BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No  318 of 2014

Date of Institution: 6.06.2014

Date of Decision:8.12.2015

Mr.  Gurinder Singh Grover Son of Sh.Santokh Singh R/o A-5/303,n Type 3 BHK, Crescent Parc-Ashberry Homes, G.T.Road Bye Pass,Near Vallah,Amritsar

Complainant

Versus

Tata AIG General Insurance Co.Ltd. through its Chairman/Managing Director/Principal Officer service through its Branch Office at District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager

Opposite Party

Complaint under section 11 and 12 of the Consumer Protection Act, 1986

Present:    For the Complainant                  :  Sh.Deepinder Singh,Advocate

               For the Opposite Party      : Sh.P.N.Khanna,Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Sh. Anoop Sharma, Member

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Gurinder Singh Grover under the provisions of the Consumer Protection Act alleging therein that he obtained mediclaim policy (Wellsurance Family Policy) for himself , his wife and children from the opposite party for the period from 28.4.2013 to 27.4.2014 by paying premium of Rs. 10757/- with sum assured Rs. 2 lacs vide policy No. WFEB1000000762. According to the complainant he fell ill and was to be hospitalized for the period from 26.9.2013 to 2.10.2013 at Hargun Hospital where he incurred Rs. 63938/- on his treatment. Complainant lodged claim with the opposite party and the opposite party paid the amount of Rs. 20500/- to the said hospital as the policy was cashless policy and the rest of the amount of Rs. 43438/- was paid by the complainant from his own pocket. Complainant visited the opposite party many times for the payment of the balance amount of Rs. 43438/- but the opposite party did not pay any heed to the request of the complainant. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to pay the amount of Rs. 43438/- alongwith interest @ 12% p.a. Compensation of Rs. 50000/- alongwith litigation expenses were also demanded.
2. On notice, opposite party appeared and filed written version in which it was submitted that complainant is covered under Wellsurance Family Classic Policy bearing No. WFEB1000000762 which is a fixed benefit health plan and the benefit is paid on the number of days of hospitalization multiplied by per day limits. The benefits available under the policy are as under:-

3.       It was submitted by the opposite party that as per documents submitted by the complainant , it was observed that the complainant was admitted in Hargun Hospital for  a period from 26.9.2013 to 2.10.2013 i.e. 7 days, out of which 5 days the complainant stayed in ICU and rest of the two days he stayed in General ward for suffering head injury alongwith SDH with Contusions with Aspiration Pneumonia. The claim was reported with the opposite party which was duly registered . On receipt of the treatment record and bills submitted by the complainant was of Rs. 62938/-, which was inclusive of various particulars which was outside the scope of the benefits mentioned in the Classic Policy of Wellsurance, the claim was accordingly processed by EMSL TPA and as per the terms and conditions of the policy payment of Rs. 20500/- was made to the hospital in the following manner:-

It was submitted that the total amount of Rs. 20500/- was paid to the hospital vide cheque No. AXISP13317046711 dated 13.11.2013  and there is no deficiency of service on the part of the opposite party qua the complainant.

4.       Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-5.

5.       Opposite party tendered affidavit of Mr.Mohd.Azhar Wasi , Head North Zone Claims Ex.OP1, affidavit of Mr.Anil Kumar Gupta, authorized signatory of M/s. E-Meditek TPA Ex.OP/2 alongwith documents  letter dated 2.2.2013 Ex.OP/3 and insurance policy alongwith terms and conditions Ex.OP/4.

6.       We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the  parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.

7.       From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant obtained mediclaim policy bearing No. WFEB1000000762 for the period from 28.4.2013 to 27.4.2014 on payment of premium of Rs. 10757/- with sum assured Rs. 2 lacs. The complainant fell ill and was admitted in Hargun Hospital,Amritsar on 26.9.2013 and was discharged  on 2.10.2013. The Complainant spent Rs. 63938/- on his medical treatment. Claim was lodged with the opposite party as the policy was cashless policy. Opposite party paid amount of Rs.20500/- only to the hospital and the balance amount of Rs. 43438/- was paid by the complainant to the hospital authorities. Complainant approached opposite party for the payment of balance amount of Rs. 43438/- to the complainant, but the opposite party did not pay this amount to the complainant. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party qua the complainant.

8.       Whereas case of the opposite party is that the complainant was covered under Wellsurance Family Classic Policy No. WFEB1000000762 . As per this policy the benefits available are hospital cash upto 90 days (per day) to the tune of Rs. 2000/-, ICU benefit maximum 15 days (per day) = Rs. 3000/-, Convalescence benefit payable after 5 days stay Rs. 1500/-. The complainant was admitted in Hargun Hospital ,Amritsar for the period from 26.9.2013 to 2.10.2013 i.e. for 7 days , out of which 5 days the complainant stayed in ICU and rest 2 days he stayed in general ward for suffering head injury alongwith SDH with Contusions with Aspiration Pneumonia. Claim for hospitalization of the complainant was reported to the opposite party which was duly registered. On receipt of the treatment record and bills submitted by the complainant for Rs. 62938/- including various particulars which were outside the scope of the benefits mentioned in the policy in question, claim was accordingly processed by EMSL TPA and  as per terms and conditions of the policy, payment of Rs. 20500/- was made to the hospital as the insured had availed cashless facility i.e. hospital cash 2 days x Rs.2000/- = 4000/-, ICU benefit for 5 days x Rs.3000/- = Rs.15000/- and convalescence benefit Rs.1500/-. This amount was paid to the hospital vide cheque dated 13.11.2013 from TPA. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party qua the complainant.

9.       From the entire above discussion, we have come to the conclusion that complainant has obtained mediclaim policy for the period from 28.4.2013 to 27.4.2014 Ex.OP4 on payment of premium of Rs. 10757/- with sum assured Rs. 2 lacs. The complainant fell ill and was admitted in Hargun Hospital,Amritsar on 26.9.2013 and was discharged on 2.10.2013 as per discharge card Ex.C-5. The complainant spent Rs. 62938/- as per bill issued by Hargun Hospital Ex.C-3. Opposite party was duly informed. The policy was with cashless facility. The opposite party paid Rs. 20500/- only to the hospital and the complainant has to pay the balance amount Rs. 42438/- from his own pocket. The opposite party has paid Rs. 20500/- only with details that hospital charges for 2 days @ Rs.2000/- amounting to Rs. 4000/- (instead of  Rs. 5000/- claimed by Hargun Hospital), ICU benefit for 5 days @ Rs. 3000/- amounting to Rs. 15000/- (instead of Rs. 20500/- claimed by Hargun Hospital), but the opposite party could not produce any evidence nor could cite any clause of the policy on the basis of which the opposite party had not paid the following charges mentioned in the bill of the hospital Ex.C-3:-

10.     Opposite party was not justified in not making the payment of this amount of Rs. 35,688/- nor the opposite party could produce any evidence to prove that this amount is not payable to the complainant as per the terms and conditions of the policy.

11.     So the present complaint is partly allowed and the opposite party is directed to pay this amount of Rs. 35688/- to the complainant within one month from the date of receipt of the copy of this order ; failing which opposite party shall be liable to pay interest @ 9% p.a. on this amount of Rs. 35688/- from the date of filing of the complaint till payment is made to the complainant. Opposite party is also directed to pay litigation expenses Rs. 2000/- to the complainant. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

8.12.2015                                                             ( Bhupinder Singh )

President

/R/                        ( Kulwant Kaur Bajwa)           (Anoop Sharma)

Member                                   Member