DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 414 of 29.9.2016

                                      Decided on: 22.1.2021

Asha Sharma w/o Sh.Vishnu Sharma aged about 58 years resident of 2243 Latoorpura, near Victoria School, Patiala now r/o Shanti Jeevan Marg, Ranbir Marg,Patiala.

                                                                   …………...Complainant

                                      Versus

National Insurance Co. Ltd., through its Manager 26,Factory Area, Main Road, Patiala.

                                                                   …………Opposite Party.

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Sh. Jasjit Singh Bhinder, President

                                      Sh.Vinod Kumar Gulati, Member    

ARGUED BY

                                      Sh.Dinesh Sharma, counsel for complainant.

                                      Sh.B.L.Bhardwaj, counsel for OP.                      

 ORDER

                                      JASJIT SINGH BHINDER, PRESIDENT

1. This is the complaint filed by Asha Sharma  (hereinafter referred to as the complainant) against National Insurance Co. Ltd. (hereinafter referred to as the OP/s).
2. The brief facts of the complaint  are that the complainant holds National Mediclaim policy No.401406/48/14/8500000250 w.e.f.10.2.2006 issued by the OP. The complainant got renewed the policy from time to time and lastly the same was renewed on 9.2.2015.
3. It is averred that on 8.12.2015, the complainant due to heart problem was admitted in Fortis Escorts Heart Institute and Research Centre, New Delhi and stenting was done. The said institute charged Rs.4,83,837/- for the said purpose out of which Rs.3,82,337/- were paid by the OP to the complainant   viz Rs.2,80,278/- paid by the OP on 3.12.2015 on account of cash less amount of Rs.34,420/- had been transferred by OP in her account on 2.2.2016.Rs.67,639/- was transferred by the OP in her account on 26.2.2016.Thus a sum of Rs.1,01,500/-remains due to the complainant from the OP.
4. It is averred that withholding of Rs.1,01,500/.- is illegal, unjust, unfair, without any reasons and is against all cannons of justice and rather it amounts to deficiency in service on the part of the OP. The complainant made oral as well as sent legal notice for the payment of this amount but the OP did not make the payment of this amount. Hence this complaint with the prayer to accept the complaint by giving directions to the OPs to pay Rs.1,01,500/- alongwith interest @18% per annum from the date of submission of claim till its realization; to pay Rs.50,000/- as compensation and Rs.25000/-as costs of the complaint.
5. Notice of the complaint was given to the OP, who appeared through counsel and contested the complaint by filing written reply. In the written reply the OP raised preliminary objections that the present complaint is not maintainable that the complainant has no locus standi to file the present complaint; that the complainant has no cause or reason to file the present complaint and that the complainant has not come to the Forum with clean hands.
6. On merits it is stated that National Mediclaim policy has been issued for the period from 10.2.2015 to 9.2.2016 in the name of Vishnu Sharma vide which Vishnu Sharma and Smt.Asha Sharma were covered for a sum of Rs.3lac + cumulative bonus of Rs.1.5 lac each.
7. It is further averred that the insured is covered under National Mediclaim policy with sum insured of Rs.3lacs + 1.5 lacs towards CB amount, totaling Rs.4,50,000/-.It is further averred that the policy provides limits/sub-limits for room rent, doctor’s fee and other expenses as per clause 2.1,2.2 and 2.3 of the policy
8. It is submitted that the total claimed amount is Rs.4,83,837/- and insured had been paid total amount of Rs.3,34,420/- which includes GIPSA package of Rs.1,08,500/- for PTCA. It is further submitted that an amount of Rs.19,722/- has been earlier paid for hospitalization for the period 14.11.2015 to 15.11.2015 to the complainant under the policy in question. It is further averred that full and final payment as was due has already been paid to the complainant. There is no deficiency in service on the part of the OPs. After denying all other averments made in the complaint the OPs prayed for the dismissal of the complaint.
9. In evidence the ld. counsel has tendered affidavit of the complainant, Ex.CA alongwith documents Exs.C1 to C4 and closed the evidence.
10. The ld. counsel for the OP has tendered Ex.OPA affidavit of Sh.Bhupinder Singh alongwith documents Exs.OP1 to OP5 and closed the evidence.
11. The OP filed the written arguments. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
12. The ld. counsel for the complainant has argued that the complainant holds National Mediclaim Policy w.e.f.10.2.2006 issued by the OP and was renewed from time to time and was lastly renewed on 9.2.2015. On 8.12.2015, the complainant was admitted in Fortis Escorts Heart Institute/ Hospital due to heart problem and said hospital charged Rs.4,83,837/-.The ld. counsel further argued that out of the said amount Rs.382337/- has been paid by the OP to him. The ld. counsel further argued that the OP has illegally withheld Rs.1,01,500/-.So the complaint be allowed and the OP be directed to pay the said amount.
13. On the other hand, the ld. counsel for the OPs has admitted that the policy has been  issued in the name of Vishnu Sharma as well as Asha Sharma and were covered for a sum of Rs.4,50,000/-.The ld. counsel further argued that the amount which was payable has been paid and now nothing is due. The ld. counsel further argued that they have clearly mentioned in the written statement that how said amount has been paid, so complaint be dismissed.
14. To prove this complaint complainant Asha Sharma tendered her affidavit,Ex.CA and has deposed as per his complaint. Ex.C1 is the policy of OP, Ex.C2 is the legal notice,Ex.C3 is another legal notice,Ex.C4 is postal receipt.
15. On the other hand Sh.Bhupinder Singh Malik ,Branch Manager has tendered his affidavit, Ex.OPA and he has deposed as per the written statement. He has tendered Ex.OP1 policy, Ex.OP2 guidelines of the policy,Ex.OP3 is document of claim, Ex.OP4 is receipt of payment of Rs.280278/-.
16. It is admitted fact that complainant is holder of National Mediclaim Policy,Ex.C1 bearing No.401406/48/14/8500000250 w.e.f.10.2.2015 to 9.2.2016 and it was renewed on 9.2.2015. Smt.Asha Sharma, complainant was admitted in Fortis Escort Hospital, New Delhi and total amount of Rs.4,84,837/- was charged this institute. It is admitted fact that Rs.3,82,337/- has been paid by the insurance company to the complainant and now Rs.1,01,500/- remains to be paid. The written statement is very material for disposal of the case. In para No.1 on merit , it  is stated that Sh.Vishnu Sharma as well as Asha Sharma were covered for a sum of Rs.3lac + cumulative bonus of Rs.1.5lac each as per above said insurance policy issued as per terms and conditions of National Mediclaim Policy. It  is further mentioned that the insured is covered under National Mediclaim Policy with sum insured of Rs.3lacs + Rs.1.5 lacs towards CB amount, totaling Rs.4,50,000/-.So from the policy it is clear that the  maximum amount that insurance can pay was Rs.4.5lac but they paid Rs.3,83,337/- and now Rs.67,663/- remains to be paid. In the written statement the OP has deducted Rs.1,47,717/- of stent charges and  they have approved remaining entire amount of three charges of the hospital. It is not made clear that how they have deduced Rs.1,47,717/- of the stent charges. It is admitted that the bill of Rs. 4,83,837/- was given by the complainant to the OP. So OP was duty bound to explain in the written statement that how they have not paid the amount  but they have failed to do so and it is not clear, as already stated above that how they have deducted the stent charges from this amount.
17. The complainant is demanding Rs.1,01,500/- .The maximum amount can be paid Rs.4,50,000/- as per the policy. So now the complaint stands partly allowed and the OP is directed to pay Rs.67,663/-the remaining amount to the complainant alongwith interest @6% per annum from 2.2.2016  till realization. The OP is also directed to pay Rs.5000/-as compensation and Rs.5000/-as costs of litigation.         

Compliance of the order be made by the OP within a period of 45 days from the date of the receipt of the certified copy of this order.

ANNOUNCED

DATED:22.1.2021       

                             Vinod Kumar Gulati             Jasjit Singh Bhinder

                                    Member                                       President