Delhi

East Delhi

CC/852/2013

POONAM KHANNA - Complainant(s)

Versus

NATIONAL INS. - Opp.Party(s)

15 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 852/13

 

Smt. Poonam Khanna

W/o Shri Rattan chand Khanna

R/o K-76, 1^st Floor

Chhachi Building, Krishna Nagar

Delhi – 110 051                                                                              ….Complainant

 

Vs.

 

M/s. National Insruance Co. Ltd.

(Govt. of India Undertaking)

Div. Off.: 28, Scope Minar

11^th Floor, District Centre

Laxmi Nagar, Delhi – 110 092                                           ….Opponent

 

Date of Institution: 27.09.2013

Judgment Reserved on: 15.11.2017

Judgment Passed on: 27.11.2017

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Ms. Harpreet Kaur Charya (Member)

 

JUDGEMENT

            Jurisdiction of this forum has been invoked by the complainant, Smt. Poonam Khanna, against M/s. National Insurance Co. Ltd. (OP) with allegations of deficiency in services and unfair trade practice.

2.        Facts in brief are that the complainant being the holder of mediclaim policy no. 361700/48/128500003622, Member                       ID-M5813435867 entitled to benefits of policy for a period from 03.01.2013 to 02.01.2014.  On 13.03.2013, the complainant underwent knee replacement surgery from Sant Parmanand Hospital for which                 Rs.3,00,000/- with room rent of Rs. 3000/- per day and ICU rent of        Rs. 3,000/- per day were approved by Raksha, TPA of OP.  It has been stated that the total expenditure on treatment was Rs. 4,32,200/- and the difference was paid by the complainant.  It has further been stated that Raksha, TPA, the agent of OP, subsequently revised/reduced the amount to Rs. 2,25,000/- without intimation.  Thus, the complainant was forced to pay Rs. 75,000/- to the hospital. 

            The complainant has stated that the cover was for Rs. 3,78,750/- including Rs. 78,750/- as CB.  It was also averred that the room rent       @ Rs. 3,000/- and ICU charges of Rs. 6,000/- were allowed as against         admissible Rs. 3,357/- and Rs. 7,575/- per day.  Despite letter dated 02.05.2013 and legal notice dated 20.08.2013, OP has failed to pay       Rs. 75,000/-.  The claim of the complainant has been declined vide letter dated 03.09.2013, hence, the present complaint praying for compensation of Rs. 75,000/- as deficient amount of policy, Rs. 50,000/- as compensation for mental and physical harassment and Rs. 10,000/- as cost of litigation.

            Complainant has annexed copy of insurance policy, copy of final bill, discharge slip, receipt for Rs. 75,000/-, another final bill dated 19.03.2013 and letter dated 02.05.2013 by the complainant to OP.

3.        OP in their WS took several pleas such as there was no deficiency in service on the part of OP; the claim of the complainant was covered under the exclusion clause 4.3 of the policy, according to which “treatment for joint replacement due to degenerative conditions, age related osteoarthritis and osteoporosis were not payable for first four years of operation of the policy.  If these diseases are pre-existing at the time of proposal will be covered only after four continuous claim free policy years”.

            It was further stated that the complainant took the policy for the sum insured of Rs. 1,50,000/- upto 02.01.2012 and with the malafide intention, he increased the sum insured amount by Rs. 75,000/- in the year 2012-13 and again Rs. 75,000/- in the year 2013-14 just to get the benefit of the increased sum insured.  Hence, the complainant was not entitled to get the benefit of increased sum insured within first four years of operation of the policy, from the operation of the each increment in the sum insured.

            It was further stated that the reply of the letter dated 02.05.2013 was given to the complainant by the Raksha TPA on 20.06.2013 clarifying the whole facts and reply of legal notice dated 03.09.2013  was also sent to the complainant.  Other facts have also been denied.       

            Insurance policies alongwith terms and conditions and report of Raksha TPA were enclosed with the reply. 

4.        The complainant has filed rejoinder to the WS of OP-1, wherein she has controverted the pleas taken in the WS and reasserted her pleas.

5.             Evidence by way of affidavit was filed by the complainant where she deposed on oath the contents of the complaint and got exhibited copy of mediclaim insurance policy (Ex.CW-1/1), copy of final bill, submitted to Raksha TPA (Ex.CW-1/2), letter dated 19.03.2013 (Ex.CW-1/2A), discharge slip (Ex.CW-1/3), paid bill dated 18.04.2013 for Rs. 75,000/- (Ex.CW-1/4), letter written to Raksha TPA dated 02.05.2013 (Ex.CW-1/5), bill dated 19.03.2013 (Ex.CW-1/6), copy of legal notice alongwith postal receipt (Ex.CW-1/7 and 1/8) and reply of the respondent dated 03.09.2013 (Ex.CW-1/9). 

            OP examined Shri Ajay Kumar, Asstt. Manager, who reiterated the contents of their reply. He has also got exhibited documents such as copy of terms and conditions of policy (Ex.RW-1/1), copy of policy no. 361700/48/12/8500003622, valid from 03.01.2013 to 02.01.2014 (Ex.RW-1/2), copy of mediclaim policy for the sum insured of                  Rs. 1,50,000/- for the year 2011-2012 (Ex.RW-1/3), copy of policy for the year 2012-2013 (Ex.RW-1/4), Letter by Raksha TPA to the complainant (Ex.RW-1/5), Letter written by Raksha TPA to the Division Manager (Ex.RW-1/6) and reply of notice (Ex.RW-1/7).    

6.        We have heard Ld. Counsel for the parties and have perused the material placed on record.  It has been alleged by the complainant that initially Rs. 3,00,000/- had been approved by TPA, but subsequently without prior intimation reduced/revised it to Rs. 2,25,000/-.  The complainant has got exhibited the policy document as Ex.CW1/1 and authorization letter as Ex.CW1/A dated 19.03.2013 where the “authorization for extension of credit facility for the treatment of B/L OA Knee for Surgery” where it has been written as amount payable to Hospital is Rs. 3,00,000/- (inclusive TDS).  Further, this document also bears “This is initial approval, for further enhancement send us the final bill and discharge summary”.

            Thus, simple reading of this authorization letter, which has been issued by TPA on behalf of OP, where Rs. 3,00,000/- have been approved to be paid to the hospital.  The reduction of amount from Rs. 3,00,000/- to      Rs. 2,25,000/- is arbitrary, nowhere in the authorization letter, it has been mentioned that the amount approved can be reduced.  Thus, OP has acted in an arbitrary and imperious manner.  Thus, we direct OP to pay Rs. 75,000/- to the complainant as the approved amount was reduced by Rs. 75,000/-.  We also award Rs. 15,000/- as compensation for mental and physical harassment.  This shall be inclusive of litigation expenses.

Copy of the order be supplied to the parties as per rules.

File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member    

 

            (SUKHDEV SINGH)

             President