Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No.240/02.09.2019
Shri Manjeet Singh Chadha, s/o of Sh Jagat Singh Chadha
Resident of J-18, Ganga Ram Vatika, Chaukhandi Road,
New Delhi …Complainant
Versus
Oriental Insurance Company Limited
4th Floor, Aggarwal House, Asaf Ali Road,
New Delhi ...Opposite Party
Senior Citizen's Case
Date of filing: 02.09.2019
Coram: Date of Order: 06.06.2024
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
ORDER
Inder Jeet Singh , President
The case is scheduled today for order (item no.8)
1.1. (Introduction to case of parties) – Briefly, the consumer dispute is that the complainant/insured was hospitalized and he paid medical bill of Rs.78,000/-, however, the OP/Insurer reimbursed only Rs.18,000/- and declined the remaining amount of Rs.60,000/-. The complainant is aggrieved that his valid claim was not considered, which is deficiency of services.
1.2. It is opposed by OP that legible amount of Rs.18,000/- was allowed in terms of policy but the other amount was not eligible, that is why it was declined. There is no deficiency of services on the part of OP.
2.1. (Case of complainant) –The complainant took Medi-claim policy bearing no. 215102/48/19/02027 from OP (briefly, the 'insurance policy') against payment of policy premium and he has been paying premium regularly. On 17.11.2018 he was admitted in BLK Super Specialty Hospital but at the time of his discharged, the hospital demanded medical treatment bill of Rs. 78,000/-, which was the responsibility of OP to pay the raised bill. The complainant had furnished all documentary record and requested the OP to make the payment of said amount.
2.2. However, after examining the documents by the OP, OP paid an amount of Rs. 18,000/- out of total amount of Rs. 78,000/-. The complainant protested it and requested the OP to release the amount being its obligation and liability under the policy.
On 13.05.2019, the complainant also wrote a letter to Sh. Y. K. Rao, Chief Manager, Customer Service Department, while requesting again to release the amount but no amount was paid. On 21.06.2019, the complainant sent another letter while informing that he had spent amount of Rs. 78,000/- and in terms of insurance policy, the entire amount was to be reimbursed. There was no payment, thus ultimately on 04.07.2019 a notice was sent through the Advocate besides complaint to Public Grievances Cell on 27.07.2019. The complainant received reply dated 05.08.2019 of the notice, however, it is fabrication of false story just to avoid its liability. The OP has withheld balance claim amount of Rs. 60,000/-, which OP is liable to pay with interest at the rate of 18%pa. The complainant, being senior citizen, was mentally depressed on account of attitude and behavior of OP and its employees, the complainant is entitled compensation of Rs. 1 lakh in lieu of mental harassment and agony caused. The complainant also seeks cost of litigation and other relief against OP.
2.3 The complaint is accompanied with copy of additional document request, reply to the query, affidavit (in respect of misplaced of original receipt), claim form, email dated 07.05.2019, statement of transaction, OP’s letter dated 15.05.2019, review of policy and email dated 27.05.2019 if claim of balance amount of Rs. 60,000/-, request of review of policy (for clarification of invoking 30% co-pay clause in place of 10% co-pay), legal notice dated 04.07.2019 and reply dated 05.08.2019, complaint dated 27.07.2019 to the Public Grievances Cell and to Chief Manager, Customer Service Department.
3.1 (Case of OP)-The OP denies the allegations of complaint by written statement (under preliminary objections and para-wise reply), precisely, that complainant has suppressed the material facts in the complaint as well as in the legal notice. There were deductions in the amount but the same were as per the terms and conditions of policy. The complainant was reimbursed the amount for which he was entitled under the coverage allowed as per policy.
3.2. The complainant denies all other allegations of the complaint that the OP was liable to pay amount of Rs. 78,000/-. Since the admissible amount was determined as per the terms of policy and deductions were made accordingly, therefore, the complainant is not entitled for any amount of Rs. 60,000/- with interest being no liability nor compensation of Rs. 1 lakh or other relief. The complainant is very much aware about the terms and conditions of policy as well as the coverage allowed there under. The complaint is liable to be dismissed.
3.3 The written statement is accompanied with terms and conditions of Happy Family Floater policy containing the coverage and other terms and conditions and email with detail of deductions in the attachment.
4. (Replication of complainant) – The complainant also filed rejoinder to complaint as a reply to written statement, he reiterates all the plea taken in the complaint as correct and denies allegations of written statement.
5.1. (Evidence)- In order to establish the complaint, the complainant Shri Manjeet Singh Chadha filed his exclusive affidavit of evidence with the support of document filed with the complaint.
5.2. On the other side, OP led evidence by filing affidavit of Mahender Kumar Sharma, Divisional Manager of OP.
6. (Final hearing)- Both the parties have filed their written arguments. At the stage of oral submissions, Ms. Sonika Khandelwal, Advocate for OP presented their respective submissions, however, the complainant had not appeared for oral submission. Earlier the complainant used to send request for his exemption (from appearance before Commission) being senior citizen and his request was also considered. His contention as mentioned in case and written arguments will be considered.
7.1 (Findings)- The case of parties and their contentions are considered by taking into account stock of evidence of parties, the documentary record and other circumstances. The case of parties have already been narrated in detail in paragraphs 2 and 3 above. After taking analyzing and considering them, the following conclusions are drawn:-
(i) There is no dispute that the complainant was issued the insurance policy and he was hospitalized during the currency of policy. There is also no dispute that the complaint had lodged the claim of Rs.78,000/- but he was reimbursed the partly claim of Rs.18,000/-.
(ii) It is settled principle that the insurance policy a contract between the parties and they are governed by its terms and conditions.
(iii) The complainant has proved email dated 7.5.2019, legal notice and its reply vis a vis OP has also proved terms and conditions of policy and record of deductions, which were item-wise with specifications of amount deducted as well as percentage of deductions.
(iv) There is no proof of other record or material by the complainant to rebut the terms of policy or deductions were contrary to contract entered between the parties.
(v) The eligible amount was paid to the complainant and remaining amount was not eligible. The deductions were under the covenants of insurance contract between the parties. It does not make out case of deficiency of services.
7.3. In view of above, the complaint fails. The complaint is dismissed. No order as to costs.
8. Announced on this 6th day of June 2024 [ज्येष्ठ 16, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.
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