DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 856/2015
D.No._________________________ Dated: _________________
IN THE MATTER OF:
PRINCE MANGLA,
S/o LATE SH. NARESH MANGLA,
R/o A-1/205, PRINTERS APARTMENTS,
SEC.-13, ROHINI, DELHI-110085. … COMPLAINANT
Versus
ORIENTAL INSURANCE CO. LTD.,
(THROUGH ITS MANAGING DIRECTOR),
ORIENTAL HOUSE, A-25/27, ASAF ALI ROAD,
NEW DELHI-110002.
ALSO AT: (THROUGH ITS MANAGER),
2/13-14, SARAI JULLENA, NEW DELHI-110025.
ALSO AT: (THROUGH ITS MANAGER),
215, RAMA MARKET, PITAM PURA,
NEW DELHI-110034. … OPPOSITE PARTY
CORAM:SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 04.08.2015
Date of decision: 26.03.2019
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against the OP under Section 12 of the Consumer Protection Act, 1986 thereby alleging that the complainant has taken a Mediclaim Insurance
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policy from OP bearing no. 272100/48/2014/1804 for more than a decade without any discontinuity and the complainant and his family members are covered under the Gold Plan of Happy Family Floater policy schedule from OP for the assured amount of Rs.6,00,000/-. On 31.08.2014, the complainant got admitted in Max Super Specialty Hospital where he was diagnosed with a case of Myocardial Infraction or ACS on 01.09.2014 and the doctor advised for an Angioplasty.As it is a costly procedure, his brother namely Sh. Prashant Mangla called up OP to ask whether OP can get this procedure value be paid under the Mediclaim Policy or not and the representative of OP said yes for the same and stated that he would get the complete value without any conditions and the complainant decided & then the Angioplasty done. On 04.09.2014, the complainant was waiting for the TPA approval and the TPA desk in the hospital informed his brother that Medical consumable Stunt amount to Rs.1,98,000/- and the same was approved for the amount of Rs.1,18,000/- only as this is a cashless facility and this is a set package under GIPSA and GIPSA was not mentioned in the policy and even clause 3.12 and the complainant filed a complaint regarding the same to OP bearing Authorization no.04AOIA0915088, claim no.15OIA2352 for policy no.272100/48/ 2014/1804 and file no. 15CB01OIA1928 and the complainant and his family members were shocked as OP asked him to pay the
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difference amount of Rs.80,000/- via e-mail dated 22.10.2014. The complainant further alleged that the complainant belong to a middle class family & to pay the amount in 10 minutes was not possible and the complainant directed the executive of OP to approve the balance amount of Rs.80,000/- at the earliest in order to resolve the matter but even after that no positive response has been taken by OP and the complainant even sent an application to OP on 08.09.2014 to get the approval of Rs.80,000/- but of no avail and has caused a lot of trouble to the complainant and OP has made false promise to the complainant that the full amount would get approved. Thereafter, the complainant has been trying to communicate with OP but there has been no response from their side, the complainant is entitled for undisrupted and honest services by them and their act of nuisance cannot under any circumstances be overlooked. The complainant further alleged that the complainant tried to resolve the dispute amicably by sending a letter dated 05.06.2015 to OP but to no avail and OP has failed to release the claim despite repeated requests of the complainant and approach of OP amounts to deficiency in services and unfair trade practice.
2. On these allegations the complainant has filed the present complaint praying for direction to the OP to apologize for all the inconvenience caused to the complainant, to refund the amount of
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Rs.80,000/- as well as compensation of Rs.50,000/- for causing damages for mental pain, agony, harassment and has also sought Rs.1,000/- towards cost of litigation.
3. OP has been contesting the complaint and has filed written statement. In its written statement, OP submitted that the complaint is not maintainable and is liable to be dismissed and there is no deficiency in service on the part of OP. OP further submitted that the complainant is seeking to deny the clause 3.12 and clause 3.12 as: “Reasonable & Necessary expenses: A) For a network hospital means the rate pre-agreed between the network hospital and the TPA/company, for surgical/medical treatment that is necessary for treating the insured person who was hospitalized.” OP further submitted that the hospital where the complainant sought treatment is a network hospital and as per the said insurance policy OP is obliged to the extent of ‘necessary’ expenses alone, as per the “rate pre-agreed between network hospital and the TPA/company, for surgical/medical treatment.” OP further submitted that the ‘rate pre-agreed between the network hospital and the TPA/company’ are provided under the GIPSA package and as per the said rates the stent implants are to be paid @ Rs.1,18,000/- and as per GIPSA PPN package with this hospital there are choices of three types of stents i.e. Rs.55,000/-, Rs.66,500/-, Rs.1,18,000/- and OP has given maximum charges for
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stent i.e. Rs.1,18,000/- and OP proactively settled the claim of the complainant and has paid a total sum of Rs.2,59,500/- to the network hospital directly on behalf of the complainant.
4. In order to prove his case, the complainant filed his affidavit in evidence and also filed written arguments. The complainant also placed on record copy of Happy Family Floater Policy for the period from 09.01.2014 to 08.01.2015 (mid-night), copy of Inpatient Bill Summary no. SBIC34010 dated 04.09.2014 for Rs.3,40,800/- issued by MAX Super Specialty Hospital, Shalimar Bagh, Delhi, copy of mail dated 22.10.2014 sent by OP to the complainant, copy of application dated 08.09.2014 sent by the complainant to OP alongwith postal receipts and copy of letter dated 05.06.2015 sent by the complainant to OP alongwith courier receipts.
5. On the other hand, Sh. Ajay Soni, Senior Divisional Manager of OP filed his affidavit in evidence. OP also filed copy of rates agreed with the hospital. OP has also filed written arguments.
6. This forum has considered the case of the complainant as well as OP in the light of evidence and documents placed on record by the complainant. The documents and evidence of the parties shows that the complainant was admitted in MAX Super Specialty Hospital, Shalimar Bagh, Delhi on 31.08.2014 and was discharged from the hospital on 04.09.2014 and due to Myocardial Infraction or ACS.On the other hand, the copy of rates placed on record by OP
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contains the names of Escorts Okhla, Jessa Ram/Escorts Faridabad & Fortis Vasant Kunj/Shalimar Bagh/Noida and thus it shows that copy of rates placed on record by OP does not show about any agreement of rates with MAX Super Specialty Hospital, Shalimar Bagh, New Delhi. So, OP cannot derive any benefit from the copy of agreement of rates agreed with the hospital which has been placed on record. Accordingly, we are of opinion that there is no merit in the defence of OP and OP ought not to have repudiated the claim of the complainant. Since OP has not released the said amount to the complainant, so, while refusing the claim, OP has indulged in unfair trade practice and deficiency in service. Thus, OP is held guilty accordingly.
7. Thus, holding guilty for the same, we direct the OP as under:
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ii) To pay to the complainant an amount of Rs.40,000/- as compensation for harassment and mental agony suffered.
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8. The above amount shall be paid by the OP to the complainant within 30 days from the date of receiving copy of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10%
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per annum from the date of receiving copy of this order till the date of payment. If OP fails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.
9. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 26th day of March, 2019.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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