Chandigarh

DF-I

CC/368/2015

Ankit Aggarwal - Complainant(s)

Versus

Oriental Insurance Company Limited. - Opp.Party(s)

Vinod Mahendru

05 Jan 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Consumer Complaint  No	:	368 of 2015
Date  of  Institution	:	9.6.2015
Date   of   Decision	:	5.1.2016

 

 

 

 

 

 

Ankit Aggarwal, resident of house No. 5744, Modern Housing Complex, Manimajra, U.T., Chandigarh.

….Complainant

Vs.

 

1. Oriental Insurancae Company Ltd. SCO No. 176-177, Sector 22-B, 1^st floor, Chandigarh through its Manager.

 

 

2.  M/s Vipul Medcorp TPA Private Limited SCI 98, Industrial Area, Phase II, Chandigarh through its authorized signatory.

 

…… Opposite Parties 

 

BEFORE: 

MRS.SURJEET KAUR                            PRESIDING MEMBER

SH. SURESH KUMAR SARDANA          MEMBER

 

 

For Complainant	:	Sh. Vinod Mahendru, Advocate
For OP No.1	:	S. J.P. Nahar, Advocate
For OP No.2	:	Ex parte.

 

 

PER SURESH KUMAR SARDANA, MEMBER

 

                                                                                                                              

 

 

                The facts, in brief, are that the complainant  purchased Happy Family Floater Policy 23130/48/2014/1617 from Opposite Party No.1 for himself as well as on behalf of dependents parents Sh. Anand Parkash and Ms. Dazy Rani covering the risk from 29.3.2014 to 28.3.2015.   According to the complainant surgery of his dependent Sh. Anand Parkash was done in Virdi Eye Hospital and he was discharged on 19.12.2014. The said hospital charged bill of Rs.36,000/-. The complainant sent intimation to Opposite Party No.2 to this effect vide letter dated 23.12.2014 (Annexure C-2) and on the same day submitted his claim with it.  It has been alleged that Opposite Party No.2 approved the claim of the complainant to the tune of Rs.21,420/- after deducting Rs.14,580/- from the actual claim.  The complainant vide Annexure C-7 protested the same. Yet  Opposite Party No.2 without the consent of the complainant transferred an amount of Rs.21,420/- to his account.  It has further been alleged that the complainant purchased the policy from Opposite Party No.1 but it did not inform the complainant that claims are to be settled by Opposite Party No.2.  Hence the Opposite Party No.2 with whom the complainant had no privity of contract illegally and arbitrarily deducted the amount from the actual claim of the complainant.  The complainant sent a notice Annexure C-9 to the Opposite Parties for arbitrarily deducting the aforesaid amount but to no effect. Alleging deficiency on the part of the Opposite Parties the instant complaint has been filed.

2.             Notice of the complaint was sent to Opposite Parties seeking their version of the case. However, since nobody appeared on behalf of Opposite Party No.2 despite service, therefore, it was proceeded ex-parte on 14.09.2015.

 

3. No.1 in its reply while admitting the factual matrix of the case stated. The complainant did not approach the TPA for cashless facility despite the fact that the hospital in question is empanelled under GIPSA-PPN with TPA serving public sector insurance companies including oriental insurance company.  The TPA has the cashless facility with the hospital in question under which the hospital charges Rs.22,800/- for a cataract surgery. The complainant instead of approaching the TPA to avail cashless facility, got the operation done and submitted the bills for Rs.36,000/- and the TPA paid the claim of Rs.21,420/- as per terms and conditions of the policy and as per rates approved by the GIPS.  It is averred that as the complainant did not avail the cashless facility he himself is responsible for paying excess amount to the hospital.  As such the deduction of Rs.14,580/- was made as per terms and conditions of the policy. It was further stated, that neither there was any deficiency, in rendering service, on the part of the answering Opposite Party nor it indulged into unfair trade practice. The remaining allegations, were denied, being wrong

 

4.          The complainant has filed a rejoinder, wherein he has reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties.

 

5.          Parties were permitted to place their respective evidence on record, in support of their contentions.

 

6.          We have heard the learned counsel for the parties and have perused the record.

 

7.          The insurance policy for self and dependent parents of the complainant covered the risk from 29.3.2014 to 28.3.2015. The complainant’s father had undergone the cataract surgery in the Virdi hospital. He was admitted on 18.12.2014 and discharged on 19.12.2014. The main contention of the complainant is that the bill was not completely reimbursed by the Opposite Party.

 

8.          It is seen that the complainant had purchased the policy from Opposite Party NO.1 and Opposite Party No.1 had failed to inform the complainant about signing of Memorandum of Understanding with Opposite Party No.2. The terms and conditions were never supplied by Opposite Party No.1 to the complainant. Hence the complainant did not approach the TPA  first for cashless facility. Hence release of partial amount of claim in the absence of non supply of terms and conditions and MOU etc. to the complainant amounts to unfair trade practice and held to be deficiency in rendering service.  

 

9.          In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in giving proper service to the complainant and having indulged in unfair trade practice. Hence, the present complaint of the Complainant deserves to succeed.  Accordingly the same is allowed. The Opposite Parties are, jointly and severally, directed  to:-

 

[a]     To pay the balance claim amount Rs.14,580/-  with interest @9% p.a. from the date of claim filed by the complainant till realization.

 

[b]     To make payment of Rs.15,000/- to the complainant towards compensation for causing mental and physical harassment.

 

[c]      To make payment of Rs.10,000/- to the complainant as litigation expenses.

 

 

10.          The above said order be complied with by the Opposite Parties, within 30 days from the date of receipt of its certified copy, failing which the amounts at Sr. No.[a] shall carry interest @12% p.a. from the date of claim filed by the complainant till realization & [b] shall carry interest @12% per annum from the date of filing of the present Complaint, till actual payment, besides payment of litigation costs.

 

11.          The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

5.1.2016                   

 

Sd/-

 (SURJEET KAUR)

PRESIDING MEMBER

Sd/-

 (SURESH KUMAR SARDANA)

MEMBER