Chandigarh

DF-I

CC/263/2022

Anil Garg - Complainant(s)

Versus

The Branch Manager, The Oriental Insurance Co. Ltd. - Opp.Party(s)

Anil Kumar Garg

14 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/263/2022
Date of Institution	:	3.3.2022
Date of Decision	:	14.8.2023

 

Anil Garg Advocate H. No.1004, Sector 9, Panchkula.

 

… Complainant

V E R S U S

1.   The Branch Manager, the oriental Insurance Company Ltd. SCO No. 48-49, Sector 17-A, Chandigarh 160017.

2.   Health Insurance TPA Pvt. Ltd. SCO No.39, 1^st floor, Sector 26, Madhya Marg, above Barbeque Nation, Chandigarh 160019, Mr. Ravi.

3.   The Manager, OJAS Medical Service Private Ltd. H-1, Sector 26, Panchkula 134116.  

.  … Opposite Party

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                       

ARGUED BY		Complainant in person.
		Sh. Nikunj Dhawan, counsel for OP No.1
		OP No.2 exparte.
		OP No.3 exparte.

 

Per SURESH KUMAR SARDANA, Member

2.      Briefly stated the complainant purchased a mediclaim policy from OP No.1 by paying premium of Rs.10,730/- which was valid from 17.12.2020 to 16.12.2021. The complainant suffered from Dengue fever and admitted in OJAS Hospital Sector 26 Panchkula on 14.10.2021 and discharged on 17.10.2021. Since the policy was cashless therefore, the complainant submitted all the documents. It is alleged that at the time of discharge the  OP hospital  demanded an amount of Rs.14065/-  from the complainant as OP No.1 has not cleared the outstanding amount of OP No.3 hospital. The complainant many times approached the OPs and even sent legal notice but nothing was done by the OPs. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed
3. The Opposite Parties NO.1 in its reply stated that the total expenses incurred by the complainant in the hospital was to the tune of Rs.51,704/- out of which Rs.14065/-  was repudiated  by the  answering OP as after going through the documents it was observed that cashless claim settlement in respect of the hospitalization was done according to terms and conditions of the policy. Sum insured under the policy is Rs.4.00 lakh  so eligibility for the room rent is limited upto Rs.4000/- per day and all other expenses need to be deducted proportionately as per the policy condition.  Thus the claim of the complainant was settled after due consideration of the claim by TPA thereby reimbursing reasonable charges and as such the amount of Rs.14,065/- was repudiated as per clause 1.2 of the terms and conditions of the policy. All other allegations made in the complaint has been  denied being wrong.
4. OP No.2 in its reply its reply stated that it has no role to play in the instant dispute as the medi-claim policy was issued by the OP No.1 and it only acts as a facilitator for the processing of the claim as per terms and conditions of the policy laid down by OP No.1. Denying all other allegations it is prayed that the complaint be dismissed.  
5. OP No.2 after filing reply and evidence did not turn up on 1.8.2023, hence, it was proceeded exparte on the said date whereas OP No.3 did not turn up despite due service, hence vide order dated 1.2.2023 it was proceeded against exparte
6. Rejoinder was filed and averments made in the consumer complaint were reiterated
7. Contesting parties led evidence by way of affidavits and documents.
8. We have heard the learned counsel for the contesting parties and gone through the record of the case.
9. The main grievance of the complainant is that in spite of having proper medical insurance cover the OPs have illegally deducted an amount of
   Rs.14,065/-  from the amount of claim bill payable.
10. On perusal of terms and conditions annexed as R/1 by the OP No.1, it is observed that there is a condition with regard to payment of expenses, based on the room rent limit. An extract of the same is reproduced here below:-

 

Sr. No.	Expenses Covered	Silver	Gold	Dianond
i.	Room, Boarding and Nursing expenses as provided by the hospital/Nursing Home	1% OF THE SUM INSURED PER DAY	XXXXX	XXXXX
Ii	Intensive care Unit(ICU) Expenses  as provided by the Hospital/Nursing Home	2% of the sum insured  per day	Xxxxxx	XXXXX

 

Number of days under ‘i’ and ‘ii’ above should not exceed total number of days of admission in the hospital. All related expenses (including iii and iv below) shall also be payable as per the entitled room category based on the room rent limit as mentioned above. This will not apply on medicines/pharmaceuticals and body implants. 

 

11. On perusal of Annexure C-6 which is a detailed statement of reimbursement of claim, containing details of expenses, bills, deduction, approved amount and reasons for deductions if, any, it is observed that necessary deductions have been made as per  terms and conditions of the policy.  The said statement contains, the reason of deductions as well.
12. Hence, in view of the foregoing, we are of the view that the deductions have been made in pursuance to the terms and conditions of the policy. Thus, the complainant  has failed to prove his case  
13. In view of the aforesaid discussion, the present consumer complaint, being devoid of any merit, is hereby dismissed leaving the parties to bear their own costs.
14.     Certified copies of this order be sent to the parties free of charge. The file be consigned

			sd/- [Pawanjit Singh]
			President
			sd/-
			[Surjeet Kaur] Member sd/-
14.8.2023			[Suresh Kumar Sardana]
mp			Member