Chandigarh

DF-I

CC/99/2018

Megha Ahluwalia - Complainant(s)

Versus

Oriental Insurance Company Ltd., - Opp.Party(s)

Gaurav Gupta Adv. & Karan Verma Adv.

21 Aug 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/99/2018
Date of Institution	:	16/02/2018
Date of Decision	:	21/08/2019

 

1.     Megha Ahluwalia wife of Kamal Preet Singh.

2.     Achal Raheja son of Bihar Lal Raheja.

        Both R/o H.No.3179/3, Sector 44-D, Chandigarh.

…..Complainants

V E R S U S

 

1.     Oriental Insurance Company Limited, Office: Quiet-15, Sector 35-A, Chandigarh, through its Senior Divisional Manager.

 

2.     M/s Mediassist Insurance TPA Limited, Regional Office, Aarpree Chamber, 4^th, 5^th and 6^th Floor, Shagbaug, Off Andheri Kurla Road, Marol, Andheri East, Mumbai – 400059, through its Regional Manager.

 

3.     Healing Hospital and Institute of Paramedical Science, through its Managing Director, SCO 18-19, Sector 34-A, Chandigarh.

……Opposite Parties

QUORUM:	SH.RATTAN SINGH THAKUR	PRESIDENT
	MRS.SURJEET KAUR	MEMBER
	SH. SURESH KUMAR SARDANA	MEMBER

                                                       

ARGUED BY	:	Sh.Guarav Gupta, Counsel for Complainants.
	:	Sh.Vinod Chaudhri, Counsel for OPs No.1 & 2.
	:	Sh.Harpreet Singh, Counsel for OP No.3.

PER SURJEET KAUR, MEMBER

1.         Mrs. Megha Ahluwalia and Another, Complainants have filed this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against the Oriental Insurance Co. Limited and Others (hereinafter called the Opposite Parties), alleging that Complaint No.1 is working as a Senior Manager in Axis Bank and Complainant No.2 is father of Complainant No.1. Both Complainant No.1 and her father being dependent of Complainant No.1 are covered under a Group Insurance Policy of Axis Bank Ltd. issued by Opposite Party No.1 valid from 01.10.2016 to 30.09.2017. During the currency of the policy, Complainant No.2 suffered a massive heart attack on 30.08.2017 and was immediately taken to Opposite Party No.3 Hospital where angioplasty was done and two stents were implanted in his heart. The Complainant No.2 remained hospitalized from 30.08.2017 to 02.09.2017. The total expenses incurred on the treatment was Rs.2,33,031/-. A claim was accordingly lodged with the Opposite Parties No.1 & 2, who reimbursed Rs.1,49,676/- only and without giving any reasoning deducted an amount of Rs.83,335/- from the total claimed amount. Hence, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on their part, the complainant has filed the instant complaint.
2.         Notice of the complaint was sent to Opposite Parties seeking their version of the case.
3.         Opposite Parties No.1 & 2 contested the Complaint and filed reply, inter alia, submitting that the patient was admitted from 30.08.2017 to 02.09.2017 with the history of acute chest pain and was diagnosed to have acute interior wall MI and accordingly treated with CAG and Angioplasty. It was observed that the hospital had applied package charges for Angiography and Angioplasty Surgery. As per package Rs.1,00,000/- was for PTCA and Rs.10,000/- for CAG on which 30% emergency charges were applied which comes to Rs.13,000/- and accordingly, a deduction of Rs.29,000/- as per available package was done. This deduction was as per available package rate of PTCA between the Hospital and Medi Assist. The claim was settled in the sum of Rs.1,49,676/- as per norms being followed by the Insurer/TPA. Pleading that there is no deficiency in service or unfair trade practice on their part, Opposite Parties No.1 & 2 have prayed for dismissal of the complaint.
4.         Opposite Party No.3 filed reply, inter alia, pleading that there is no lapse or deficiency in service on its part as it had arranged the best possible service to the Complainant and had not indulged in any kind of unfair trade practice. Pleading that there is no deficiency in service or unfair trade practice on its part, Opposite Party No.3 has prayed for dismissal of the complaint.
5.         Rejoinder was filed by the Complainant reiterating his version as advanced in the Consumer Complaint.
6.         The parties led evidence in support of their contentions.
7.         We have appraised the entire evidence, written arguments submitted by the Opposite Party No.1and heard the arguments addressed by the learned Counsel for the parties. 
8.         A meticulous perusal of the documentary evidence available on the record reveals that the Complainant No.1 requested for the claim to the tune of Rs.2,33,031/- being the expenses incurred on the treatment of Complainant No.2.
9.         Perusal of one document submitted by Opposite Party No.1 reveals that deduction was as per the available package rate of PTCA which was agreed package rate between the Hospital and Opposite Party No.2. It also has been conveyed through this document that Opposite Party No.2 mailed to networking team for review of package with latest tariff, but one Mr. Vishal Bainani of networking team did not share latest package rate with it for the reimbursement of the claim.  
10.         In the wake of aforesaid discussions, we are of the concerted view that Opposite Party No.1 is giving lame excuses of non-availability of the latest package rate as agreed between the Hospital and it (Opposite Party No.1). But contrary to the same, Opposite Party No.3 has filed duly sworn affidavit stating that it do not have any tie-up with Opposite Party No.1 and it cannot provide facility of cashless claim to the Complainants. Needless to mention here that there is no authentic document/evidence on record according to which it can be concluded/formulated that the deduction made was genuine one. In these set of circumstances, the act of Opposite Parties No.1 & 2 for not clarifying the facts in the form of terms & conditions despite appearing before the Bench and arbitrarily harassing the consumers i.e. Complainants by deducting a huge amount of Rs.83335/-, tantamount to deficiency in service and their indulgence in unfair trade practice.
11.         In view of the above discussion, the complainant has produced cogent evidence to prove unfair trade practice and deficiency in service on the part of Opposite Parties No.1 & 2. We find merit in the complaint and the same is allowed against Opposite Parties No.1 & 2.  Opposite Parties No.1 & 2 are, jointly & severally, directed :-

(i)     To refund the balance amount of Rs.83,335/- to the complainants.

(ii)    To pay a compensation of Rs.10,000/- to the complainants towards mental agony and harassment.

(iii)   To pay Rs.7,000/- to the complainants as costs of litigation.

                The complaint against Opposite Party No.3 fails and is accordingly dismissed with no order as to costs. 

12.         This order be complied with by Opposite Parties No.1 & 2 within one month from the date of receipt of its certified copy, failing which they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of filing of the present complaint till realization, apart from compliance of directions at Sr.No.(iii) above.
13.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
21/08/2019	[Dr.S.K.Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
	Member	Member	President
“Dutt”