CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/274/21

          Date of Institution:-    18.10.2021

          Order Reserved on:- 17.05.2024

                     Date of Decision:-      11.06.2024

IN THE MATTER OF:

Amal Kumar Mandal,
S/o Late Dr. D. N. Mandal,

R/o C 89, RohitAptts., Plot 30,

Sector 10, Dwarka, New Delhi - 110075

.….. Complainant

VERSUS

National Insurance Co. Ltd.

Division XI, Second Floor, Padam Singh Road,

Karol Bagh, New Delhi – 110005

(Acting Thro’ TPA)

MD NDIA Health Insurances Pvt. Ltd.

18/13, W.E.A. Karol Bagh, New Delhi – 110005.

.…..Opposite Party

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under section 35 of Consumer Protection Act, 2019 (hereinafter referred to as Act) with the allegations that he is covered under medical insurance for the last 23 years. On 13.10.2020, he has consulted Dr. Ripen Gupta, Cardiologist Max Super Specialty Hospital, Saket who recommended coronary angioplasty. He was admitted to hospital where he was operated and coronary stent was inserted. He was discharged on 20.10.2020. A bill of Rs.263515/- was raised by the hospital out of which Rs.159429/- was paid by the OP and balanced of Rs.104086/- was paid by him. He has pursued the claim with OP but without any result. Hence, this complaint.

2. The OP has filed the written statement with the averments that complainant is covered under National mediclaim policy no.360500/50/19/10003926 valid from 31.03.2020-30.03.2021 for a sum insured of Rs.5 lakh and applicable sum Rs.695000/-. The complainant was admitted to hospital with chest pain who was advised to undergocoronaryangioplasty. The complainant has undergocoronaryangioplasty and remained hospitalised from 18.10.2020-20.10.2020 at Max Super Specialty Hospital, Saket. A sum of Rs.159429/- out of Rs.263515/- was approved as balance amount was deducted as per PPN package as complainant was eligible for economy ward.The OP has rightly paid the insurance amount to the complainant as a full and final settlement. The complainant was informed vide letter dated 22.09.2021 abut the closure of his claim. There is no deficiency of service on the part of OP.

3. The complainant has filed the rejoinderwherein he has denied the averments of written statement and reiterated the stand taken in the complaint.

4. The parties were directed to lead the evidence.

5. The complainanthas filed his own evidence and corroborated the version of complaint and placed reliance on the documents i.e. insurance policyEx.CW1/1, prescription slip Ex.CW/2, cashless authorization letter Ex.CW/3, detailed bill of interim supplyEx.CW/4, calculation sheet of claim amount Ex.CW/4, certificate issued by the Doctor Ex.CW/5.

6. The OP has filed the affidavit of Sh.Pratap Singh, in evidence and corroborated the version of written statement.

7. We have heardthe complainant and Ld. Proxy Counsel for the OP and perused the entire material on record.

8. It is clear from the material on record that OP has admitted the issuance of policy no.360500/50/19/10003926 to the complainant. The admission of the complainant at Max Super Specialty Hospital, Saket and subsequent coronary angioplasty are not disputed by OP. The OP has not disputed the total bill of Rs.263515/-. The OP has admitted the payment of Rs.159429/- on the premise that complainant is covered under PPN package and entitled for economy ward.

9. The question is whether OP is justified while rejecting the balance claim of Rs.104086/- raised by the complainant as said amount out of total bill was paid by him and rest was paid by OP.

10. The part claim was passed by the OP by taking the plea that complainant is covered under PPN package and entitled for economy ward.

11. Such term and condition of the insurance policy was not communicated to the complainant at any point of time by the OP so OP cannot rely upon PPN package. Such kind of clause to reduce the claim should be pointedly borough to the notice of insured to make him aware of such clause/package. The support is drawn from FA No.614/2020 titled as Bajaj Allianz Life Insurance Co. Ltd. VsBhartiMahavir Jain decided by Hon’ble National Commission.

12. The reasoning to reduce the insurance claim lodged by the complainant on the basis of PPN package was never brought to notice of the complainant so OP cannot reduce the claim. The reduction of claim on such premise is deficiency in service on the part of OP.

13. In view of our aforesaid discussion, the complaint of the complainant is allowed to the effect that OP shall pay a sum of Rs.1,04,086/- along with an interest @7% from the date of filing the complaint i.e. 18.10.2021 to the complainant till its realization. The complainant is entitled for compensation of Rs.25,000/- for mental harassment and agony and Rs.15,000/- for litigation expenses. The OP is directed to comply with the order within 45 days from the receipt of the order failing which complainant will be entitled for interest @7% p.a. on the amount of mental harassment, agony and litigation charges i.e. from the date of order till its realization.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 11.06.2024.