THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 674 of 2014
Date of Institution : 24.12.2014
Date of Decision : 09.10.2015
Balbir Singh S/o S. Teja Singh resident of village Nag Khurd, Post Office Nag Kalan District Amritsar
...Complainant
Vs.
National Insurance Company Ltd., Divisional Office, 26-D, Court Road, Amritsar through its Divisional Manager, Amritsar
....Opp.party
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh. Sanjeev Prasher , Advocate
For the opposite party : Sh. P.K. Mody,Advocate
Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member
Order dictated by :-
Bhupinder Singh, President
1 Present complaint has been filed by Balbir Singh under the provisions of the Consumer Protection Act alleging therein that he got Insurance policy for himself and his wife Harvinder Kaur i.e. policy bearing No. 401900/48/13/8500001643 for the period from 21.9.2013 to 20.9.2014. According to the complainant his wife Smt.Harvinder Kaur insured, was admitted in BBC Heart Hospital, Jalandhar on 16.6.2014 and was discharged on 23.6.2014 . The complainant paid the full amount Rs. 2,00,000/- to the hospital authorities and submitted claim with the opposite party. But the opposite party wrongly deducted Rs. 75,300/- and paid Rs. 1,24,700/- only to the complainant. Complainant has alleged that he is entitled to the entire amount of Rs. 2,00,000/- instead of Rs. 1,24,700/-. Complainant requested the opposite party to pay the remaining amount Rs. 75,300/-, but opposite party did not pay any heed to the request of the complainant. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to pay the amount of Rs. 75300/- alongwith interest. Compensation of Rs. 20,000/- alongwith litigation expenses were also demanded.
2. On notice opposite party appeared and filed written version in which it was submitted that complainant and his wife got insured initially under policy effective from 20.9.2007 to 19.9.2008 vide policy No. 401200/48/07/8500000816 with sum assured Rs 1,50,000/- .Thereafter they got the policy renewed for the period from 20.9.2008 to 19.9.2009 vide policy No. 401200/48/08/8500000876 with sum assured Rs. 1,50,000/- , then renewed further for the period from 20.9.2009 to 19.9.2010 and from 20.9.2010 to 19.9.2011 and then from 20.9.2011 to 19.9.2012 and then from 00 hours 21.9.2012 to 20.9.2013 all with sum assured Rs. 1,50,000/-. Thereafter the policy was renewed from 00 hours 21.9.2013 to 20.9.2014 with subsequent proposal dated 9.9.2013. It was denied that wife of the complainant Smt. Harvinder Kaur was admitted in BBC Heart Hospital on 16.6.2014 and was discharged on 23.6.2014. It was submitted that complainant submitted his claim for reimbursement with TPA M/s. DHS Pvt.Ltd and the same was duly processed and dealt with by the said TPA as per terms and conditions of the policy and entitlements under different heads and passed the claim for payments of five items under different heads as per reimbursement orders . The claim for OT charges dealt a Sr.No.1 of Rs. 6000/- was paid in full without any deductions, the claim for room rent charges and nursing charges dealt at Sr.No.2 of Rs. 11,200/- was paid in full without any deductions, claim for OT charges under sub head of implants was dealt at Sr.No. 3 of Rs. 1,52,000/- was paid as per entitlements in terms of policy conditions as applicable after deductions of Rs. 54500/- by allowing payments of Rs. 97500/- against the policy risk coverage of Rs. 1,50,000/- as per the entitlements + Rs. 45000/- as Cumulative Bonus with reference to clause 1 ( C) and 1 (B) of the terms and conditions of the policy . The claim for medicines and consumable under sub head of ward and medicines charges dealt at Sr.No. 4 of Rs. 20,800/- was not payable as per entitlements in terms of policy conditions and claim for OT charges dealt at Sr.No. 5 of Rs. 10000/- was paid in full without any deductions, as such the entitlements as admissible of Rs. 1,24,700/- against the claim amount of Rs. 2,00,000/- after permissible deductions of Rs. 75300/-, were passed for payment as per terms and conditions of the policy. While submitting that the claim of the complainant has rightly been paid to the extent of Rs. 1,24,700/- and there is no deficiency of service on the part of the opposite party qua the complainant.
3. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documens Ex. C-2 to Ex.C-4.
4. Opposite party tendered into evidence affidavit of Sh. R.L.Mehta,Divisional Manager Ex.OP1 alongwith documents Ex.OP2 to Ex.OP15.
5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e.pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant got Insurance policy for himself and his wife Harvinder Kaur i.e. policy bearing No. 401900/48/13/8500001643 for the period from 21.9.2013 to 20.9.2014. Wife of the complainant Smt.Harvinder Kaur insured, was admitted in BBC Heart Hospital, Jalandhar on 16.6.2014 and was discharged on 23.6.2014 as per discharge summary Ex.OP4 where she had undergone knee surgery for total knee replacement (bilateral) on 17.6.2014 and she paid a sum of Rs. 2 lacs to the said hospital as per bill Ex. OP5. Claim was lodged with the opposite party but the opposite party paid a sum of Rs. 1,24,700/- only and deducted Rs. 75300/- without any rhyme or reasons. The complainant requested the opposite party to pay the balance amount of Rs. 75,300/- but the opposite party refused to pay the same. Ld.counsel for the complainant submittd that complainant and his wife have been obtaining insurance policy from the opposite party for the last so many years i.e. since 20.9.2007 continuously as per policy Ex.OP10 for the year 2007- 08, Ex.OP9 for the year 2009-10, Ex.OP11 for the year 2010-2011, Ex.OP12 for the year 2011-12,Ex.OP13 for the year 2012-13,Ex.OP15 for the year 2013-14, but the opposite party has deducted this amount of Rs. 75300/- from the claim of the complainant arbitrarily. All this amounts o deficiency of service on the part of the opposite party qua the complainant.
7. Whereas the case of the opposite party is that the complainant and his wife got insured initially under policy effective from 20.9.2007 to 19.9.2008 wih sum assured Rs 1,50,000/- vide policy Ex.OP10. Thereafter they got the policy renewed for the period from 20.9.2008 to 19.9.2009 with sum assured Rs. 1,50,000/- , then renewed further for the period from 20.9.2009 to 19.9.2010 Ex.OP9 and from 20.9.2010 to 19.9.2011 Ex.OP11 and then from 20.9.2011 to 19.9.2012 Ex.OP12 and then from 00 hours 21.9.2012 to 20.9.2013 Ex.OP13 all with sum assured Rs. 1,50,000/-. thereafter the policy was renewed from 00 hours from 21.9.2013 to 20.9.2014 Ex.OP15 as subsequent proposal datd 9.9.2013 and they enhanced sum assured from Rs. 1,50,000/- to Rs. 2,00,000/-. Insured Harvinder Kaur has taken her treatment for knee surgery at BBC Heart Hospital, Jalandhar where she was admitted on 16.2014 and was discharged on 23.6.2014 as per discharge summary Ex.OP4 and she got total knee replacement (bilateral) done on 17.6.2014 and paid amount of Rs. 2,00,000/- to the hospital authorities as per bill Ex.OP5. On receipt of the claim for reimbursemen from the complainant, TPA M/s. DHS Pvt.Ltd processed/dealt with the said claim as per terms and conditions of the policy and passed the claim for payment of five items under different heads as detailed in Ex.OP7. Ld.counsel for the opposite party submitted that sum enhanced Rs. 50,000/- . As per policy documents Ex.OP9 waiting period is 4 years. Claim of knee replacement is covered after four years of policy as per clause 4.3 of the policy. So the enhanced sum of Rs. 50000/- shall applicable to the complainant after four years i.e. for the policy period 2017-18 . As per clause 1 ( C ) of the terms and conditions of the policy Ex.OP3, complainant is entitled to maximum limit per illness 50% of sum assured in case of implant i.e. knee transplantation in the present case. So the opposite party has paid Rs. 1,24,700/- to the complainant as per terms and conditions of the policy vide letter Ex.OP7. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party qua the complainant.
8. From the entire above discussion, we have come to the conclusion that complainant has been continously taking mediclaim insurance policies from the opposite party since 20.9.2007 onwards and lastly from 00.00 hours 21.9.2013 to 20.9.2014 Ex.OP15. It is the admitted case of the parties that sum assured was Rs. 1,50,000/- each for the complainant and his wife. However, they got enhanced the sum assured to Rs. 2,00,000/- in the policy for the period from 21.9.2013 to 20.9.2014 Ex.OP15. As per clause 4.3 of terms and conditions of the policy Ex.OP3 the treatment of joint replacement due to degenerative conditions, are not payable for first four years of operation of the policy and as per policy itself the enhancement amount shall be treated as a new policy so far as enhanced amount of sum assured is concerned. Therefore , for knee replacement the sum assured in the policy is to be treated as Rs. 1,50,000/-. However, complainant and his wife were entitled to Rs. 45000/- each as CB (Cumulative Bonus). So the complainant was entitled to sum assured Rs. 1,95,000/- during this policy period from 21.9.2013 to 20.9.2014 Ex.OP15. Wife of the complainant Harvinder Kaur insured underwent total knee replacement (Bilateral) at BBC Heart Care Hospital, Jalandhar on 17.6.2014 where she remained admitted from 16.6.2014 to 23.6.2014 and paid Rs. 2,00,000/- to the said hospital as per bill Ex.OP5. On receipt of the claim from the complainant, TPA M/s. DHS Pvt.Ltd processed and dealt with the claim of the complainant and passed the reimbursement order dated 13.8.2014 Ex.OP 7 &. Claim for OT charges dealt with at Sr.No. 1 of Rs. 6000/- was paid in full without any deduction, claim for room rent and nursing charges dealt at Sr.No.2 of Rs. 11,200/- was paid in full without any deduction, claim for OT charges under sub head of “implant” was dealt at Sr.No. 3 of Rs. 1,52,000/- was paid as per entitlements in terms of policy conditions as applicable after deductions of Rs. 54500/- by allowing payments of Rs. 97500/- against the policy risk coverage of Rs. 1,50,000/- as per the entitlements + Rs. 45000/- as Cumulative Bonus with reference to clause 1 ( C) and 1 (B) of the terms and conditions of the policy Ex.OP3. The claim for medicines and consumable under sub head of ward and medicines charges dealt at Sr.No. 4 of Rs. 20,800/- was not payable as per entitlements in terms of policy conditions and claim for OT charges dealt at Sr.No. 5 of Rs. 10000/- was paid in full without any deductions, as such the entitlements as admissible of Rs. 1,24,700/- against the claim amount of Rs. 2,00,000/- after permissible deductions of Rs. 75300/-, were passed for payment by TPA as per letter dated 13.8.2014 Ex.OP7 and this amount was paid to the complainant. All this fully proves that the opposite party has deducted the amount of Rs. 75300/- from the claim amount of Rs. 2,00,000/- as per terms and conditions of the policy as fully detailed in letter dated 13.8.2014 Ex.OP7 which was sent to the complainant and this amount of Rs. 1,24,700/- was paid to the complainant as per terms and conditions of the policy Ex.OP3. As such there is no deficiency of service on the part of the opposite party qua the complainant.
9. Resultantly we hold that complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
9.10.2015 ( Bhupinder Singh )
President
/R/ ( Kulwant Kaur Bajwa) Member
