Punjab

Ludhiana

CC/19/435

Mintoo Verma - Complainant(s)

Versus

New India Assurance Co. - Opp.Party(s)

Suresh Kumar Adv.

14 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 435 dated 11.09.2019.                                                        Date of decision: 14.11.2022.

 

Mintoo Verma son of Shri Amarnath Verma, C/o. M/s. Verma Tractors, Amloh Road, Khanna, District Ludhiana.                                                                                                                                                            ..…Complainant

                                                Versus

1. New India Assurance Co. Ltd., G.T. Road, Khanna, District Ludhiana through its Branch Manager.
2. M/s. Raksha Health Insurance TPA Pvt. Ltd., Regional Office: SCO 39, Ist Floor, Madhya Marg Sector 26, Chandigarh-160019 through its Manager.                                                                                                                                                                         …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Suresh Kumar Deora, Advocate.

For OP1                         :         Sh. G.S. Kalyan, Advocate.

For OP2                         :         Complaint against OP2 not admitted vide order                                           dated 18.10.2019.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that the complainant has been availing Medi-claim policies from opposite party No.1 for the last 10 years. The last policy so availed was for the period from 11.09.2018 till 10.09.2019 for a sum insured of Rs.1,00,000/-,  which was enhanced to the tune of Rs.2,00,000/-. Apart from that, the wife of the complainant was also covered under this policy.

2.                As per the complaint, on 22.04.2018, the complainant suffered from chest pain and vertigo and was suddenly got admitted in emergency ward of Hero Heart DMC Institute, Ludhiana and in the evening, he was shifted to general ward. The total hospitalization of the complainant remained from 22.04.2019 to 24.04.2019, the day on which he was discharged from the hospital. The complainant further stated that although the policy was cashless but the benefit of the same was not extended to the complainant due to non-approval by opposite party No.1 and the complainant had to deposit an amount of Rs.25,997/- despite intimation regarding hospitalization to the office of opposite party No.1. The complainant lodged a claim with opposite party No.1 trough opposite party No.2 vide claim No.9051920111210. However, the claim to the tune of Rs.11,101/- was settled vide claim settlement voucher dated 24.05.2019. It is further alleged that the deductions made by the opposite parties with regard to room rent, medicines and admission charges are wrong and illegal since the complainant did not avail the private room and the medicine so prescribed were consumed. The complainant has further stated that he has also moved  representation dated 29.07.2019 to opposite party No.1 and also sent a copy thereof to the Grievance Cell of opposite party No.1 personally as well as through email but no action was taken. The complainant by invoking jurisdiction of this Commission has claimed disbursement of the unpaid amount to the tune of Rs.14,896/- along with interest, litigation cost to the tune of Rs.20,000/- and compensation of Rs.2,00,000/- on account of mental agony, physical harassment caused to complainant on account of deficiency of service on the part of opposite parties. Hence the complaint.

3.                The complaint as against opposite party No.2 was not admitted vide order dated 18.10.2019.

4.                Notice of the complainant was issued to opposite party No.1 who put in appearance and filed written statement claiming that the complainant did not disclose the medical history at the time of subscribing to the health policy. However, it was submitted that opposite party No.1 in respect of the claim intimation duly entertained, registered and referred to opposite party No.2, its service provider. The same was processed in view of the terms and conditions of the policy and the claim of amount of Rs.11,101/- was duly approved and the payment of the said amount has been made by opposite party No.1 to the complainant. However, the following items were deducted from the claim:-

          a. Rs.4900/- deducted as per room rent capping,

          b. Rs.1620/- deducted in consultation charges as per room rent          entitlement,

          c. Rs.7042/- deducted as per room rent entitlement

          d. Rs.426/- deducted non medical consumables non payable

          e. Rs.308/- deducted in admission charges non payable

f. Rs.1200/- deducted in RMO/Nursing charges deducted as per room rent capping.

Further opposite party No.1 has mentioned that in respect of representation through email, opposite party has reviewed the claim and sent reply on 31.07.2019 whereby it was reasserted that the deductions were rightly made and all the deductions are room rent linked as the insured has opted for room rent higher than entitlement. So the deductions (medicine, nursing and consultation charges) were to be paid as per room rent entitlement only. It was further alleged that the complainant is guilty of mis-representation and distorting the facts and as such, his claim being devoid of merits is liable to be dismissed.

5.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 to Ex. C18 and closed the evidence.

6.                On the other hand, counsel for opposite party No.1 tendered affidavit Ex. RA of S. J.S. Dhaap, Authorized signatory of opposite party No.1 along with documents Ex. R1 to Ex. R7 and closed the evidence.

 

  

7.                We have heard the arguments of the counsel for the parties and gone through written arguments submitted by opposite party No.1. We have also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.       

8.                The factum of admission of the complainant in Hero Heart DMC Institute, Ludhiana on 22.04.2019 with the chest pain and vertigo and subsequent discharge on 24.04.2019 is admitted. It has also not been denied that an amount of Rs.25,997/-  was spent on treatment during the hospitalization of the complainant. It also emerges from the record that on 23.05.2019, an amount of Rs.11,101/- was settled out of the total amount of Rs.25,997/- and deductions to the effect of Rs.14,896/- were made under various heads by opposite party No.1.The representation to review the order of deduction was also declined vide letter Ex. C18. Perusal of written version shows that although opposite party No.1 has tried to justify the deduction by contending that the same were rightly made and it was made in accordance with the terms and conditions of the policy. The written statement as well as affidavit is silent about the particular terms and conditions of the policy which were invoked to effect the deduction in the claim of the complainant. Even the letter Ex. C18 vide which the review was refused is also silent about the terms and conditions which was invoked. The written arguments submitted on behalf of opposite party No.1 appears to be a verbatim reproduction of  written statement, vital aspect regarding the terms and conditions of the policy is also missing.

9.                Faced with this situation, during the course of arguments, a feeble attempt was made by the counsel for opposite party No.1 to draw the attention of the Commission towards the clause 3 and clause 4 of the conditions of the policy. Clause 3 stipulates how much is to reimbursed and clause 4 provides that what was to be excluded under this policy. We have also examined these clauses. We are afraid that these clauses are general in nature and cannot be invoked unless it is proved or it is brought on the record that there was informed consent of the complainant at the time of commencement of the policy. So in these circumstances, it cannot be said that the deductions made in the claim of the complainant were fully justified.

10.              As a result of above discussion, the complaint is allowed with an order that opposite party No.1 shall pay remaining claim of Rs.14,896/- to the complainant along with interest @8% per annum from 24.05.2019 i.e. the date of partial settlement of the claim. Opposite party No.1 shall further pay a composite cost of Rs.5,000/- (Rupees Five Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (Sanjeev Batra)

                    Member                                           President

 

Announced in Open Commission.

Dated:14.11.2022.

Gobind Ram.

 

 

Mintoo Verma Vs New India Assurance Co.                  CC/19/435

Present:       Sh. Suresh Kumar Deora, Advocate for complainant.

                   Sh. G.S. Kalyan, Advocate for OP1.

                   Complaint against OP2 not admitted vide order dated 18.10.2019.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with an order that opposite party No.1 shall pay remaining claim of Rs.14,896/- to the complainant along with interest @8% per annum from 24.05.2019 i.e. the date of partial settlement of the claim. Opposite party No.1 shall further pay a composite cost of Rs.5,000/- (Rupees Five Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (Sanjeev Batra)

                    Member                                           President

 

Announced in Open Commission.

Dated:14.11.2022.

Gobind Ram.