District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.79/2020.
Date of Institution: 06.02.2020
Date of Order: 08.08.2022.
Shakuntla Devi wife of Shri Baldev Raj Sharma, resident of B/284, Chawla Colony, Ballabgarh, Distt. Faridabad.
…….Complainant……..
Versus
1. The Manager, United India Insurance Company, SCO, 106, Commercial Complex, Green Channel Road, Sector-16, Faridabad.
2. The Manager, health Insurance TPA of India Ltd. A-110, 2nd floor, majestic Omnia Building, Second Floor, Sector-4, Noida – 201301.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
PRESENT: Sh. I.D.Sharma counsel for the complainant.
Sh. D.K.Gosain counsel for opposite party No.1.
Opposite party No.2 proforma opposite party vide order dated 08.02.2022.
ORDER:
The facts in brief of the complaint are that the complainant had obtained a mediclaim policy form opposite party No.1 vide policy No. 2221002917P118600939 which was valid form 26.03.2018 to 25.03.2019 for the sum of covered Rs.2,25,000/- and reimbursement of Rs.1,12,500/-. Thereafter the complainant renewed the above said policy vide policy No.2221002818P116450728 effective from 26.03.2019 to 25.03.2020. The complainant obtained the mediclaim policy from opposite party from several years. The complainant was suffering from pain in both knees, difficulty in walking. The complainant admitted in Sarvodaya Hospital, Sector-8, Faridabad on 22.03.2019 and she diagnosed with IV antibiotics (altacef, Amikacin), PPI, Analgestic, Antiemetics and other supportive measures and discharged from the hospital with follow up advise. The complainant had paid Rs.3,04,872/- in the hospital and spent Rs.36,871/- in the medicines i.e. total amounting to Rs.2,31,743/-. From the above said amount opposite parties had paid Rs.2,25,000/- to the complainant. The complainant requested the opposite parties so many times and demanded the remaining amount of Rs.1,16,743/-. However, the reimbursed amount in the policy of the complainant was Rs.1,12,500/-. Opposite parties had also approved the above said amount but opposite parties linger on the matter linger on the matter on one pretext or the other. The complainant again admitted in Sarvodaya Hospital, sEctor-8, Faridabad on 9.9.2019 due to Immature Cataract and discharged from the said hospital on the same day i.e.09.09.2019. The complainant again admitted in Sarvodaya Hospital, Sector-8, Faridabad on 09.09.2019 due to Immature Cataract and discharged from the said hospital on the same day i.e.09.09.2019. The complainant had spent Rs.25.025/- and also spent Rs.12,652/- in the medicines. From the above said amount opposite parties had paid Rs.25,025/- to his client and as sum of Rs.12,652/- was still pending against opposite parties. The complainant submitted the claim form for knee surgery on 24.05.2019 and for Immature Cataract on 10.10.2019 and it was obligation of opposite parties to pay the claimed amount within one month from the date of submitting the claim form. The complainant requested the opposite parties so many times through telephonic calls and emails but the opposite parties had failed to pay the above said amount of Rs.1,25,152/- to the complainant. The complainant sent legal notice dated 11.01.2020 through registered post to the opposite party but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the approved amount of Rs.1,25,152/- alongwith interest @ 24% p.a. from the date of due till actual realization.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 21,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the present complaint was regard to two different claims, one under the policy No. 2221002917P118600939 valid for the period 26.03.2018 to 25.03.2019 and other claim was under policy No. 2221002818P116450728 valid for the period 26.03.2019 to 25.03.2020 and as such consolidated complaint for two different under different mediclaim policies having separate cause of action was not maintainable. The answering opposite party had issued mediclaim insurance policy No. 221002917P1186000939 valid for the period 26.03.2018 to 25.03.2019 sum insured Rs.2,25,000/- and CB amount Rs.1,12,500/- subject to the terms and conditions and exclusion clauses and the limited liability under the said insurance policy. Opposite party No.1 had also issued mediclaim policy No. 22210028185116450728 valid for the period 26.03.2019 to 25.03.2020 subject to terms and conditions and exclusion clauses of the said policy. There was no deficiency in service on the part of answering opposite party because in respect of the claim of the complainant with regard to her hospitalization in Sarvodaya Hospital, Sector-8, Faridabad on 22.03.2020 as well as her treatment and discharge from the hospital was settled in full and final for Rs.2,25,000/- the sum insured as well as Rs.1,12,500/- CB amount under policy No. 2221002817P118600939 valid for the period 26.03.2018 to 25.03.2019 as per the terms and conditions of the policy, the amount of Rs.2,25,000/- was released to Sarvodaya Hospital on 09.09.2019 and Rs.1,12,500/- was transferred in the account of Ishwar Dayal Sharma on 09.07.2020 in respect of the claim of Shakuntla Devi. Further the claim of the complainant in respect of her admission in Sarvodaya Hospital, Sector-8, Faridabad on 09.09.2019 for her treatment in respect of her eyes was settled for Rs.24,000/- as per authorization letter and transferred to Sarvodaya Hospital and Research Center, Faridabad. An amount of Rs.12,302/- on account of medicines was transferred in the account of Ishwar Dayal Sharma on 07.02.2020 in full and final settlement of the claim of Shakuntla Devi under policy NO. 2221002818P116450728 valid for the period 26.03.2019 to 25.03.2020 as per the terms and conditions of the policy. Further as the claim had been settled under the terms and conditions of the policy therefore no amount on account of medicines etc. was payable by the opposite party. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– United India Insurance Company Limited & Another with the prayer to: a) pay the approved amount of Rs.1,25,152/- alongwith interest @ 24% p.a. from the date of due till actual realization. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 21,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Shakuntla Devi,, Ex.C1 – postal receipt, Ex.C2 – track report, Esx.C3 & C4 – postal receipts,, Ex.C-5 – Adhaar card,, Ex.C6 – insurance policy, Ex.C7 – insurance policy,, Ex.C8 – OPD consultation, Ex.C9 – OPD slip, Ex.C-10 – Bill of supply, Ex.C-11 X Ray Both Knee AP/Laat, Ex.C-12 – Bill of supply, Ex.C-13 – X Ray Ls Spine Lat View, Ex.C-14 – Discharge summary, EX.C-16 – diet chart, Ex.C-17b- receipt, Exs.C-18 & 19– Investigation reports, Ex.C-20 & 21 – Tests, Ex.C-22 & 23 – Bill of supply, Ex.C-24 – details, Ex.C-26 & 27– OPD prescription, Ex.C-28 & 29 – receipt, Ex.C-30 & 31 – prescription, Ex.C-32 – OPD consultation, Ex.C-33- prescription, Ex.C34 to 38 – bills, Ex.C-39 – legal notice,, Ex.C-40 – prescription, Ex.C-41 – bill, Ex.C-42 & 43 – IPD receipts, Ex.C-44 – receipt, Ex.C-45 , 45A, 46- bills, Ex.C-47 email, Ex.C-48 – legal notice dated 11.01.2020.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Dinesh Kumar, Administrative Officer, M/s. United India Insurance Company Ltd., D.O.10, SCO-106, 2nds floor, Sector-16, Faridabad,, Ex.R1 – insurance policy, Ex.R1 – insurance policy.
6. During the course of arguments, Shri I.D.Sharma, counsel for the complainant has made a statement that “I only press litigation and harassment charges in case of deposit of the compensation by the opposite party earlier then filing of the complaint then I am ready to pay the costs for the harassment of the opposite party.” On the other hand, payment of Rs.1,12,500/- was transferred in the account of Ishwar Dayal Sharma on 09.07.2020 in respect of the claim of Shakuntla Devi. An amount of Rs.12,302/- on account of medicines was transferred in the account of Ishwar Dayal Sharma on 07.02.2020 in full and final settlement of the claim of Shakuntla Devi under policy NO. 2221002818P116450728 valid for the period 26.03.2019 to 25.03.2020 as per the terms and conditions of the policy. The Commission is of the opinion that no doubt they have harassed the complainant mentally. Hence, they are negligent on their part. Deficiency of service is proved. Hence the complaint is allowed qua the harassment & litigation charges.
7. Opposite party is directed to pay Rs.5500/- as compensation for causing mental agony and harassment. Opposite party is also directed to pay Rs.3300/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 08.08.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
