Haryana

Yamunanagar

CC/450/2013

Anil Kumar S/o Ramesh Kumar - Complainant(s)

Versus

Oriental Insurance Co.Ltd. - Opp.Party(s)

D.S. khurana

29 Aug 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR

​

                                                               Complaint No. 450 of  2013.

                                                               Date of institution: 28.05.2013.

                                                               Date of decision: 29.08.2017.

 

Anil Kumar son of Shri Ramesh Kumar aged 47, resident of House No. 70, Sector 17, HUDA, Jagadhri, Tehsil Jagadhri, District Yamuna Nagar.                                                                                                                                                                                            

 

                                                                                                                    …Complainant.

                                            Versus

1. The Oriental Insurance Co. Ltd. through its Branch Manager, Old Court Road, Jagadhri, Tehsil Jagadhri, District Yamuna Nagar.

 

2. Vipul Medicorp TPA Pvt. Ltda. 515 Udyog Vihar, Phase V, Gurgaon.

 

                   ….Respondents.

                    

BEFORE    SH. SATPAL, PRESIDENT

                   SH. S.C.SHARMA, MEMBER.

                   SMT. VEENA RANI SHEOKAND, MEMBER.          

 

Present:       Sh. D.S. Khurana, Advocate, counsel for complainant.   

                    Sh. Parmod Kumar Gupta, Advocate, counsel for OP No. 1.

                    OP No. 2 already ex-parte.

 

ORDER      (SATPAL PRESIDENT)

 

1.                Complainant Anil Kumar has filed this complaint under section 12 of the Consumer Protection Act 1986 as amended up to date.(hereinafter  the respondents shall be referred as ops)

2.                Brief facts of the complaint, as alleged by the complainant, are that the complainant along with his wife Smt. Kiran Bansal had taken a Mediclaim policy bearing NO. 261701/48/2013/262 for the past 10 years and last time the policy was renewed on 15-06-2012 and valid upto 14-06-2013, after payment of premium which was duly accepted by the OP No. 1. The policy was joint with the wife of the complainant and both were insured to the tune of Rs. 5 lacs each. The complainant suffered from Recurrent Nasal obstruction and was diagnosed with deviated Nasal septum and due to the said problem he had to be admitted in the MAX Super Specialty  Hospital on 01.05.2013 and remained admitted there till 07.05-2013. A sum of Rs.94054.60p was incurred on the treatment. The policy in question was a cashless policy wherein the complainant was not required was not required to make any payment to the hospital authorities at the time of discharge from the same and the payment was to be made directly by the OPs. The complainant could have been discharged on 06.05.2013 but the OPs did not make the payment of the hospital authorities on 06.05.2013, the complainant was forced to stay in the hospital for one extra day as the OPs failed to clear the dues on 06.05.2013 itself at the time of the discharge of the complainant from the hospital , the OPs only paid a sum of Rs.46,325/- out of total bill of Rs.94054.66p meaning thereby that there was a short fall of Rs.59555/- which was ultimately paid by the complainant from his own pocket. The complainant was not having the said money with him and he had to borrow money from his brother. The complainant had to purchase medicines worth Rs.4040/- including medicines of Rs.2020/- purchased on 07.05.2013 and Rs.2000/- on 16.05.2013 which was the medicine prescribed by the hospital authorities. Thus, a sum of Rs.63,595/- is payable by the OPs to the complainant. Further, a sum of Rs.3500/- has been retained by the hospital authorities due to non payment till date by the OPs and the said amount is also payable by the OPs to the complainant. Hence, this complaint, wherein it has been prayed the ops be directed to pay Rs.63595/- along with interest @ 24% PA from the date of approval till the date of actual payment; to pay Rs.3500/- which was retained by the hospital authorities and also to pay compensation as well as litigation expenses.

                   Upon notice, OP No. 1 appeared and filed the written statement taking some preliminary objections such as complicated  question of law and facts are involved in this case therefore this Hon.ble Forum has no jurisdiction to hear and decide the present complaint, the complainant has not come  to this Forum with clean hands and  has concealed the true and materials  facts  and has filed false and frivolous complaint, As per terms and conditions of the  policy at point no 4.1. when the cover incepts for the first time all excluded upto four years and the complainant insured amount was Rs. 3.00.000/- policy no. 48/ 09 /189  w.e.f  16.6.2008 to 15.6.2009 and he intentionally and deliberately by concealing his pre-existing disease got enhanced the insured amount and as such the claim is not a payable and he has filed a false complaint as per exclusion clause no. 4.16 which is reproduced as under

4.16 external and or durable medical/Non medical  equipment of any  kind used for diagnosis and  or treatment including CPAP, CAPD , infusion pump etc. , ambulatory devises that is walker , crutches , belts , collets , caps , splints , slings , braces , stockings, etc. of any kind, diabetic foot wear, glucometer . thermometer and similar related items etc. and also any medical equipment which is subsequently used at home etc. , some of  claim was not payable so the same was not rightly given  because the parties are bound by the terms and conditions of the policy . On merit it is submitted that the complainant took policy No.48/09/189 with effect from 16.06.2008 to 15.06.2009 in which the insured value of Rs.3 lac but he thereafter without disclosing pre existing disease got enhanced the policy amount to Rs.5 lac and as per exclusion clause of the terms and conditions of the policy, no claim on enhanced amount is payable upto 4 years and as such to say that OP no.1 is bound to indemnify the complainant to the tune of Rs.10 lac is not correct. Complainant was required to inform the TPA regarding hospitalization within 48 hours and much before the discharge from the hospital .In this case, a case of Rs.94,054.60 p was raised out of which a sum of Rs.46,325/- was payable as per terms and condition of the policy and as such the contention raised by the complainant that he is entitled to further sum of Rs.59,555/- is a total lie because the complainant is playing hide and seek and if we go through the bill Annexure R2 submitted by the complainant where it is clear that bill amount is Rs.94054.66 p/- and the complainant deposited a sum of Rs.59555/- and the company has deposited a sum of Rs.46325/- (which was payable by the company as per terms and condition of the policy ) so a sum of Rs.11825.34p was found refundable to the complainant which he has not shown deducted from the total calculation shown in the complaint and as such he has concealed this fact from this Forum intentionally and deliberately and has played a fraud. Rests contents of the complaint were denied being wrong and incorrect and lastly prayed for dismissal of the complaint .

3.                OP no.2 failed to appear despite service and as such op no. 2 was proceeded  against ex-parte vide  order dt.28.11.2014 of this Forum.

4.                Learned counsel for the complainant has tendered into evidence by way of affidavit  of the complainant as Annexure CW/A along with documents as Annexure C-1 to C-8 and closed the evidence on behalf of the complainant.

5.                On the other hand learned counsel for OP no. 1 tendered into evidence affidavit of Sh. SanjeevMadan Branch manager as Annexure RW/A and documents as Annexure R-1 to R-3  and closed the evidence on behalf of op no.1.

6.                We have heard the learned counsel for both the parties and has gone through the pleadings as well as documents placed on file very minutely and carefully.

7.                Learned counsel for the complainant has argued that the complainant has purchased one Medi Claim policy from OP No.1 which is valid from 15.06.2012 to 14.06.2013 and the complainant fell ill and remained hospitalized from 01.05.2013 to 07.05.2013 and an amount of Rs.94055.60/- was incurred on the treatment but the OP company paid only 46325/- out of bill of Rs.94054.66/-  meaning thereby that there was a shortfall of the Rs.59555/- besides this the complainant has also spent Rs.4040/- + Rs.2020/- and Rs.2000/- on purchase of medicines and as such an amount of Rs.63595/- is outstanding against the OPs. But the OPs failed to pay the aforesaid amount.

8.                On the other hand, learned counsel for the OPs argued that they have paid an amount of Rs.46325/- out of Rs.94054.60/- as per terms and conditions of the policy and nothing is due against the company and prayed for dismissal of the complaint.

9.                After hearing the learned counsel for the parties and going through the record, it is clear that the main grievance of the complainant is that he had fallen ill and admitted in hospital and Rs.94,055.60/- was incurred on his treatment but the OPs had made the payment to the tune of Rs.46325/- . The complainant is entitled for the remaining amount of Rs.49555/- + Rs.8060/- (medicines expenses). The foremost question which arises before us for consideration is that whether the complainant is entitled for remaining amount of Rs.63595/- or not?  We have perused the documents Annexure R2 wherein at Page No.2 payment details calculations breakup for claim of the complainant was given. The Vipul Med. Corp. TPA has mentioned in the column of room tariff bill an amount of Rs.15000/- and in the column of deduction has mentioned Rs.47,730/- and also mentioned in the column of payment amount to the tune of (-Rs.32730/-). This query was made by the forum from the OPs regarding deduction of Rs.47730/- in the column of room tariffs but the OPs has failed to reply the same.

                    Thus, we are of the considered view that OPs had illegally shown Rs.47730/- in the column of deduction.

                   As per annexure C3, the complainant had deposited Rs.59,555/- from his pocket against the total bill of Rs.94,054.60/- and thereafter the hospital had refunded Rs.11,825/-  on settlement of the bill which is clear from the Annexure C2. The complainant is entitled for the refund of (Rs.59555/- - Rs.11825/- = 47730/-).

                   In view of the facts discussed above, we allow the present complaint of the complainant and direct the OPs to comply with the following directions within a period of 30 days from the receipt of the copy of this order: -

1. To refund /reimburse Rs.47,730/- along with interest @ 9% per annum from the date of its deposit i.e. 06.05.2013 till its realization.
2. And also to pay Rs.5500/- as compensation as well as litigation expenses.

Copy of this order be supplied to the parties free of cost. File be consigned to the record room after due compliance.

Announced in open Court:

Dated 29.08.2017

                                                     ( SATPAL)

                                                     PRESIDENT

                                                     D.C.D.R.F.YAMUNA NAGAR

                                                     AT JAGADHRI

 

 

(VEENA RANI SHEOKAND)    (S.C.SHARMA)

MEMBER                                    MEMBER

 

 

Note: Each and every page of this order has been duly signed by me.

 

 

                                                           (SATPAL)

                                                     PRESIDENT

                                                     D.C.D.R.F.YAMUNA NAGAR

                                                     AT JAGADHRI