Chandigarh

DF-II

CC/512/2019

Satya Dev Bansal - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

Sanjeev Gupta Adv.

19 Sep 2019

ORDER

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

============

Consumer Complaint  No	:	512 of 2019
Date  of  Institution	:	04.06.2019
Date   of   Decision	:	19.09.2019

 

 

 

 

 

Satya Dev Bansal w/o Sh.Ram Karan Dass, R/o H.No.515, Preet Colony, Gali No.3, Zirakpur, Teshil Derabassi,  Distt. Mohali Punjab.

 

             …………..Complainant

 

Versus

 

Oriental Insurance Company, S.C.O. No.48-49, Sector 17-A, Chandigarh through its authorised officer.

 …………… Opposite Party

 

BEFORE:  SH. RAJAN DEWAN           PRESIDENT

                                MRS. PRITI MALHOTRA       MEMBER

SH.RAVINDER SINGH          MEMBER

           

 

Argued By: Sh.Sanjeev Gupta, counsel for the complainant

Opposite Party exparte.

 

 

PER PRITI MALHOTRA, MEMBER

 

                                 The facts in brief are that the complainant obtained Mediclaim Policy No.231200/48/2018/2544 from Opposite Party for the period 26.6.2017 to 25.6.2018, covering the complainant and his wife Indira.  Unfortunately, the wife of complainant namely Indira (insured) on having pain in uterus, visited “The Touch”, a Multi-speciality Clinic, Sector 66, Mohali, Punjab, where Dr.Preeti Jindal, MD, DNB treated her on 11.12.2017.  Thereafter, the complainant lodged claim in respect of expenses incurred on the treatment taken by his wife, with the Opposite Party for reimbursement for a total sum of Rs.1,27,146/- i.e. an amount of Rs.85,000/- on account of Hospital Main Bill, Rs.38,100/- on account of pre-hospitalization charges/bills and Rs.4046/- on account of post hospitalization charges/bills.  However, the Opposite Party paid only an amount of Rs.50,146/- against the said claim of Rs.1,27,146/-, whereas at the time of issuance of Mediclaim policy by Opposite Party, it was assured to the complainant that all type of medical claims of treatment will be paid to him without any delay, but despite that the Opposite Party failed to pay his genuine claim.  Hence, this complaint has been filed alleging the said act of Opposite Party as gross deficiency in service and unfair trade practice. 

 

2]       The Opposite Party did not turn up despite service of notice sent through regd. post on 13.6.2019, hence it was proceeded exparte vide order dated 6.9.2019.

 

4]       Complainant led evidence in support of his contentions.

 

5]       We have heard the ld.Counsel for the complainant and have perused the entire record.

6]       There is no issue in regard to issuance of Mediclaim Policy No.231200/48/2018/2544 in favour of the complainant and his wife for the period effective from 26.6.2017 to 25.6.2018.  Further the treatment availed by the complainant’s wife (insured) for Endometrial Polyp ailment is also evident on record. The claim raised for the reimbursement of the expenses incurred on account of pre-hospitalization, for the treatment taken as well as post-hospitalization charges, has been reimbursed by the Opposite Party only by making payment of Rs.50,146/- and rest of the amounts has been deducted, which forms the basis of the present dispute between the parties.

 

7]       The complainant has alleged the deduction so made by the OP from his claim, as unreasonable and prayed for reimbursement of the balance amount against his medical claim. 

 

8]       To settle the matter, we considered the Claim Settlement Voucher, placed on record by the complainant himself at page No.8, which shows that against the claim amount of Rs.95,146/- an amount of Rs.50,146/- has been paid to the complainant through NEFT and the balance amount has been deducted under different heads.  The relevant extract of the said Claim Settlement Voucher is reproduced as under:-

Details of Deductions

Expense name	Billed Amt.(Rs)	Deduction Amt (Rs)	Approved Amt(Rs)	Reason of Deduction (If any)
Single Room	4500	0	4500
Single Room	4500	0	4500
Single Room	4500	0	4500
Doctor Fees C.F	2400	0	2400
Anesthesia Charges	8000	1474	6526	Rs.1474 DEDUCTED AS PER REASONABLE CUSTOMARY RATE
Surgeon Fees	20000	20000	0	Rs.20000 DEDUCTED AS PER REASONABLE CUSTOMARY RATE
Investigation  Charges	1500	0	1500
Hospital Services	6200	5000	1200	Rs.5000 DEDUCTED FOR ASSITANT CHARGES NON PAYABLE
Medication Charges	19900	6526	13374	Rs.6526 DEDUCTEDFOR CONSUMABLE CHARGES NON PAYBALE
Post Hospitalisation Charges	7196	0	7196
Registration Fee	500	500	0	Rs500 DEDUCTED FOR REGISTRATION CHARGES
Operation Theatre Charges	10000	10000	0	Rs.1000 DEDUCTED AS PER REASONABLE CUSTOMARY RATE
Pre Hospitalisation Charges	2950	0	2950
RMOI/Nursing	3000	1500	1500	Rs.1500 DEDUCTED FOR NURSING CHARGES.

9]       In our considered view, all the deductions, as shown in the above chart, nowhere justifies to be genuine. The Opposite Party also preferred to be proceeded exparte despite being duly service, projecting that it has nothing to contradict the genuine demand of the complainant, so an adverse inference is drawn against the Opposite Party and in favour of the complainant. Also there is no terms & conditions mentioned in the policy document which reflects the deductions so made by the Opposite Party as correct and genuine.

 

10]      In our opinion, the deductions so made by the Opposite Party on various accounts, referred to above, mentioning it to be ‘as per reasonable customary rate’ is totally just arbitrary and whimsical deductions.  The reasonable customary rates has nowhere been explained by the Opposite Party in the Claim Settlement Voucher or Policy. Thus, the complainant is held to be fully entitled for the balance amount of the claim, so lodged with OP.

 

11]      In view of the above discussion and findings, we are of the opinion that the Opposite Party has wrongly deducted the balance amount from the Mediclaim of the complainant and as such, rendered deficient services.  Therefore, the present complaint is allowed against the Opposite Party with direction to refund to the complainant the balance amount of Rs.45,000/- (Rs.95146-Rs.50146) and also to pay with compensatory cost as well as litigation expenses to the tune of Rs.15,000/-.

         This order shall be complied with by the Opposite Party within a period of 30 days from the date of receipt of copy of this order, failing which the Opposite Party shall be liable to pay additional compensatory cost of Rs.15000/- apart from the above relief. 

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

Announced

19^th September, 2019                                                                         Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

sd/-

(RAVINDER SINGH)

MEMBER