Chandigarh

DF-II

CC/782/2016

Arun Mahajan - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

Sanjay Judge Adv.

18 Apr 2017

ORDER

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

Consumer Complaint  No	:	782 of 2016
Date  of  Institution	:	19.09.2016
Date   of   Decision	:	18.04.2017

 

 

 

 

Arun Mahajan, resident of House NO.1030/2,  Sector 39-B, Chandigarh.    

 

              …………..Complainant

 

VERSUS

 

1]   Oriental Insurance Company Limited, A-25/27, Asafali Road, New Delhi (through its Regional Manager).

2]   Max Super Specialty Hospital, Near Civil Hospital, Phase-6, Mohali (Punjab) through its Director.

3]   Raksha TPA Pvt. Ltd., SCO 359-360, First Floor, Sector 44-D, Chandigarh through its Branch Manager.

                                 …………… Opposite Parties

 

BEFORE:   SH.RAJAN DEWAN          PRESIDENT

                                MRS.PRITI MALHOTRA           MEMBER

SH.RAVINDER SINGH            MEMBER

           

Present:   Sh.Rajinder Pandey, counsel for complainant.

Sh.J.P.Nahar, Counsel for OPs No.1 & 3.

            OP No.2 Exparte.

 

RAVINDER SINGH, MEMBER

 

         The facts in issue are that the complainant availed Mediclaim policy No.231203/48/2016/1441 (Ann.C-1) from OP NO.1 effective from 14.3.2016 till 13.3.2017 by paying premium of Rs.10,573/-.  It is averred that on 4.8.2016, the complainant fell ill and was admitted in Max Super Specialty Hospital, Phase-6, Mohali on account of Dyspepsia, pain abdomen and was diagnosed as Cholelithiasis with Choledocholithiasis and Hypertension.  It is averred that the OP NO.1 initially approved Rs.10,000/- in response to cashless policy.  It is also averred that the complainant after about 7 days was discharged from the hospital on 10.8.2016 (Ann.C-3) and a bill of Rs.1,66,628.32 (Ann.C-4) was raised by the Hospital.  However, the OP No.1 against the said bill amount, paid initial amount of Rs.10,000/- and Rs.55,824/- (Ann.C-5) whereas Rs.24,600/- was adjusted by OP No.2 (Ann.C-6).  It is submitted that the act of omission and commission on the part of the OPs, compelled the complainant to pay a sum of Rs.61,704.32 to OP No.2, despite the fact that the complainant was fully covered for all expenses incurred in the hospital as per Mediclaim policy. Thereafter, the complainant sent a legal notice dated 16.8.2016 to the OPs, but to no avail.  Hence, the present complaint has been filed alleging the above act of the OPs as deficiency in service.

 

2]       The OPs No.1 & 3 have filed joint reply and while admitting the factual matrix of the case, stated that the available sum insured for settlement of claim is Rs.1,25,000/- and admittedly an amount of Rs.55,824/- plus Rs.24,600/- has been paid, a total of Rs.80,424/- by OP No.1 to OP No.2.  It is also stated that as per entitlement for Room, Boarding and Nursing Expenses, the amount admissible comes to Rs.7500/- whereas the claimed amount is Rs.45,950/- (Rs.42,000/- for Room and Rs.3950/- for Nursing), thus the amount of Rs.38,450/- has been rightly deducted.  It is further stated that similarly, the amount towards the Doctor’s Fees and Investigation Charges have been reduced in proportion of the Room Rent entitlement i.e. in the ration of Rs.7000/- to Rs.1250/- (1% of Rs.1,25,000/- the sum insured).  It is submitted that the Doctor’s Fee of Rs.13,500/- will be paid as follows: 13,500/-X1250/7000=2410/- and Rs.11,090/- have been deducted.  Similarly, Investigation Charges of Rs.74,560/- will be paid as follows: 74,560/-X1250/7000=13,314/- and Rs.61,246/- have been deducted.  It is denied that the complainant was made to pay an amount of Rs.61,704.32 though fully insured.  It is also submitted that the amount of claim has been paid as per the terms of the policy and thus no further amount is payable to the complainant.  Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint.

         Opposite Party No.2 did not turn up despite service, hence it was proceeded exparte vide order dated 03.11.2016.

 

3]       The complainant also filed rejoinder replication reiterating contentions as raised in the complaint.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have carefully examined the facts and pleadings along with entire evidence on record.

 

6]       To sum up, Arun Mahajan, the complainant, had Mediclaim Insurance Policy valid from 14.3.2016 to 13.3.2017 of the Oriental Insurance Company Limited.  As per Policy Ann.C-1 as well as Ann.R-1 & R-2,  the policy has insurance cover of Rs.1,50,000/-.

 

7]       The OP No.1, however, stated that the sum insured was only Rs.1,25,000/- as on 4.8.2016 under the Mediclaim policy, which on the face of record is misleading and mischievous too, just to deprive the complainant from the entitled benefits under the Mediclaim policy. 

 

8]       The complainant fell sick and admitted in Max Super Specialty Hospital, Mohali on 4.8.2016 and discharged on 10.8.2016 after treatment.  During the period under treatment, the complainant had a cover of insurance of Rs.1,50,000/-. 

9]       The Max Super Specialty Hospital, Mohali, presented a bill of Rs.1,66,628/- (Ann.C-4) on account of medical expenses/treatment of complainant with effect from 4.8.2016 to 10.8.2016.  The details of charges claimed in the bill are as below:-

Sl.No.	Service Name	Amount (Rs.)
1	Consultations	13,500.00
2	Drugs	2,930.21
3	Endoscopy	60,200.00
4	Laboratory Service	6,260.00
5	Medical Consumables	29,688.11
6	Medical Supervision Fee	3,950.00
7	Radiology Service	8,100.00
8	Room Rent	42,000.00
	Grand Total:	166,628.32

 

10]          Under the medical claim insurance policy applicable to the claim of the complainant, envisaged as follow:-

 

A.	HOSPITALISATION BENEFITS
	Expenses covered	Limits of Covered Expense
a.	Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing Homes.	Not exceeding 1% of the Sum Insured per day
b.	Intensive Care Unit (ICU) expenses as provided by the Hospital/Nursing Home	Not exceeding 2% of the Sum Insured per day
	Number of days of stay under ‘a’ and ‘b’ above should not exceed total number o days of admission in the hospital. Admissibility of all related expenses (c and d), except for medicine/pharmacy bills and body implants, shall also be as per the entitled category vis-à-vis room rent.
c.	Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees	As per the limits of the sum insured
d.	Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices like Pacemaker implanted during surgical procedures, relevant laboratory/diagnostic tests, X-ray, and similar expenses.	As per the limits of the sum insured.
B.	DOMICILIARY HOSPITALISATION (as defined under clause 2.13)
a.	Surgeon, Medical Practitioner, Consultants, Specialists Fees, Blood, Oxygen, Surgical Appliances, Medicines & Drugs, Diagnostic Material and Dialysis, Chemotherapy, Nursing expenses.	20% of the Sum Insured subject to maximum of Rs.50,000 per Insured Person, during the entire policy period.

 

 

11]      For the payment of Surgeon fee (Clause B (a) above), the mediclaim policy enumerations “20% of the Sum Insured subject to maximum of Rs.50,000 per Insured Person, during the entire policy period.” Meaning thereby, 20% of the sum insured of Rs.1,50,000/-, which comes to Rs.30,000/- is admissible to the complainant.  However, the OP No.1 deducted Rs.11,090/- out of Doctor Fee of Rs.13,500/- and approved only Rs.2410/-, which is illegal and utter violation of terms & conditions as laid down in the Mediclaim policy.

 

12]       As per the policy A(a) above, admittedly, 1% of the Sum Insured per day on account of room charges, are admissible under the policy to the complainant/insured.  Meaning thereby, the 1% of the sum insured in the present case comes to Rs.1500/-.  The complainant remained admitted in the Hospital for 6 days i.e. from 4.8.2016 to 10.8.2016 and as such entitled for room rent of Rs.1500X6 = Rs.9000/-, but the OP No.1 approved only Rs.7500/-, which is also illegal. 

 

13]       Under the policy A(d) above, the expenses incurred on “Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices like Pacemaker implanted during surgical procedures, relevant laboratory/diagnostic tests, X-ray, and similar expenses.” , is permissible to the complainant/insured as per the limits of the sum insured i.e. upto an amount of Rs.1,50,000/-.  However, the OP No.1, in the present case, while considering the claim of the complainant have unauthorizedly, without application of mind, have deducted Rs.61,246/- out of the billed amount of Rs.74,560/- and paid only Rs.13,314/-, which is also illegal. 

 

14]       The medical charges i.e. the amount spent on drugs and medical consumables, are permissible upto the insured amount i.e. Rs.1,50,000/- as in the present case.  However, the OP No.1 have deducted Rs.2328/- under medical charges, which is also illegal.

 

15]       The OP No.1 – Insurance Company explicitly, as is apparent from the perusal of the above facts, have committed grave illegality, just to deprive the complainant from the bonafide financial benefits, which was permissible to him under the Mediclaim insurance policy applicable thereto, hence committed deficiency in rendering proper service.

 

16]       Keeping in view the above facts, the complaint is hereby allowed against Opposite Party No.1/Insurance Company with direction to pay the balance amount of Rs.61,704/- to the complainant(insured) along with litigation expense of Rs.10,000/-, within a period of 30 day from the date of receipt of copy of this order.

 

17]       However, the complaint stands dismissed against OPs NO.2 & 3.

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

Announced

18^th April, 2017                                                                            

                                            Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER