Chandigarh

DF-I

CC/540/2018

Karamveer Singh - Complainant(s)

Versus

Religare Health Insurance Co. Ltd. - Opp.Party(s)

Vikram Tandon

29 Nov 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

                                                    ========

 

                                     

Consumer Complaint No.	:	CC/540/2018
Date of Institution	:	30/10/2018
Date of Decision	:	29/11/2019

 

Karamveer Singh S/o Sh. Harvinderpal Singh, R/o H.No.88/1, Phase-VII, S.A.S. Nagar, Mohali – 160022.

…..Complainant

 

V E R S U S

 

 

Religare Health Insurance Co. Limited, Branch Office, SCO No.           55-58, 1^st Floor, Sector 9-D, Chandigarh, through its Branch Manager.

…… Opposite Party

QUORUM:	MRS.SURJEET KAUR	PRESIDING MEMBER
	DR.S.K.SARDANA	MEMBER

                                                                       

ARGUED BY	:	Sh. Vikram Tandon, Counsel for Complainant.
	:	Sh. Sachin Ohri, Counsel for Opposite Party.

 

Per Dr.S.K.Sardana, Member

1.         Adumbrated in brief, the facts necessary for the disposal of the instant Consumer Complaint are, the Complainant took Health Insurance Policy namely, Care Policy for his parents, which was valid from 7.3.2017 to 6.3.2018 by paying the requisite premium. The Complainant on 18.12.2018 got operated the right eye of his father Sh.Harvinderpal Singh for cataract from Virdi Eye Hospital, Sector 34-A, Chandigarh and accordingly, submitted the bills for Rs.1,05,000/-. Thereafter, again on 16.01.2018, the Complainant got operated the left eye of his father and submitted the bills for Rs.1,05,000/-. On 09.01.2018 the Opposite Party sent a claim approval & settlement letter by which only an amount of Rs.35,936/- was disbursed against the first bill and against the second only an amount of Rs.35,280/- approved. Later, both these amounts were transferred to the account of the Complainant as full & final settlement. It has been alleged that at the time of issuing the policy, it was told that there will be no capping of any type in the settlement of the medi-claim. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Party, the complainant has filed the instant Consumer Complaint.
2.         Notice of the complaint was sent to Opposite Party seeking its version of the case.
3.         Opposite Party contested the Complaint and filed reply, inter alia, admitting the basic facts of the case. It has been pleaded that the in the first bill, the answering Opposite Party in accordance to the policy terms & conditions deducted an amount of Rs.68,163/- and paid an amount of Rs.35,936/- to the Complainant towards the expenses incurred by him for the treatment of his father. While on receipt of the second bill, the answering Opposite Party settled the reimbursement claim for a cumulative amount of Rs.35,280/- and deducted an amount of Rs.60,900/- under Reasonable & Customary Charges and an amount of Rs.8820/- was deducted as co-payment subject to the policy terms & conditions. Pleading that there is no deficiency in service or unfair trade practice on its part, Opposite Party has prayed for dismissal of the complaint.
4.         The parties led evidence in support of their contentions.
5.         We have gone through the record and heard the arguments addressed by the learned Counsel for the parties.
6.         It has come on record that the Complainant had purchased the Health Insurance Policy (CARE) Floater for his mother and father for a sum insured of Rs.10,00,000/- subject to the policy terms and conditions. The settlement of the claim was subject to reasonable customary charges and the policy terms and conditions only. The clause pertaining to Reasonable and Customary Charges is as under: - 

1.61 Reasonable & Customary Charges means the charges for services or supplies, which are the standard charges for specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved.

                We have also gone through the comparative analysis regarding package for Cataract Surgery with other hospitals in the vicinity and find that the claim reimbursed by the Opposite Party appears to be reasonable.  Also, it is observed that at the time of the first policy with the company the age of the insured person was more than 61 years and the insured had to co-pay 20% per claim. Hence, the Opposite Party was also justified in deducting additionally Rs.8984/- and Rs.8820/- respectively as co-payment as per the policy terms and conditions.

7.         Ld. Counsel for the Complainant has argued that no terms and conditions were ever supplied to the Complainant and therefore, the same are not applicable to the Complainant. We do not find any substance in the said arguments, in as much as, at this belated stage, the said objection cannot be taken if the Complainant had not been supplied with the policy terms and conditions at the time of taking of the policy, he could have asked for the same. Thus, it is construed that the terms and conditions of the policy were duly supplied to the Complainant at the time of taking of the policy.
8.         For the reasons recorded above, we do not find even a shred of evidence to prove any deficiency in service or unfair trade practice on the part of Opposite Party. Consequently, the Consumer Complaint fails and the same is dismissed, leaving the parties to bear their own costs.
9.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
29/11/2019	[Dr.S.K.Sardana]	[Surjeet Kaur]
	Member	Presiding Member
“Dutt”