DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No.177 of 17.5.2017
Decided on: 28.2.2018
Gian Chand Bansal son of Late Sh.Mohan Lal Bansal, aged about 70 years resident of 8-F, Model Town, Patiala (Punjab)-14001.
…………...Complainant
Versus
- The National Insurance Company Ltd., 3, Middleton Street, Kolkata(WB)-700071.
- The National Insurance Company Ltd., Cinema Road, Nabha, District Patiala (Punjab)-147201.
- Vipul MedCorp TPA Private Limited S.C.I.No.98, 1st Floor, Industrial Area Phase-2, Chandigarh-160002.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.M.L.Sharma,Advocate, counsel for complainant.
Sh.D.P.S.Anand,Advocate, counsel for Opposite parties
No.1&2
Opposite party No.3 ex-parte.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Sh.Gian Chand Bansal, 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 the O.Ps.)
2. The brief facts of the complaint are that the complainant was holder of medical insurance policy namely “Hospitalization Benefit Policy” since 12.8.2006 which continued till 8/2014. The same was issued by the OPs. However, the OPs without taking the consent of the complainant changed the same from “Hospitalization Benefit Policy” to Varisthab Medical Policy for the period from 8/2014 to 8/2015 and 8/2015 to 8/2016. The policy (Hospitalization and Domiciliary Benefit Policy) bearing No.401407/48/15/85000000 was issued by Op no.2 for the period from 12.8.2015 to 11.8.2016. Under the policy complainant and his wife Smt. Raj Rani were covered for medi claims upto Rs.1,00,000/- and for critical med claims up to Rs.2,00,000/-. It is stated that on 12.5.2016 Smt. Raj Rani, wife of the complainant was admitted in Dr. G. S. Randhawa, Eye Hospital & Lasic Centre, Patiala for the treatment of cataract left eye. After treatment (cataract extraction 7 PCIOL(Lens) she was discharged on 13.5.2016. On the verbal instruction of the hospital/doctor an amount of Rs.25000/- was deposited by the complainant to hospital vide receipt No.3504 dated 12.5.2016. The Hospital i.e. Dr. G. S. Randhawa issued bill No.109 dated 13.5.2016 for Rs.35000/- after less of Rs.10,000/- under cashless deduction under PGEPHIs (being the complainant a Govt. employee). After completing all formalities the complainant submitted the claim to the OPs on 11.6.2016.In compliance of letter dated 5.7.2016 of OP no.3, he also submitted all the documents as required by it vide letter dated 22.7.2016.After a period of five months,the OPs i.e. insurance company repudiated the claim vide its letter dated 1.11.2016 on the ground ,” Reference to the claim papers, the concerned TPA M/s Vipul Medcorp Insurance TPA Pvt. LTD. has informed vide their letter dated 5.10.2016 that as per the policy terms and conditions, maximum approval for cataract surgery is Rs.10,000/- which has already been paid to you by MD India TPA. Thus the claim is not admissible and we also agree to it. So your claim is repudiated”. The complainant vide letters dated 16.12.2016, 25.1.2017 and e-mails dated 5.3.2017, 19.3.2017, 25.3.2017 and 29.3.2017 tried his best to convince the OPs that repudiation of the claim is baseless and not as per terms and conditions of the policy. The maximum limit for payment of Rs.10,000/- for cataract surgery to govt. employees/retired employees was for their indoor medical treatment under cashless scheme of Punjab Govt. i.e. PGEPHIS which has no concern with the individual insurance policy. The repudiation of the claim and change of the policy for the period from 8/2014 to 8/2015 and 8/2015 to 8/2016 without the consent of the complainant amounted to deficiency of service on the part of the OPs. The act and conduct of the OPs caused mental agony and physical harassment to the complainant. Hence this complaint with a prayer for giving direction to the OPs to settle & pay the med claim amounting to Rs.25000/- alongwith interest @9% per annum, to pay Rs.50,000/- as compensation for causing mental agony and physical harassment, Rs.5500/-as litigation expenses and also to grant any other relief which this Forum may deem fit.
3. On being put to notice OPs No.1&2 appeared and filed their written version whereas OP no.3 despite service failed to come present and was accordingly proceeded against ex-parte.
In the written version filed by OPs No.1&2, preliminary objections have been taken that the complaint is not maintainable as the claim of the complainant has already been repudiated vide letter dated 1.11.2016, the complainant is not entitled to claim the amount twice. On merits , it is stated that OPs had issued Hospitalization and Domiciliary Benefit policy in favour of the complainant for the period from 12.8.2015 to 11.8.2016 covering the risk of mediclaims for Rs.one lac for medical sum insured of complainant and his wife Smt. Raj Rani and Rs.2lacs for critical sum insured. It is further stated that on receipt of complete record of treatment of Smt. Raj Rani, of Dr.G.S.Randhawa Eye Hospital and Lasic Centre, Patiala, consisting of discharge slip, treatment bills, pharmacy test reports etc. , the same were sent to M/s Vipul Med Corp TPA Pvt. Ltd. Chandigarh, who after examination of the same found that the claim was not payable as per the policy terms and conditions of the policy as the maximum liability of the company was Rs.10,000/- in case of Cataract surgery, which the complainant had already received from the MD India TPA and thus the claim of the complainant has rightly been repudiated by the OPs.It is denied that change of the policy for the period from 8/2014 to 8/2016 was without the consent of the complainant, rather the same had been changed as desired by the complainant on furnishing of proposal form. There is no deficiency of service on the part of the OPs. After denying all other averments made in the complaint, it was prayed to dismiss the complaint.
4. In support of the complaint, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C11 and closed the evidence of the complainant.
The ld. counsel for OPs No.1&2 has tendered in evidence Ex.OPA affidavit of Sh.Prabhjot Singh, Br.Manager, Ex.OPB affidavit of Dr.Monika Sharma alongwith documents Exs.OP1 to OP4 and closed the evidence.
5. We have heard the ld.counsel for the parties, gone through the written arguments filed by the ld. counsel for the complainant and have also gone through the record of the case, carefully.
6. The ld. counsel for the complainant has submitted that the first grievance of the complainant is that he had been holding “Hospitalization Benefit Policy” since 12.8.2006 upto 8/2014. Thereafter, the OPs without taking his consent had issued the policy Varisthab Medical Policy . On the contrary, the ld. counsel for the OPs has submitted that the Varisthab Medical Policy was issued to the complainant on receipt of the proposal form from him.
7. From the perusal of proposal form, Ex.OP4, it is evident that , it is meant for Varisthab Medi claim for Senior Citizen. It is also found that the said proposal form had been duly filled in and signed by the complainant. Thus, we do not find any substance in the submission of the ld. counsel for the complainant that the OPs issued the policy in question in the name of the complainant without his consent.
8. The ld. counsel for the complainant has also submitted that the wife of the complainant had gone through cataract surgery of her left eye and incurred expenses of Rs.35000/-. After deducting Rs.10,000/- under cashless deduction under PGEPHIS ( complainant being a govt. employee) Rs.25000/- were to be paid by the insurance company. Accordingly, he lodged the claim with the insurance company and also provided all the relevant documents to the OPs. However, the insurance company repudiated the claim vide letter dated 1.11.2016 arbitrarily.
9. The ld. counsel for the OPs No.1&2 has submitted that as per the terms and conditions of the policy, the liability of the OPs was to pay upto Rs.10,000/- , for the cataract surgery , which had already been paid by the OP no.3 under the scheme, to the complainant, being the Govt. employee. Since the maximum amount which was payable under the policy in question had already been paid to the complainant, therefore, he is not entitled to get the said amount twice.
10. In the terms and conditions of the policy, Ex.OP2, it is mentioned that the company’s liability in respect of claims arising due to cataract is upto Rs.10,000/-. It may be stated here that the parties are bound by the terms and conditions of the policy. From the copy of claim form annexed alongwith letter dated 22.7.2016, Ex.C4, it is evident that an amount of Rs.10,000/- under cashless facility had already been paid by the TPA i.e. OP no.3 for the cataract surgery of left eye of the wife of the complainant, under Pb. Govt. scheme. This fact has fairly been admitted by the complainant. Once the OPs had paid the amount, which they were to pay under the policy in question, therefore, the OPs cannot be held deficient in providing the service to the complainant.
11. In view of the aforesaid discussion, we do not find any merit in the present complaint. Consequently, we dismiss the same without any order as to costs. Certified copies of this order be sent to the parties free of costs under the Rules. Thereafter file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:28.2.2018
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
