Haryana

Ambala

CC/83/2019

Sh Ashish Narang - Complainant(s)

Versus

New India Insurance Co Ltd - Opp.Party(s)

Manu Rastogi

29 Nov 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                          Complaint case No.: 83 of 2019.

                                                          Date of Institution  :  19.03.2019.

                                                          Date of decision    :  29.11.2019.

 

Sh. Ashish Narang son of late Sh. Jagdish Chander Narang, aged about 48 years, c/o Narang Medical Hall, Nicholson Road, Ambala Cantt.

          ……. Complainant.

                                                Versus

 

1. New India Assurance Co. Ltd. Ambala Cantt. Divisional office at 172 S.B. Road, Ambala Cantt. Through its Divisional Manager.
2. Raksha TPA Pvt. Ltd. SCO No.359-360, Ist Floor, Sector 44/D, Chandigarh-160047.

 

               ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.         

                            

Present:       Shri Manu Rastogi, Advocate, counsel for complainant.

Shri Shubham Aggarwal, Advocate, counsel for the OPs No.1.

OPs No.2 ex parte vide order dated 18.06.2019.           

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the claim amount of Rs.70,380/- along with interest @ 18% p.a. from 10.12.2017 till the date of payment to the complainant .
2. To pay Rs.50,000/- as compensation for the mental agony and physical harassment suffered by the him.
3. To pay Rs.22,000/- as litigation charges.

 

Brief facts of the case are that the complainant took a medi-claim policy under Customer ID 2H3491379 from the OP No.1 about 7-8 years back and got it renewed upto 05.05.2019, vide policy No.35350134182800000046. All the family members of the complainant were covered under this policy. In the month of December, 2017, wife of the complainant Mrs. Palka Narang had undergone surgery at Dogra Nursing Home and Endoscopy Centre Sector 19/A, Chandigarh. On 07.12.2017, wife of the complainant got admitted in the hospital and discharged on 10.12.2017. An amount of Rs.1,05,680/- was spent on the treatment of the his wife. For reimbursement of the expenses incurred by the complainant on the treatment of his wife, lodged a claim with OP No.2. He submitted all the relevant documents with the OP No.2 under claim No.9051718439289. On 26.03.2018, complainant received a letter from OP No.2 to submit all the original documents within 15 days to enable to process the claim. The Ops reduced the claim amount from Rs.1,05,680/- to Rs.83,280/-, without assigning any reason. Complainant without any delay on 09.03.2018, posted the original discharge summary of Mrs. Palka Narang as required by OP No.2. Vide claim settlement voucher dated 03.05.2018, OP No.2 only passed a meagre amount of Rs.35,300/- out of the claim amount of Rs.1,05,680/-. Complainant was paying the premium regularly from the last 7-8 years. Complainant served a legal notice dated 26.11.2018, upon the OPs, but of no avail. By not paying the medical expenses of Rs.1,05,680/- spent by the complainant on the treatment of his wife, the OPs have committed deficiency in service. Hence, the present complaint.

2.                 Upon notice, OP No.1 appeared through counsel and filed written version raising preliminary objections regarding no cause of action; jurisdiction etc. On merits, it is admitted that complainant took a New India Floater Medi-claim policy in question for himself, his wife and his children, having validity upto 05.05.2018. It is stated that as per the discharge summary, the date of discharge of wife of the complainant is 09.12.2017 and not 10.12.2017. As per claim Form submitted by the claimant/complainant, an amount of Rs.83,280/- was spent by the complainant for the surgery of the Uterus of his wife at Dogra Nursing Home and Endoscopy Centre, Sector 19-A, Chandigarh, which includes the tests expenses/Diagnostics of Rs.17,780/- and Rs.65,000/- being total hospital bill. After lodging of the claim by the complainant, an investigation was got conducted and the hospital gave summary of bills of Rs.83,280/-. Subsequently, the complainant was asked to submit the original documents for processing his case. Thereafter, without any delay, after making deductions as per Clause 3, 4, 5 and Annexure-1 of the terms and conditions of New India Floater Mediclaim Policy, the claim of the complainant was settled vide claim settlement voucher dated 03.05.2018 and on 27.04.2018, an amount of Rs.35,300/- was disbursed to the complainant through NEFT. The OP No.1 has disbursed the amount of claim for which the insured was entitled without any delay in a just and fair manner. The OP No.1 has passed the claim as per rules and instruction and the terms of the policy and MOU. As such the OP No.1 cannot be said to be deficient in providing services and the present complaint filed against it be dismissed.  

                   Upon notice OP No.2, failed to appear and was proceeded against ex-parte vide order dated 18.06.2019.

3.                The complainant tendered his affidavit as Annexure CW1/A along with documents as Annexure C-1 to C-28 and closed his evidence. On the other hand, learned counsel for OP No.1 tendered affidavit of Shri Kamal Kishore Sachdeva, Senior Divisional Manager, New India Assurance Co. Ltd. as Annexure OP1/A alongwith document Annexure OP1 to OP4 and closed the evidence on behalf of OP No.1.

4.                We have heard the learned counsel of the parties and carefully gone through the case file and also the written arguments filed by the learned counsel for the parties. 

5.                The Learned counsel for the complainant argued that he took a medi-claim policy from the OP No.1 about 7-8 years back and got it renewed from time to time, upto 05.05.2019. All the family members of the complainant were covered under the said policy. In the month of December, 2017 wife of the complainant undergone surgery at Dogra Nursing Home and Endoscopy Centre. Complainant spent Rs.1,56,080/- on her treatment. For reimbursement of the said amount, he lodged the claim with the OPs, however they instead of paying medical claim of Rs.1,56,080/- had paid a meagre amount of Rs.35,300/-.

                   The Ld. counsel for the OP No.1 admitted the factum of taking of the policy by the complainant and renewal thereof upto 05.05.2019. He argued that from the policy schedule, for the period from 06.05.2015 to 05.05.2016, it is evident that the complainant was insured for Rs.3,00,000/-, his wife for Rs.2,00,000/-, and his two children for Rs.1,00,000/- each. The complainant got the said policy renewed for the period from 06.05.2017 to 05.05.2018, by increasing the sum insured to Rs.5,00,000/- as is evident from the Annexure OP-4. Since, the wife of the complainant had taken the treatment before the expiry of the 24 months from the date of enhancement of the sum insured, therefore he is not entitled to get the claim amount for the sum insured of Rs.5,00,000/-. But he is entitled to get medical expenses as per terms No.3 to 5 mentioned in the terms and conditions of the policy and the said amount has already been paid to the complainant.

6.                From the perusal of the terms and conditions of the policy Annexure OP-1, it is revealed that in the term No.5.11 ‘Enhancement of the Sum Insured’ of the terms and conditions of the policy (Annexure OP-1), it is categorically mentioned that in respect of any increase in sum insured, exclusion 4.1, 4.2, 4.3.1 and 4.3.2 would apply to the additional sum insured from the date of such increase.  In term No.4.3.1., it is mentioned that unless the insured person has continuous coverage in excess of twenty four months, expenses on the following treatment are not payable:

4.3.1 Unless the Insured person has Continuous Coverage in excess of twenty four months, expenses on treatment of the following illnesses are not payable:

1.       All internal and external benign tumours, cysts, polyps of any kind, including benign breast lumps.

2.       Benign ear, nose, throat disorders

3.       Benign prostate hypertrophy

4.       Cataract and age related eye ailments

5.       Diabetes Mellitus

6.       Gastric/Duodenal Ulcer

7.       Gout and Rheumatism

8.       Hernia of all types

9.       Hydrocele

10.     Hypertension

11.     Non Infective Arthritis

12.     Piles, Fissures and Fistula in anus

13.     Pilonidal sinus, Sinusitis and related disorders

14.     Prolapse inter Vertebral disc and Spinal Diseases unless arising from accident

15.     Skin Disorders

16.     Stone in Gall Bladder and Bile duct, excluding malignancy

17.     Stones in Urinary system

18.     Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed Uterus

19.     Varicose Veins and Varicose Ulcers

          Since, the wife of the complainant had undergone surgery in the same year, the complainant got renewed the policy in question with enhanced sum insured. Therefore, as per term No.4.3.1, complainant is not entitled to get the claim amount for the sum insured of Rs.5,00,000/-. Undisputedly, the complainant got renewed the policy in question continuously, thus his case falls under the term No.2.7 ‘Continuous coverage’, which reads as under:-

“CONTNUOUS COVERAGE means uninterrupted coverage with us till the date of commencement of Period of Insurance of the Insured Person under Family floater Mediclaim Policy (2007) or under Family Mediclaim 2012 Policy or NEW INDIA FLOATER MEDICALIM Policy from the time the coverage incepted under any of these Policies. A break in insurance for a period not

exceeding thirty days shall not be reckoned as an interruption in coverage for the purposes of this Clause. In case of change in Sum Insured during such uninterrupted coverage, the lowest Sum Insured would be reckoned for determining Continuous Coverage.”

                   Undisputedly, the coverage in the previous policy was of Rs.2,00,000/-, as such complainant is entitled to get the reimbursement of medical expenses incurred by him, in the same proportion as mentioned in the term No.3 ‘How much we will reimburse’of the terms and conditions of the policy which reads as under:-

 

3.1(a)	Room Rent, including but not limited to boarding and nursing expenses, actually incurred or 1% of the Sum Insured per day, whichever is less.
3.1(b)	Intensive Care Unit (ICU)/Intensive Cardiac Care unit (ICCU) expense, actually incurred or 2% of Sum Insured per day, whichever is less.
3.1(c)	Surgeon, Anestheist, Medical Practitioner, Consultants’ Specialist fees.
3.1(d)	Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant Laboratory/Diagnostic test, X-Ray and other medical expenses related to the treatment.
Reimbursement/payment of Room Rent, including but not limited to boarding   and nursing expenses, incurred at the Hospital shall not exceed 1% of the Sum Insured per day. In case of admission to Intensive Care Unit or Intensive Cardiac Care unit, reimbursement or payment of such expenses shall not exceed 2% of the Sum Insured per day. In case of admission to a Room Rent/ICU/ICCU at rates exceeding the aforesaid limits, the reimbursement/payment of all other expenses incurred at the Hospital, with the exception of cost of medicines and implants, shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day for Room Rent (including but not limited to boarding and nursing expenses)/ICU/ICCU charges.
3.1(e)	Pre-Hospitalization Medical Expenses, not exceeding thirty days.
3.1(f)	Post-Hospitalization Medical Expenes, not exceeding sixty days.

 

                   In the said term it is clearly mentioned that in case of admission to a room rent/ICU/ICCU at rates exceeding the aforesaid limits, the reimbursement/payment of all other expenses incurred at the hospital, with the exception of cost of medicines and implants, shall be effected in the same proportion as the admissible rate per day beers to the actual rate per day for room rent (Including but not limited to boarding and nursing expenses)/ICU/ICCU charges.

                   From the claim settlement voucher (Annexure C-7), it is evident that OPs paid Rs.35,300/- to the complainant in lieu of medical claim after making following deductions:-

Details of Deduction
Expense Name	Billed Amt (Rs.)	Deduction Amt (Rs.)	Approved Amt (Rs.)	Reason of Deduction (If any)
Single Room	3000	1000	2000	Rs. 2000 Deducted as per room rent capping
Single Room	3000	1000	2000	Rs. 11750 deducted as per room rent entitlement
Surgeon Fees	23500	11750	11750	Rs. 1100 deducted 16.09.2017 no prescription
Consultant Charges	1100	1100	0	Rs.2750 deducted as per room rent entitlement
Consultant Charges	5500	2750	2750	Rs.4280 deducted for no reports 07.12.2017, 11.12.2017 and 15.11.2017
Investigation Charges	12180	4280	7900	Rs.400 deducted as per room rent entitlement
Investigation Charges	800	400	400	Rs.17000 deducted equipment charges non payable
Hospital Services	17000	17000	0	Rs.200 registration charges non payable
Admission Charges	200	200	0	Rs.7500 deducted as per room rent entitlement
Operation theatre Charges	15000	7500	7500	Rs.2000 deducted as per room rent capping
RMO/Nursing	2000	2000	0
Hospital Cash	1000	0	1000

 

                   It may be stated here that the deductions made by the OPs are not in proportion as per term No.3. As per the said term, the complainant is entitled to get Rs.15,667/- as Surgeon fee,  Rs.3667/- as consultant charges, Rs.533/- as Investigation Charges, Rs.11,333/- as hospital services, Rs.10,000/- as operation theatre charges. Complainant is also entitled to get Consultant Charges of Rs.733/- and Rs.8120/- as investigation charges as mentioned at Sr. No.4 and Sr. No.6 respectively in the Claim Settlement Voucher, because he had produced the bills in this regard and as per terms and conditions of the policy it is not mandatory to produce the prescriptions or report. The complainant is thus entitled to get the medical claim of Rs.55,053/-, as such he is entitled to get Rs.19,753/- more (Rs.55053-Rs.35,300/-). Admittedly, the complainant is duly insured with the OP No.1, therefore it being the insurer is liable to pay Rs.19,753/- to the complainant alongwith interest. OP No.1 is also liable to compensate the complainant for the mental agony and physical harassment caused to him alongwith litigation expenses. Since, the OP No.2 is working for and on behalf of OP No.1and the claim amount has to be paid by the insurer, therefore, no liability can be fastened against the OP No.2 and the complaint filed against OP No.2 is liable to be dismissed

7.                In view of the aforesaid discussion, we hereby dismiss the present complaint against OP No.2 and partly allow the same against OP No.1 directing it in the following manner:-

1. To pay Rs.19,753/- alongwith interest @7% per annum w.e.f. 03.05.2018 i.e., claim settlement voucher date till its realization.
2. To pay Rs.5,000/- as compensation for mental agony and physical     harassment suffered by the complainant.
3. To pay Rs.3,000/- as litigation expenses.

 

                   The OP No.1 is further directed that the awarded amount be paid within 30 days from the date of receipt of the certified copy of this order, failing which the amount mentioned at serial No.(i) shall carry penal interest @ 9% per annum instead of @ 7% per annum and the amount mentioned at serial no.(ii) & (iii) shall carry interest @ 9%  from the date of filing of the complaint i.e. 19.03.2019, till its realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :29.11.2019.

                   (Vinod Kumar Sharma)  (Ruby Sharma)               (Neena Sandhu)

                        Member                         Member                       President