Chandigarh

DF-II

CC/245/2016

Nirmal Singh - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

In Person

28 Sep 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	245/2016
Date of Institution	:	08.04.2016
Date of Decision	:	28.09.2016

 

                                       

                                               

Nirmal Singh aged about 59 s/o Dalan Singh r/o Q.No.12, Upkar Nagar, Gurudawar Dukh Niwaran Sahib, Patiala.

                                ...  Complainant.

Versus

1.     Oriental Insurance Co. Ltd., Branch M.M.Malnia Road, Amritsar through its Manager.

 

2.     Oriental Insurance Co. Ltd., Regional Office at SCO 109-111, Surendra Building, Sector 17-D, Chandigarh through its Manager.

…. Opposite Parties.

BEFORE:  SHRI RAJAN DEWAN, PRESIDENT

SMT.PRITI MALHOTRA, MEMBER

 

Argued by: Complainant in person.

                Sh.D.C.Kumar, Adv. for the Opposite Parties

 

PER RAJAN DEWAN, PRESIDENT

1.         In brief, the case of the complainant is that he purchased the policy of health insurance bearing No.235300/48/2014/1378 which was valid from 01.01.2014 to 31.12.2014.  It has further been averred that he was operated for stone in gall bladder at Gobind Hospital, Tripuri Town, Patiala during the existence of the policy and made cash payment to the said hospital.  He applied for recovery of the claim amount with OP No.1 and sent complete file after fulfilling all the formalities as required.  It has further been averred that as desired by the OPs, he immediately submitted the OPD paper but the OPs failed to settle the claim. It has further been averred that the OPs have illegally and arbitrarily retained the claim despite service of the legal notice dated 01.10.2015. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the complainant has filed the instant complaint.
2.         In their written statement, the OPs pleaded that the complainant lodged the claim for Rs.22,744/- instead of Rs.32,068/- with the TPA and the claim of Rs.17,394/- has already been paid to him after deducting a sum of Rs.4,350/- which were not payable as per the terms and conditions of the Insurance Policy. It has further been pleaded that the complainant is not entitled for any damages from the OPs.  The remaining allegations were denied, being false. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made.
3.         We have heard the complainant, in person, and learned counsel for the OPs and have gone through the documents on record.
4.         It is an admitted fact between the parties that the complainant was operated for removal of stone in the gall bladder during the currency of the Insurance Policy in the Gobind Hospital and Lab, Patiala.   In the complaint, the complainant has claimed Rs.32,068/- on account of his treatment whereas the case of the OPs is that the complainant is only entitled to the sum of Rs.18,394/- as assessed by the TPA vide letter dated 02.05.2016 and the same already stood paid to the complainant.       The details of the amount payable and the deductions made from the claim amount of Rs.32,058/- as given in written arguments of the OPs is as under:

1. The bills for Rs.650/- and Rs.5200/- are of date 16.09.2014 and 23.08.2014 and do not fall in and pertain to the period of admission in the hospital of 18.08.2014 to 21.08.2014 and, therefore, are not payable under the terms and conditions of the Policy.
2. An amount of Rs.4,124/- has been claimed twice. One through separate bill and again through consolidated bill, therefore, this amount has been deducted.
3. Rs.3,500/- has been deducted from the room rent being excess rent paid over the rent of his eligibility as per policy.
4. Rs.200/- paid as admission charges were not payable.

                The details of the amounts payable and deductions made have also been exhibited in Annexure R-1  issued by the Third Party Administrator i.e. E-meditek (TPA) Services Ltd.  On the contrary, the complainant has failed to adduce any evidence to prove that he is entitled to sum of Rs.32,068/- as claimed by him. In this view of the matter, we are of the considered view that the complainant is entitled to Rs.22,744/- as assessed by the TPA. 

5.         Undisputedly, the complainant took the treatment in the month of September, 2014 and he submitted the claim with the requisite documents with the OPs in the year 2014 itself. However, the OPs took more than one and half years to settle the genuine claim vide letter dated 02.05.2016 without explaining any plausible reason for such a long delay. The OPs have also not been able to adduce on record any copy of the letter whereby they ever requested the complainant to submit any document to process the claim.  Had the OPs settled the claim of the complainant within a reasonable period then the position certainly would have been different.
6.          In this view of the matter, the OPs have committed grave deficiency in service by not settling the genuine claim of the complainant within a reasonable period and, therefore, they are liable to compensate for the mental agony and physical harassment undergone by him on this count besides litigations expenses.
7.         For the reasons stated above, the present complaint deserves to be allowed and the same is accordingly allowed. The Opposite Parties are directed as under ;-

1. To pay a sum of Rs.5,500/- to the complainant for causing mental agony and physical harassment to him.
2. To pay Rs.2,500/- to the complainant as litigation expenses.      

8.         This order be complied with by the Opposite Parties, within 45 days from the date of receipt of its certified copy, failing they shall pay the awarded amounts to the complainant alongwith interest @9% per annum from the date of this order, till actual payment.
9.         Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

28.09.2016                                                                       sd/-

          (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER