DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-V

NORTH-WEST DISTRICT, GOVT. OF NCT OF DELHI

CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

CC. No.1128/2016

IN THE MATTER OF :

NARENDER KUMAR

S/O LATE SH. HARI KARAN SINGH,

R/O WP-448, VILLAGE-WAZIRPUR, ASHOK VIHAR, DELHI-11052

                                                                                                                                                     ….                                Complainant

VERSUS

     1.   THE MEDICAL SUPERINTENDENT

RG STONE UROLOGY & LAPAROSCOPY HOSPITAL,

194-195, DEEPALI CHOWK, PITAMPURA, DELHI-110034

2. THE BRANCH MANAGER,

THE OREINTAL INSURANCE COMPAN LTD.,

28/12, EAST PUNJABI BAGH, RING ROAD,

NEW DELHI-110026.

3. GOOD HEALTH PLAN LTD (TPA),

4/23, (UG), EAST PATEL NAGAR, NEW DELHI-110008.

                                                                                                                                                         ….                               Opposite Party

ORDER

28.04.2023 (corrected on 03.08.2023)

MS NIPUR CHANDNA, MEMBER

1. A complaint under Section 12 of Consumer Protect Act 1986 (hereinafter referred to as C.P.Act) filed by Sh. Narinder Kumar (hereinafter referred to as complainant). The complainant is seeking release of balance claim amount of Rs.63,336/- with interest @ 24% p.a till its realization, Rs.2,00,000/- as compensation on account of mental agony, physical harassment, conveyance etc and Rs.15,000/- cost of legal proceedings against OP2 and 3.
2. In brief facts of the present case are that the complainant had taken a Medi-claim Policy bearing No. 271900/48/2016/767 from OP2 Oriental Insurance company (hereinafter referred to as OP2). It is stated that the insured person’s against this Policy are Narender Kumar (Self), wife Smt. (Kusum Lata). It is further stated that the sum insured is Rs.3,00,000/- for the said Policy bearing no. 271900/48/2016/767. It is stated that the insured period is 27.05.2015 to Midnight 26.05.2015. The renewal Policy insured period is 27.05.2016 to Midnight 26.05.2017.
3. In the month of April-2016, the complainant was having severe pain in abdomen with fever and chills. The complainant was admitted on 20.04.2016 in RG Stone Urology & Laparoscopy Hospital (hereinafter referred to as OP1). It is further stated that the treatment/Operation was done in OP1 Hospital and thereafter complainant got discharged on 28.04.2016.
4. The Hospital raised a bill of Rs.1,48,679/-, out of which OP2 paid only Rs.48,577/- to Hospital and balance/remaining amount Rs.1,00,102/- was paid by complainant under protest. It is alleged that the OP2 is not releasing the balance-claim under one pretext or the other.
5. It is alleged that the  complainant supplied all relevant documents to  OP2 and Good Health Plan Ltd.(hereinafter referred to as OP3) but the officials of the OP2 and OP3 are not giving proper response in this matter nor releasing the total-claim. The complainant approached the OP2 and OP3 several times and lodged complaints also but all in vain. It is further alleged that finally, the OP2 repudiated the claim. It is further stated that on 13.10.2016, the OP2 transferred the sum of Rs.36,766/- in complainant’s Bank-account.
6. It is stated that OP2 failed to release the total-claim despite repeated requests of the complainant, which has caused  great mental tension pain, agony, harassment, inconvenience and loss to the complainant.

7. The officials of OP2 and OP3 have  failed and neglected to discharged their duty, which compelled the complainant to knock the door of this Commission, hence, present complaint filed.
8. OP1 and OP3 served but failed to contest the complaint and also failed to file their WS therefore they were ordered to be proceeded ex-parte vide order dated 25.10.2017.
9. On merit all the allegations are denied. It is stated that under cashless already  a sum of Rs. 36,776/- has been paid to complainant and thereafter further sum of  Rs.36,776/- paid on submission of the relevant medical documents. It is further stated that as per the opinion of TPA and the documents submitted by complainant already maximum payable amount of the claim as per GIPSA package (B) has been released in favour of the complainant and remaining amount of Rs.63,336/- was found not admissible under  the terms and conditions of the Insurance policy and GIPSA Package (B), therefore no case of deficiency of service can be made out qua OP-2. It is further prayed that present complaint be dismissed with cost.
10. Complainant filed rejoinder to the written statement of OP2 and denied all the allegations made therein and reiterated contents of the complaint.
11. Complainant filed  evidence by way of affidavit. In the affidavit contents of complaint reiterated. Complainant relied on insurance policy A3 and A4, discharge summary of RG Stone Urology and Laproscopy Hospital B1 and B2, the bill raised by hospital C1 –C8, complaint lodged against OP2 and 3 D, repudiation letter dated 10.06.2016 E, and bank account showing receiving of Rs.36,766/- on13.10.2016 from OP2 F1-F2.
12. As per record OP-2 filed its evidence, however failed to place on record the policy terms and conditions as well as terms and conditions pertaining to GIPSA package (B).  Written arguments filed by complainant as well as by OP2. We have heard  Sh. D.K sinha counsel for complainant, Sh. Vijay gupta counsel for OP2 and perused the record.
13. Some facts are not denied by the parties such as the policy in question as well as the treatment undergone by the complainant. During the course of treatment the complainant incurred total expenses to the tune of Rs. 1,48,679/- out of which the OP-2 paid Rs. 85,343/- and a sum of Rs. 63,336/- remained unpaid being non – admissible on account of the terms and conditions of the policy as well as per the GIPSA package(B).
14. Perusal of the record shows that OP filed its WS, evidence by way of affidavit as well as written arguments but failed to place on record the policy terms and conditions as well as the policy pertaining to GIPSA package (B) on the basis of which the OP-2 is justifying the deductions.
15. In view of the above discussions we are of the considered view that non-filing of the policy terms and conditions as well as the documents pertaining to GIPSA package (B) on record unable OP-2 to stand on his leg and justify the repudiation of the balance claim. Non submission of the documentary evidence on the part of OP-2 compelled this Commission to hold the repudiation unjustified. Holding repudiation unjustified, We hold OP-2 guilty of deficiency in service and direct it as under:
    1. Release the balance claim of the complainant for a sum of Rs. 63,336/- along with 6% interest from the date of filing of complaint i.e. 25.10.2016 till realization.
    2. Pay to the complainant a sum of Rs. 10,000/- on account of pain mental agony suffered by him which will also include cost of litigation.

OP is further directed to comply the order within 30 days from the date of receipt of this order failing which OP is liable to pay to the complainant interest @9% per annum from the date of non-compliance till realization.

Copy of the order be sent to the parties free of cost. The orders be uploaded on www.confonet.nic.in.

File be consigned to Record Room.

Announced in open Forum on  28.04.2023.

SANJAY KUMAR                                                                            NIPUR CHANDNA

PRESIDENT                                                                                             MEMBER