BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 157 of 2012
Date of Institution : 9.8.2012
Date of Decision : 8.9.2015
Subhash Chander Gupta, Advocate, Mandi Dabwali, District Sirsa.
….Complainant.
Versus
National Insurance Co. Ltd., Mandi Dabwali District Sirsa through its Branch Manager.
..…Opposite party.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: Smt. Gurpreet Kaur Gill….. Presiding Member
Sh. Rajiv Mehta ….. Member
Present: Sh.A.K.Gupta, Advocate for the complainant.
Sh.R.K.Chaudhary, Advocate for opposite party.
ORDER
The facts rising the present complaint in brief are that Complainant purchased a medi claim policy no. 420703/48/10/8500000027 w.e.f. 27.7.2010 to 26.7.2011 from OP company for medi claim risk, hospitalization etc. The sum insured was Rs. 1,00,000/- but after adding the cumulative bonus the sum insured become Rs. 1,30,000/-.
2. As alleged complainant developed some problems in his right eye and was treated at Garewal Eye Institution on 20.6.2011. Total treatment expenditure was of Rs. 39,000/- for which he lodged his claim with the OP with all the bills
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etc. It is further alleged policy was issued as cashless but the treating hospital demanded Rs. 15,000/- in cash against total expenditure of Rs. 39,000/-. But the OP asked to Garewal Eye Institution to entertain the policy up to Rs. 24,000/-. In the circumstances complainant paid the additional treatment amount. There was no benefit of cashless policy due to attitude of the OP. Complainant also paid Rs. 742/- on medicines for which bills were sent to the OP. Legal notice was also got served upon the OP but OP took no pain to settle the claim of the complainant. Hence this complaint for seeking the relief of Rs. 15742/- on account of the amount spent during treatment alongwith interest @ 18 %, compensation of Rs. 10,000/- on account of damages physical and mental harassment and to pay Rs. 5000/- cost of litigation expenses.
3. On notice, OP appeared and filed their reply. Op company case is that as per Memorandum Of Understanding (MOU) executed between TPA and the Eye Institute the total amount for such disease was to be charged as Rs. 24,000/- but the complainant himself opted for surgery package of higher cost lenses and agreed to pay for extra cost of Rs. 15,000/- as such his claim for Rs. 24,000/- was approved.
4. In order to make out his case, the complainant has placed on record Ex.C1-his own supporting affidavit; Ex.C2- insurance policy, which is also in the name of the complainant; Ex.C3-copy of legal notice; Ex.C4-copy of corrigendum to legal notice; Ex.C5-registered A.D. and Ex.C6- receipt of speed post; Ex. C7 to Ex. C9- receipts of speed post; Ex. C10 and Ex. C11- acknowledgements; Ex. C12- photocopy of receipt of Rs. 15,000/-; Ex. C13- photocopy of receipt of Rs. 200/-; Ex. C14- photocopy of receipt of Rs. 100/-; Ex. C15- bill of Rs. 442.20/- and Ex. C16- copy of legal notice dated 22.9.2011 regarding medi claim policy no. 420703/48/10/8500000027.
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5. In reply thereto, opposite party has placed on record Ex.R1-supporting affidavit of Sh.Ashok Kamboj, its Assistant Manager; Ex.R2-copy of willingness certificate and Ex.R3-copy of memorandum of understanding; Ex. R4– copy of bill no. 2444 dated 20.6.2011and Ex. R5- copy of bill 451 etc. dated 20.6.2011 etc.
6. We have gone through the record of the case carefully and have heard Shri A.K.Gupta, learned counsel for the complainant and Shri R.K.Chaudhary, learned counsel for the opposite party.
7. Complainant is consumer of Ops since last 7-8 years and getting the no claim bonus regularly. He is insured with Ops upto the extent of Rs. 1,30,000/-. First time he lodged the claim under medi-claim policy. Claimant paid the premium to the Ops for cashless treatment policy. Ops stated in reply that Vipul TPA is third party administrator working on behalf of insurance company for providing health services etc. Vipul TPA executed memorandum of understanding (MOU) with Garewal Eye Institute Chandigarh, for extending medical facilities and treatment. They have agreed to charge Rs. 15000/- to Rs. 24000/- for the standard surgery package. The complainant has himself agreed to opt higher cost lenses and to pay voluntarily for the extra cost of lenses Rs. 15000/-.
8. At the time of purchase of policy complainant has contacted/agreed with insurance company not with Vipul TPA. Ops has not introduced to Vipul TPA with complainant, not disclosed any such type of agency, not explained any terms and conditions and memorandum of understanding to the complainant at the time of insurance. MOU is their internal document. Insurance company not produced any document in this Forum to show that at the time of purchasing of policy, the Vipul TPA was party in the policy in question. Complainant has no concern with the memorandum of understanding (MOU). Such type of terms and conditions of third party are not applicable to the complainant.
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9. This is clear from document willingness certificate (Ex. R2) given by the complainant for additional amount of Rs. 15000/-. The willingness given by the complainant in compelling circumstances at the time, of his operation. Complainant has no alternate except to giving the willingness for additional amount, because complainant has problem in his right eye. In the above mentioned circumstances complainant paid additional amount to Garewal Hospital Chandigarh. The memorandum of understanding (MOU) between the insurance company and Vipul TPA is their own contract and complainant is not party thereto. contrary document. So the conditions of limited liabilities is not binding upon the complainant because complainant purchase the cashless mediclaim policy up to extent of Rs. 1,30,000/- . Complainant has paid Rs. 15000/- additional surgery charges and Rs. 300/- as medicines charges from his pocket.
10. In the light of our above discussion, we accept the complaint of the complainant with cost of Rs. 1000/-. The respondent-company is directed to make the payment of remaining amount to the tune of Rs. 15300/- to the complainant alongwith interest @ 9 % per annum from the date of filing of this complaint i.e. 9.8.2012 till actual payment. The compliance of the order be made within a period of one month, failing which the complainant is at liberty to initiate the legal proceedings against the respondent-company. A copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance.
Announced in open Forum. Presiding Member,
Dated:8.9.2015. Member District Consumer Disputes
Redressal Forum, Sirsa.
Subhash Chander Vs. NIC
Present: Sh.A.K.Gupta, Advocate for the complainant.
Sh.R.K.Chaudhary, Advocate for opposite party.
Arguments heard. For order to come up on 8.9.2015.
Presiding Member,
Dt.3.9.2015. D.C.D.R.F,Sirsa.
Member.
Present: Sh.A.K.Gupta, Advocate for the complainant.
Sh.R.K.Chaudhary, Advocate for opposite party.
Order announced. Vide separate order of even date, complaint has been allowed with costs. File be consigned to record room after due compliance.
Announced in open Forum. Presiding Member,
Dated:8.9.2015. District Consumer Disputes
Redressal Forum, Sirsa.
Member.
