTD.

        B-25, Ist Floor, Sector-I,

        (Behind Indian Oil Building),

        Noida-201301 (U.P.)

        ....OPPOSITE PARTY-II

 

PRESIDENT: S.K. SARVARIA

 

ORDER

 

 

The case of the complainant in this complaint filed under sections 12 and 13 of The Consumer Protection Act, 1986 is that he obtained mediclaim policy from OP 1, but did not raise any claim for the last five years, so he was entitled to  no claim bonus in the sum of Rs. 75,000/- extra over the policy amount of Rs. 4,00,000/- raising the insured value for the complainant of Rs. 4.75 lakhs during the year of policy period with effect from 1/10/2009 to 30/9/2010. In fact, the complainant has been taking Medi claim insurance policy from OP 1 since 1/10/1992, i.e., for almost 18 years till 2009/2010. OP 1 has appointed OP 2 as their TPA to extend cashless medical facilities for payment of all hospital expenses, but Sitaram Bharatiya Hospital declined to extend cashless facility for the cases dealt with by the OP 2 on account of the reasons that the said hospital already had a number of previous pending claims against OP 2, who did not settle their earlier dues. This was informed by the hospital to the complainant only at the last moment. The complainant had no other alternative but to arrange funds including loan etc to arrange for advance payments and to clear the hospital bills on discharge.

 

The complainant filed the insurance claim, with OP 1 insurance company with all original medical reports, bills and receipts of payment by letter dated 12/3/2010 for a claim of Rs. 3,88,793/– towards hospitalisation expenses. After a lot of follow-up OP 1, sent the payment in the sum of Rs.3,30,125/– with a delay of about two months and with the deduction of Rs.58,668/–. According to the complainant she spent additional claim of Rs.29,340/– for pre-and post-hospitalisation expenses with all necessary documents in general, by letter dated 28/6/2010, followed by several reminders. After a lapse of about four months the complainant was shocked to receive a check in the sum of Rs. 1400/– only on 11/10/2010 against the claim of Rs. 29,340/– from OP 1. Therefore, according to the complainant balance hospital expenses of M/S Sitaram Bharatiya Hospital amounting to Rs.55,238/– and pre and post hospitalisation expenses in the sum of Rs. 29,340/– are due making a total pending claim of Rs. 83,178/– against the OP 1.

 

The complainant has prayed for direction to the OP 1 to reimburse the pending dues in the sum of Rs. 83,178/– along with interest at the rate of 18% per annum. In addition, the complainant has demanded the compensation in the sum of Rs. 10,000/– for mental harassment and agony suffered by the complainant besides demanding litigation cost.

 

The notice of the complaint was issued to the opposite parties. OP 1 and OP 2 contested the complaint and filed joint written statement admitting that the complainant was the insurance policy holder bearing number 71250034093800000020 effective from 1/10/2009 to 30/9/2010. According to OP 1 and OP 2, the insurance claim, and documents for treatment of knee replacement was submitted by the complainant and the claim was settled by OP 2 TPA of the OP 1 company for Rs. 3,24,525/– plus Rs. 1400/– erroneously against the admissible amount of Rs. 288,750/–. According to them excess payment in the sum of Rs. 38,175/– was made to the complainant due to oversight, by letter dated 17/5/2010 and letter dated 5/10/2010 the complainant was required to return to OP 1. The said payment was released with the stipulation that any disagreement has to be intimated within 10 days, otherwise the same shall be deemed as accepted. According to OP & the insurance is a contract like other general contact and the terms and conditions of contract are binding on both parties. As per OP & clause 1.1 of the policy was not adhered to leading to excess payment to the complainant. The complainant having received the said payment without protest is not entitled to claim it now. The OPs have denied that there was any deficiency in service on their part, and have denied other facts stated in the complaint, and have prayed for dismissal of the complaint.

 

In the rejoinder the complainant has denied the averments made in the joint written statement of the opposite parties and has reaffirmed the facts stated in the complaint. In support of her case, the complainant has filed her affidavit in evidence. On behalf of the opposite parties, the affidavit in evidence of Mr DS Dhabas an officer of the OP 1 is filed. The complainant has filed her written arguments and on behalf of the opposite parties joint written arguments are filed.

 

We have heard the learned authorised representative and husband of the complainant, Mr Ram Kumar and authorised representative of opposite parties, Mr OP Narain and have gone through the written arguments of the parties, record of the case and relevant provisions of law. No authority is produced from either side for perusal of this District Forum.

 

In this case it is not disputed that the complainant had obtained mediclaim policy bearing number 71250034093800000020 effective from 1/10/2009 to 30/9/2010  from the OP 1 insurance company for the sum insured being Rs. 400,000/-.  It is also admitted that after the knee operation of the complainant, she submitted insurance claim with OP 1 in the sum of Rs.3,88,793/- towards hospitalisation expenses but OP 1 allowed and had paid the sum of Rs. 330,125/- to the complainant towards hospitalisation expenses. The complainant in the present complaint has made the claim of the amount of Rs. 58,668/- allegedly withheld by OP 1. Another medical insurance claim for pre-and post hospitalisation expenses in the sum of Rs. 29,340/- was made by the complainant from OP 1, but only a sum of Rs. 1400/- was allowed and paid by OP 1 against this claim.

 

In the backdrop of the above admitted position the complainant has claimed the amount of Rs. 29,340/- towards pre and post hospitalisation expenses and also the balance amount of Rs. 58,668/- withheld by OP 1, making the total claim of refund in the sum of Rs. 83,178/- along with interest at the rate of 18% per annum, while according to OP 1 in the light of terms and conditions contained in Clause 1.1 of the insurance policy in question complainant is entitled to less amount while OP 2 TPA calculated wrong amount in the sum of Rs. 330,125/- and an excess payment in the sum of Rs. 38,175/- was made to the complainant for hospitalisation expenses which the complaint is liable to refund.

 

 

We have carefully considered the respective stand of the parties, and find force in the contention raised on behalf of OP 1 and OP 2 so far as the claim made by the complainant with regard to hospitalisation expenses in connection with the knee operation of the complainant. On this count, we do not find any deficiency in service on the part of the opposite parties or entitlement of the complainant to claim the said alleged balance amount of Rs. 58,668/-. However, as regards pre and post hospitalisation expenses claimed by the complainant in the sum of Rs. 29,340/-we find the claim of the complaint justified. OP 1 has allowed only a claim of Rs. 1400/- towards pre and post hospitalisation expenses of the complainant regarding knee operation without any reasonable or justifiable cause leading to the conclusion of deficiency in service on the part of OP 1 with regard to pre and post hospitalisation claims made by the complainant. However, although the complainant has claimed the amount of Rs. 29,340/- but when admittedly, she has received the amount of Rs. 1400/- from OP 1, then this amount of Rs. 1400/- needs to be deducted from the claim amount of Rs. 29,340/- leading to the balance amount of Rs. 27,940/- to which the complaint is entitled from the OP 1.

 

In view of the above, we allow the complaint partially and direct the OP 1 to pay a sum of Rs. 27,940/– to the complainant along with simple interest at the rate of 10% per annum from the date of filing of the complaint till realisation of the said amount. In addition, we also direct OP 1 to pay the compensation in the sum of Rs. 15,000/– on account of the mental agony and harassment suffered by the complainant, including the litigation cost. In case the said amount is not paid within a period of one month from today, the same shall be recovered from OP 1 along with interest at the rate of 10% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy of this order each be sent to the parties to the present complaint free of cost by post.

 

The file be consigned to the record room.

 

Pronounced in open Forum on ­­­­­­22.07.2016.

 

(S K SARVARIA)

PRESIDENT

 

 

                                                  (H M VYAS)

MEMBER

 

 

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