Punjab

Fatehgarh Sahib

RBT/CC/254/2018

Vinod Kumar Joshi - Complainant(s)

Versus

National Insurance Co. Ltd - Opp.Party(s)

Harvinder Kumar

16 Dec 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHGARH SAHIB.

                                                                    RBT/CC/254/2018

Complaint No. 254 of 2018

                                                                   Date of Institution:26.02.2018

                                                                   Date of Decision: 16.12.2021

          Vinod Kumar Joshi S/o Sh. G.L. Joshi, Ho No.1363, Sector 40, Chandigarh.     

                                                                                   …………....Complainant(s)

                                                Versus

1. National Insurance Co. Ltd. , SCO No.40-41, Phase-5 Mohali
2. Safeway TPA Services Pvt. Ltd., 815,Vishwasadan, District Centre, Janakpuri, New Delhi-110058.
3. ACE Heart and Vascular Institute, Shivalik Hospital Premises, Sector 69, Mohali.

 

  ……….........Opposite Party(s)

Complaint under Section 12/14 of Consumer Protection Act 1986

Quorum

Sh. Pushvinder Singh, President

Sh. Manjit Singh Bhinder, Member

 

Present: Sh.Harwinder Singh, counsel for the Complainant.

    Sh.S.K. Arora, counsel for OP No.1  

    OP No.2 ex parte

               Sh.Subhash Chand, counsel for OP No.3

Order By

Pushvinder Singh, President

 

1.                 The complainant filed this complaint with the request to direct the OPs to pay a sum of Rs.66,933/- to the claim which she had to pay out of his pocket to get discharged from OP No.3. The complainant has also claimed compensation and the costs.
2.                  It is an admitted fact that complainant took a mediclaim policy from OP No.1 which was valid from 26.03.2017 to 25.03.2018 in the name of complainant and his wife. During the said period complainant underwent hospitalization from 22.05.2017 to 24.05.2017 in the hospital i.e. OP No.3 and a bill of Rs.2,10,298/- was raised by OP No.3 but the OP No.2 has passed the claim for only Rs.1,43,365/- and the balance claim of Rs.66,933/- was disallowed. The complainant has alleged that he is entitled for a mediclaim for the entire amount of Rs.2,10,298/-. The order was passed by OP No.2 for disallowing the claim of Rs.66,933/-.
3.                   In the present complaint OP No.2 has not come forward to contest the compliant and was proceeded against ex parte. The OP No.3 is hospital where the complainant was admitted and took the treatment when the OP Nos.1 and 2 disallowed the claim of Rs.66,933/- then the complainant paid the said amount to OP No.3 from his own pocket. The complainant has produced insurance policy as Ex.C-1 which clearly shows that the complainant was insured for a sum of Rs.3,50,000/- and the authorization letter issued by OP No.2 is Ex.C-2 on the file vide which the amount of Rs.66,933/- was disallowed. But we find that the OP No.1 and 2 have failed to prove any valid ground to disallow the amount of Rs.66,933/- when the complainant was insured with OP No.1 for the mediclaim up to Rs.3,50,000/- then the OP No.1 should have paid the entire amount of Rs.2,10,298/- to the complainant. No claim has been raised against OP No.3 as the OP No.3 provided medical treatment and received the bill amount. The bill amount was to be paid by OP No.1 and 2 but without any valid and reasonable ground they disallowed the amount of Rs.66,933/- for which the complainant is entitled to recovery from OP No.1 and 2.
4.                   In view of the our above-mentioned discussion the complaint is allowed to the extent that OP No.1 and 2 are directed to pay a sum of Rs.66,933/- to the complainant as the remaining bill amount and the complainant is also entitled to the compensation for physical and mental harassment to the tune of Rs.10,000/- and the complainant is also entitled to recover the amount of Rs.10,000/- as the cost of litigation. The OP No.1 and 2 are directed to pay the same to the complainant within a period of 60 days jointly and severally, on receipt of certified copy of this order. The copy of this order be provided to the complainant and OPs free of cost. The file be return back to the District Consumer Commission, Mohali for consignment.
5.  
6.  

 

                                                                              (Pushvinder Singh)

                                                                              President

 

 

(Manjit Singh Bhinder)

                                                                             Member