Punjab

Sangrur

CC/277/2018

Om Parkash - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

Sh.Vinay Kumar Jindal

26 Apr 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                         Complaint No. 277

 Instituted on:   15.06.2018

                                                                         Decided on:     26.04.2022

 

Om Parkash Joshi aged 53 years son of Sh. Jamna Dass, R/O #117, Ward No.12, Guru Nanak Nagar, Dhuri, Tehsil Dhuri, District Sangrur.

                                                          …. Complainant.     

                                                 Versus

1.     Oriental Insurance Company through its Branch Manager, above OBC Bank, Meera Ghati Chowk, Karnal 132001 (Haryana).

2.     Raksha TPA Pvt. Ltd. through its M.D. SCO 359-360, 1^st Floor, Sec-44D, Chandigarh.

             ….Opposite parties. 

For the complainant  : Shri Vinay Jindal, Adv.              

For the OP 1            : Shri Ashish Garg, Advocate.

For OP No.2             : Exparte.

 

Quorum                                          

Ashish Kumar Grover, President

Sarita Garg, Member

 

ORDER BY:     

Ashish Kumar Grover, President.

1.             Complainant has approached this Forum/Commission alleging inter-alia that the complainant is an employee of KRBL company at Bhasaur and the complainant is taking regularly Oriental Bank Medical claim policy at Dhuri from OP number 1 through online and the complainant also got renewed policy bearing number 281301/1048/2016/3363 on 13.2.2017 by paying the requisite premium of Rs.6990/- which was deducted from the bank account of complainant. It is further averred that the complainant is having his bank account number 50100010680105 with HDFC Bank Ltd branch Dhuri.  On 13.2.2017 the complainant asked OP number 1 that he has not received any confirmation of above renewal of policy, then OP number 1 sent reply through email to complainant and felt regret due to inconvenience to complainant and told that his policy has already been renewed vide policy number 261301/48/2017/3863 vide which complainant and his family members i.e. his wife Usha Sharma, daughters Sakshi and Aditi were covered for Rs.5,00,000/-. Further it is stated that the complainant was told by OP number 1 that complainant and his family members can get cashless medical treatment in case of illness.

2.             Further case of complainant is that on 29.12.2017, the daughter of complainant namely Aditi @ Adity became serious due to illness and as such she was taken to Sibia Health Care Pvt. Ltd. in emergency where she was admitted and remained under treatment from 29.12.2017 to 31.12.2017 and spent an amount of Rs.15,232/- on her treatment as the OP number 1 refused to make the payment.  Thereafter the complainant lodged the claim with the OP number 1 and submitted all the documents, but  OP number 1 did not pay any claim. 

3.             Further case of complainant is that on 1.2.2018, Aditi again became serious due to suffering of fever, nausea, vomiting, loose stools and as such she was admitted in DMC Hospital, Ludhiana in emergency, where she was diagnosed as Pulmonary Koch’s and Febrile illness and she remained admitted in the hospital from 1.2.2018 to 14.2.2018. The DMC Hospital Ludhiana raised a bill of Rs.1,04,278/- for the treatment, but the OP number 1 accepted the claim to the tune of Rs.59,223/- only  and an amount of Rs.45,055/- was paid by the complainant from his own pocket to the hospital authorities. The complainant requested the OP number 1 to pay Rs.45,055/- to the complainant, but nothing was paid. As such, total claim amount of Rs.60,287/- in total remains to be paid by OP number 1 to the complainant. Thus, alleging deficiency in service on the part of the Ops the complainant has prayed that the Ops be directed to pay him an amount of Rs.60,287/- alongwith interest and further to pay compensation of Rs.20,000/- and litigation expenses of Rs.10,000/-.

4.             Record shows that  OP number 2 did not appear despite service, as such OP number 2 was proceeded against exparte on 1.8.2018.

5.             In reply filed by Op number 1, it is submitted that OP number 1 issued a OBC Oriental Royal Mediclaim policy to the complainant for the period from 28.2.2017 to 27.2.2018 and the sum insured was Rs.5,00,000/-. It is further admitted that Smt.Usha Sharma wife, Sakshi and Aditi were also covered under the policy. It is further admitted that Aditi remained admitted in DMC Hospital from 1.2.2018 to 14.2.2018 for getting treatment and after receiving the request for cashless treatment, the TPA of OP number 1 assessed Rs.57,148/- only as the hospitalization charges were payable for five days only and over stay is not justified as per clause 3.12 of the policy, therefore the OP number 1 paid an amount of Rs.59,133/- to the complainant.  Further as regards the daughter of complainant admitted in Sibia Hospital Sangrur in emergency, the same has been denied, as such it is stated that OP number 1 is not liable to pay the claim amount of Rs.15,232/-.  Lastly, the OP number 1 has prayed that the complaint be dismissed with special costs.

6.             The complainant has produced Ex.C-1 to Ex.C-5 copies of insurance policy, Ex.C-6 to Ex.C-14 are the medical record of Sibia Hospital, Sangrur, Ex.C-15 is copy of bank statement, Ex.C-16 to Ex.C-22 are medical record of DMC Hospital Ludhiana, Ex.C-23 to Ex.C-32 are copies of emails, Ex.C-33 is the copy of letter and Ex.C-34 affidavit of complainant and closed evidence.

7.             The learned counsel for OP number 1 has produced Ex.OP-1/1 copy of insurance policy, Ex.OP1/2 copy of terms and conditions, Ex.OP1/3 letter dated 7.3.2018, Ex.OP1/4 copy of payment sheet, Ex.OP1/5 copy of letter dated 15.3.2018 and Ex.OP1/6 affidavit of Shri Mukesh Malhotra, D.M. and closed evidence.

8.             It is an admitted fact that OP number 1 issued a OBC Oriental Royal Mediclaim policy to the complainant for the period from 28.2.2017 to 27.2.2018 and the sum insured was Rs.5,00,000/-.

9.             It is further admitted fact of the OPs that Smt.Usha Sharma wife, Sakshi and Aditi were also covered under the policy and it is further admitted that Aditi daughter of the complainant remained admitted in DMC Hospital from 1.2.2018 to 14.2.2018 for getting treatment and after receiving the request for cashless treatment, the TPA of OP number 1 assessed Rs.57,148/- only against the total bill of DMC Hospital Ludhiana to the tune of Rs.1,04,278/-, as the hospitalization was payable for five days only and over stay was not justified, as such OP number 1 paid an amount of Rs.59,133/- to the complainant.  Further as regards the daughter of complainant admitted in Sibia Hospital Sangrur in emergency, it is argued by the Ops that no claim is payable as no documents have been submitted by the complainant to the Ops.  As such, the learned counsel for OP number 1 has contended that the remaining amount of the claim has rightly been denied.

10.           Ex.C-6 to Ex.C-8 are the medical record of Sibia Hospital, Sangrur which clearly shows that the complainant spent an amount of Rs.11,180/- on the treatment of her daughter Adity as she remained admitted in the said hospital from 29.12.2017 to 1.1.2018. Ex.C-9 is the copy of claim form which clearly reveals that the complainant lodged the claim with the OP number 1.   Ex.C-10 to Ex.C-21 are the copies of medical record of DMC Hospital Ludhiana  which clearly shows that the hospital authorities raised a bill for Rs.1,04,278/-, but out of which the OP number 1 paid an amount of Rs.59223/- only and the remaining amount of Rs.45,055/-was paid by the complainant from his own pocket.  The OP number 1 deducted the amount of Rs.45,055/- on the ground that hospitalization for more than five days is not justified in the present case, but we are unable to accept this contention of OP number 1 as hospitalization is not in the hands of the complainant or any one rather the same is at the discretion of the hospital authorities for which days a patient is required to be hospitalized. More over, there is nothing mentioned in clause 3.12 of the policy about the admission of days in the hospital.  As such, we are unable to accept such a contention of the OP number 1 to deduct an amount of Rs.45,055/- from the bill of the hospital.  Accordingly, we find that since the policy of the complainant was for Rs.5.00 Lacs and by not paying the full claim to the complainant, we are of the considered opinion that it is a clear cut case of deficiency in service on the part of the OP number 1. As discussed above, we find that the OP number 1 is liable to pay to the complainant a total amount of Rs.56235/- (Rs.11180/- + Rs.45055/-).

11.           In view of our above discussion, we allow the complaint partly and direct OP number 1 to pay to the complainant an amount of Rs.56,235/- alongwith interest @ 7% per annum from the date of filing of present complaint i.e.15.6.2018 till realization in full.   We further direct OP number 1 to pay to the complainant an amount of Rs.5000/- as costs and Rs.5000/- as compensation on account of mental agony and harassment to the complainant. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.

                                Pronounced.

 

                                April 26, 2022.

 

            (Sarita Garg)                           (Ashish Kumar Grover)

                 Member                                         President