Haryana

Yamunanagar

CC/264/2012

Parmod Narang S/o Sunder Lal - Complainant(s)

Versus

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

Dalip Kumar

24 Apr 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                         Complaint No… 264  of 2012.

                                                                                         Date of institution: 13.03.2012

                                                                                         Date of decision: 24.04.2017

1. Sh. Parmod Narang aged about 56 years son of Sh. Sunder Lal, R/o # 525-L, Model Town, Yamuna Nagar.
2. Mrs. Renu Narang wife of Sh. Parmod Narang son of Sh. Sunder Lal, R/o # 525-L, Model Town, Yamuna Nagar.
3. Mr. Raman Narang son of Sh. Parmod Narang son of Sh. Sunder Lal, r/o # 525-L, Model Town, Yamuna Nagar.
4. Mr. Vishesh Narang son of Sh. Parmod Narang son of Sh. Sunder Lal, R/o # 525-L, Model Town, Yamuna Nagar.

…Complainants.

 

                                    Versus

1. National Insurance Company Limited having its Regional Office, SCO No. 337-340 Sector-35B, Chandigarh.
2. National Insurance Company Ltd. through its Branch Manager, Near New Fountain Chowk, Yamuna Nagar-135001.     

 

                                                                                                                 …Respondents 

 

BEFORE:       SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

                        SMT. VEENA RANI SHEOKAND, MEMBER.

 

Present:  Sh. Dalip Kumar, Advocate, counsel for complainant.  

                Sh. Parmod Gupta, Advocate, counsel for respondents.       

             

 

ORDER   (ASHOK KUMAR GARG PRESIDENT)

 

1.                        Complainants have filed the present complaint under section 12 of the Consumer Protection Act amended up to date.  

2.                     Brief facts of the present case, as alleged by the complainants, are that  the complainant No.1 purchased being head of the family mediclaim policy bearing cover note No. 140380 on 08.07.2008 valid from 08.07.2009 to 07.07.2010 from the respondents (hereinafter respondents will be referred as OPs Insurance Company) and all the complainants No.2 to 4 also covered under this policy. The mediclaim policy was further renewed/ extended for the period from 08.07.2009 to 07.07.2010 vide cover note No. 148047 dated 08.07.2009 and the same was also extended for the period from 08.07.2010 to 07.07.2011 vide cover note No. G-40-42-420911181378 dated 08.07.2010. Complainant No.1 was covered for Rs. 3,00,000/- whereas complainant No.2 was covered for Rs. 1,50,000/- and complainants No.3 & 4 were covered for Rs. 75,000/- each. The complainant No.4 was suffering from chronic inflammatory granulation tissue and he was admitted in hospital and his registration in the health services was made. In this way he was admitted in Ganga Ram Hospital on 19.06.2011 and discharged on 21.06.2011. Thereafter, through course of his admission in hospital investigations summary of the patent was prepared comprising of four pages. Thereafter, gross discrepancy and microscopic examination was also conducted. In this way, a sum of Rs. 25,000/- was paid on 19.06.2011 in hospital against receipt and thereafter a sum of Rs. 25,000/- were also paid in hospital on 20.06.2011. Thereafter, a sum of Rs. 30,307/- was also paid in hospital vide receipt dated 21.06.2011. In the same manner Rs. 600/-, 460, 565/-, 600/-, 1278/-, 500/- and Rs 1100/-  were paid on 19.06.2011, 15.06.2011, 11.07.2011, 25.06.2011, 01.07.2011 and 11.07.2011 respectively. In this way, the complainant spent a sum of Rs. 85,410/-  whereas the OPs have paid a sum of Rs. 31,638/- to the complainant. The Ops Insurance Company has clearly written that they have got the package with that of medsave healthcare (TPA) Ltd. Chandigarh for setting the payment of medi-claim. This type of settlement is not applicable upon the complainants as the complainants have purchased the medi- claim policy from OP Insurance Company. Such type of agreement has got no validity and is not applicable upon the complainants. The complainant made several requests to make the balance payment but they failed to entertain the claim of the complainant inspite of repeated reminders telephonically as well as in writing. Lastly, prayed for directing the Ops Insurance Company to make the payment of medical claim bills already submitted by the complainant alongwith compensation as well as litigation expenses. Hence, this complaint.

3.                     Upon notice, OPs Insurance Company appeared and filed its written statement by taking some preliminary objections such as complaint is bad for non-joinder and mis joinder of necessary parties. It is clearly mentioned in the policy, given to the insured that all the dealings and claim etc. will be processed by TPA M/s Medsave Health Care, Chandigarh and their telephone number and fax number and e.mail address are also mentioned on the said policy and it was also clearly told to the complainant that the OPs Insurance Company nowhere comes in the picture and all is to be done by TPA but the complainant has not impleaded the TPA in the array of respondents and as such complaint is liable to be dismissed. As per record, maintained by the TPA M/s Medsave Health Care (TPA Ltd.) in ordinary course of their business it was revealed that Ganga Ram Hospital was under Gipsa-PPN rate list and as per discharge summary of patient he had under gone treatment of excision pilonidal sinus with Flap Cover for which as per package rate was Rs. 34,000/- but inadvertently the package settled from the insured and negotiated package rate for this procedure was Rs. 27,000/- and after taking into all the aspects and bills etc. a sum of Rs. 31,638/-       ( Rs. 27,000/- + 4638 for pre and post hospitalization was passed which stands released to the insured vide cheque No. 641088 dated 26.11.2011 and the same has been admitted by the complainants in their complaint. It has been further submitted that a cashless treatment was allowed to the insured vide claim No. 3116018B009C01 Vide File No.20110618B009C3A093 but the cashless was not used by the insured for the reasons best known to them and on merit controverted the plea taken in the complaint and reiterated the stand taken in the preliminary objections and lastly prayed for dismissal of complaint.

4.                     To prove the case, counsel for the complainant tendered into evidence affidavit of complainants as Annexure CW/A and documents such as Photo copy of insurance cover notes as Annexure C-1 to C-3, Photo copy of registration certificate in health services as Annexure C-4, Photo copy of Investigation summary as Annexure C-5, Photo copy of discrepancy and microscopic examination as Annexure C-6, Photo copy of receipt of Rs. 25,000/- as Annexure C-7, Photo copy of receipt of Rs. 25,000/- as Annexure C-8, Photo copy of receipt of Rs. 30307/- as Annexure C-9, Photo copy of receipt of Rs. 600/-, 460/-, 600/-, 1278/-, 500/-, 1100/- as Annexure C-10, C-11, C-12, C-13, C-14 and C-15 respectively, Photo copy of deduction memo dated 12.12.2011 as Annexure C-16, Photo copy of discharge summary as Annexure C-17, Photo copy of claim form as Annexure C-18 and closed the evidence on behalf of complainant.

5.                     On the other hand, counsel for the OPs tendered into evidence affidavit of Sh. Praveen Arora, Administrative Officer, NIC as Annexure RA and documents such as Photo copy of proposed package charges of Sir Ganga Ram Hospital as Annexure R-1 and R-2, Photo copy of letter dated 18.04.2012 for sanctioning of Rs. 31,638/- as Annexure R-3, Photo copy of claim process sheet as Annexure R-4 and closed the evidence on behalf of OPs.   

6.                     We have heard the counsels of both the parties and have gone through the pleadings as well as documents placed on the file carefully and minutely.

7.                     It is not disputed that the complainants took a mediclaim policy from the OPs vide cover note No. G-40-420911181378 dated 08.07.2010 valid from 08.07.2010 to 07.07.2011( Annexure C-3). It is also not disputed that Vishesh Narang son of complainant No.1 was suffering from chronic inflammatory and remained admitted in Sir Ganga Ram Hospital, New Delhi from 19.06.2011 to 21.06.2011 which is evident from investigation summary of Sir Ganga Ram Hospital (Annexure C-5).

8.                     The only version of the OPs Insurance Company is that after going through the claim file by the TPA, it was found that the patient Mr. Vishesh Narang son of the complainant No.1 Parmod Narang had undergone treatment of Excision of Pilonidal Sinus with Flap Cover for which there was a package rate with the Sir Ganga Ram Hospital, New Delhi for Rs. 34000/- but inadvertently the package settled for the insured was Excision of Pilonidal Sinus with Primary Closure for which the package rate was Rs. 27,000/- alongwith this package an amount of Rs. 4638/- was sanctioned for pre or post hospitalization coverage. Meaning thereby that total amount of Rs. 31,668/- ( Rs. 27,000+ 4638/-) has been paid to the complainant, however, the complainant was entitled to get the amount of Rs. 38,638/- ( Rs. 34,000+ 4638/-). Learned counsel for the OPs draw our attention towards the letter dated 18.04.2012 (Annexure R-3 wherein the above noted facts are duly mentioned and argued that the Ops Insurance Company maximum is liable to pay difference amount of Rs. 7000/- as the OPs Insurance Company had already paid Rs. 31,638/-. But this plea of the Ops Insurance Company is not tenable as the OPs Insurance Company has totally failed to place on file any document through which the Ops Insurance Company intimated regarding the package of Rs. 34,000/- or Rs. 27,000/- whatsoever to the complainant at the time of issuance of insurance policy in question. Even, the OPs Insurance Company has also not placed on file any terms and conditions of the insurance policy in question. The package rates may be between the TPA and Hospital concerned but the complainant has no concerned whatsoever with that agreement in the absence of any knowledge or any tripartite agreement.  When the complainant has paid an amount of Rs. 85,410/- on account of ailment in question to Sir Ganga Ram Hospital which is also duly evident from the bills of the hospital placed on file, then how the OPs Insurance Company can be allowed to pay or settle the claim of the complainant according to the package whatsoever. Further, it is not the case of the OPs Insurance Company that expenses incurred by the complainant on the treatment of his son not covered in the Insurance Policy. On the other angle also, if the TPA or OPs Insurance Company have any package with the said hospital then the said insurance company or TPA have right to recover the balance amount i.e. excess amount charged by the hospital from the complainant to recover the same from the hospital but the complainant cannot be allowed to suffer the loss on this account.

9.                     In the circumstances noted above, we are of the considered view that the complainant is entitled to get some relief i.e. entire amount of Rs. 85,410/- as mentioned above. We have perused the insurance cover note valid from 08.07.2010 to 07.07.2011 Annexure C-3 for the relevant period on which the complainant No.4 remained under treatment, as per this cover note there was sum insured of Rs. 75,000/- on account of mediclaim insurance in respect of complainant No.4, so, the complainant cannot claim the amount more than sum insured of Rs. 75,000/-.

10.                   Resultantly, we partly allow the complaint of complainant and direct the OPs Insurance Company to pay the balance amount of Rs. 43,362/- (75,000-31638/-) to the complainant No.4 alongwith interest at the rate of 7% per annum from the date of filing of complaint till its realization. Parties are left to bear their own costs. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court. 24.04.2017.

                                                                                                (ASHOK KUMAR GARG)

                                                                                                PRESIDENT

 

 

 

                                    (VEENA RANI SHEOKAND)          (S.C.SHARMA)

                                     MEMBER                                          MEMBER