Punjab

Moga

CC/15/36

Jyoti Parkash Gupta - Complainant(s)

Versus

The National insurance Company limited - Opp.Party(s)

Sh. Jasvir Singh Kalra

13 Aug 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

Complaint No.36 of 2015 

Instituted On: 09.06.2015 

                                                                                           Decided On: 13.08.2015

 

Jyoti Parkash Gupta son of Mani Lal Gupta resident of Sham Lal Advocate Wali Gali, Opposite Saheed Bhagat Singh Shopping Complex, District Ferozepur.

                                                                             ……..Complainant 

Versus  

1.       The National Insurance Company Limited, SCO 96,  1^st Floor, Secter

16, Near IDBI Bank, Faridabad.  

2.       The National Insurance Company Limited, Regional Office, SCO 332-334, Sector -34A, Chandigarh-160022.

3.       The National Insurance Company, Divisional Officer, Above Vijaya

Bank, Bhai Jaimal Singh Complex, Moga 1420001, Punjab.

4.       Vipul Madcorp TPA, Pvt. Ltd.  515 Audyog Vihar, Phase-V, Gurgaon,  Haryana 120016.   

               ……..Opposite Parties

 

 

Complaint under Section 12 of the

        Consumer Protection Act, 1986.

 

 

Coram:      Sh.S.S.Panesar, President

                   Smt Vinod Bala, Member

         Smt.Bhupinder Kaur, Member

 

Present:      Sh. Kapil Grover, Advocate counsel for complainant

                    Sh.Ajay Gulati, Advocate counsel for Opposite party Nos.

        1 to 3.

        Opposite party no.4 exparte. 

ORDER

(S.S.Panesar, President)

The complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986 (herein-after referred to as ‘Act’) against The National Insurance Company Limited and others (herein-after referred to as ‘opposite parties’)- directing them to pay the remaining amount of Rs.36,848/- out of the claim submitted to the opposite parties alongwith interest @ 18% p.a. from the date of claim till date, to pay Rs.50,000/- as damages on account of harassment, mental tension and agony and to pay Rs.22,000/- as litigation/complaint expenses to the complainant and also to grant any other relief to which this Forum may deem fit.

2.                Briefly stated, the complainant had purchased Health Insurance Policy bearing No.401700/48/13/8500000002 from the opposite parties in which the complainant and his wife were covered, which was valid w.e.f. 06.04.2013 to 05.04.2014, which was in continuation of policy no.361102/48/08/8500000073 valid w.e.f 6.4.2008 to 5.4.2009. During the continuation of the policy w.e.f 6.4.13 to 5.4.13, the wife of the complainant namely Shakuntla Devi Gupta slipped on 6.05.2013 and got injured. She remained admitted in Ranjit Hospital, Putligarh for the period w.e.f. 08.5.2013 to 15.5.2013 where she was operated upon on 09.5.2013. After discharging from the hospital, the wife of the complainant remained fit for 4-5 days and thereafter she had again problem. She was taken to Ranjit Hospital, where she had expired on 24.05.2014. The complainant spent an amount of Rs. 1,01,220/- on her treatment. The complainant had submitted his claim alongwith all the documents with opposite parties for re-imbursement of the mediclaim.  After going the documents and medical reports submitted by the complainant, the opposite parties rejected the claim of the complainant on the ground that the patient had history of hypertension since two years and as per clause 4.3/Medi Claim hypertension is not payable for first two years of operation of the policy. As per the said letter dated 24.01.14 issued by opposite party no.4, the policy of the insured is in second year. Hence claim is not payable. The opposite parties without any rhyme and reason repudiated the claim on the ground that the policy was in second year, whereas the said policy is continuing form year 2008 without any lapse and as such policy is running for last six years. Thereafter, the complainant had filed complaint before this Forum vide order dated 19.11.14 directing the complainant to approach the insurer for getting the mediclaim reprocessed and further complainant was directed to file the mediclaim alongwith all supporting documents within 15 days of passing of the order to the insurance company i.e. opposite party nos. 1 to 3, which will decide the claim of the complainant within further period of two months therefrom. In compliance of the order, the complainant had submitted the mediclaim alongwith the documents to the opposite parties and in furtherance of the mediclaim an amount of Rs.64,372/- was approved against the claim of Rs.1,01,220/- and further no interest have been paid on the delayed payment and no reason has been assigned for disapproving the claim of the complainant qua the remaining amount to which the complainant was entitled. The claim of the complainant has been cut short without any rhyme and reason. Due to deficiency in service and unfair trade practice on the party of the opposite parties complainant is suffering from mental and physical harassment and economic loss.  Hence the present complaint.

3.                Upon notice, opposite party Nos. 1 to 3 appeared through Sh.Ajay Gulati Advocate and filed written reply contesting the same. They took up preliminary objections that as per terms and conditions of the mediclaim insurance policy, the alleged claim has already been paid upto extent of Rs.64,372/- to the complainant and the amount of Rs.36,050/- as claimed by the complainant is not allowed and thus payable under the terms and conditions of the insurance policy in question. The complainant has already been fully informed about the approval of claim and he has fully explained about what was to be deducted from the amount he had claimed under the Insurance Policy. The detail of deductions as per terms and conditions has already been supplied to the complainant. The claim of the complainant was duly entertained, investigated and after due application of mind and as per terms and conditions of the insurance policy in question, the same has already paid and received by the complainant without any objection.  On merits submitted that the genuine and approved claim has already been paid to the complainant as per rules. It is submitted that out of total claimed amount the following deductions for Rs.36,050/- have been made:

Sr. No.	Bill No.	Main Head	Sub Head	Amount	Deduction	Reason for Deduction
1.	194	Others	File/Admission/ Registration	250	250	Admission charges not payable
2.	194	Room Tariff	Nursing charges	2000	2000	Part of RR
3.	194	Room Tariff	Room	21000	14000	Max. RR 1000/day payable including Nursing charges
4.	194	Surgical & OT Charges	OT Charges	30000	19800	IB. Limit Exhausted
Grand Total                                                             53250      36050

 

Further denying the content of all other paras of the complaint, opposite party nos.1 to 3 prayed for the dismissal of the complaint.

4.                Upon notice, despite due service, none of the opposite party no.4 came to contest the complaint. As such, opposite party no.4 was ordered to be proceeded against exparte.

5.                In order to prove his case, the complainant tendered in evidence his affidavit Ex.C-1 and copies of documents Ex.C-2 to Ex.C-14 and closed his evidence.

6.                To rebut the evidence of the complainant, opposite party Nos.1to 3 tendered affidavit of Sh. P.K.Mangla, Divisional Manager Ex.OP1,2,3/1 and copy of document Ex.O.P.No.1,2,3/2 and closed their evidence.

7.                We have heard the learned counsel for the parties and have also carefully gone through the record.

8.                On the basis of the evidence on record, learned counsel for complainant has vehemently contended that it is admitted that the complainant and his wife Smt.Shakuntla Devi Gupta had availed mediclaim policy, copy whereof is Ex.C-5, which was in vogue w.e.f 06.04.13 to 05.04.14. The policy in dispute was continuing mediclaim policy w.e.f 06.04.08 to 05.04.09. It is also not disputed that wife of the complainant Smt.Shakuntla Devi Gupta slipped and got injured. She had to be admitted in Ranjit Hospital, Putlighar, Amritsar on 08.05.13. She was operated on 09.05.13 and got discharged from the hospital on 15.05.13. Later on after 4-5 days, she was again admitted in Ranjit Hospital, Putlighar, Amritsar, where she expired on 24.05.13. The complainant submitted claim of Rs.1,01,220/- on account of expenses incurred by him on the treatment of his wife Smt.Shakuntal Devi Gupta. However, the opposite parties approved mediclaim to the tune of Rs.64,372/-, while the remaining claim of Rs.36,050/- was declined without any rhyme or reason. The opposite parties are deficient in service. No deduction could have been made from the claim made by the complainant. It has contended that the complaint may be allowed in view of the prayer made therein alongwith costs.

9.                Learned counsel for opposite party nos. 1 to 3 has vehemently contended that the claim filed by the complainant was duly processed and an amount of Rs.64,372/- was sanctioned while remaining amount of Rs.36,050/- was deducted in view of the terms and conditions of mediclaim policy, copy whereof is Ex.OP1,2,3/2. A reference has been made to relevant extract of clause no.1.0 of the insurance policy, which reads as under:-

            "In the event of any claim(s) becoming admissible under this scheme the Company will pay to the Insured Person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably and necessarily incurred thereof by or on behalf of such. Insured Person, but no exceeding the Sum Insured in aggregate mentioned in the schedule hereto.

A.        Room, Boarding Expenses as provided by the hospital/nursing home upto the maximum of 1% of Sum Insured per day and 2% of Sum Insured per day for ICU/ICCU. Room rent shall include nursing care, RMO charges, IV Fluids/Blood Transfusion/Injection administration charges.

B.        Surgeon, Anaesthetist, Medical Practitioner, Consultants and Specialist Fees.

C.        Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances (any disposable surgical) consumable subject to upper limit of 10% of the S.I.), Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artifical Limbs and cost of stent and implants.

                   In consonance with clause 1.0 of the insurance policy, the deductions have been made to the tune of Rs.36,050/- detail whereof is as under:-

Sr. No.	Bill No.	Main Head	Sub Head	Amount	Deduction	Reason for Deduction
1.	194	Others	File/Admission/ Registration	250	250	Admission charges not payable
2.	194	Room Tariff	Nursing charges	2000	2000	Part of RR
3.	194	Room Tariff	Room	21000	14000	Max. RR 1000/day payable including Nursing charges
4.	194	Surgical & OT Charges	OT Charges	30000	19800	IB. Limit Exhausted
Grand Total                                                         53250        36050

                   Learned counsel for the complainant did not point out any flaw or illegality in deductions made by the opposite parties out of mediclaim amount. There is no deficiency in service on the part of the opposite parties. It has contended that complaint may be dismissed being false and frivolous.

10.              We have given thoughtful consideration to the rival contentions.

11.              There is no denying the fact that complainant and his wife Smt.Shakuntla Devi Gupta was insured with the opposite parties vide insurance cover, which was effective w.e.f 06.04.13 to 05.04.14. It was continuing the mediclaim policy w.e.f 06.04.08. It has also not denied that Smt.Shakuntla Devi Gupta got slipped and sustained multiple injuries. She had to be admitted at Ranjit Hospital, Putlighar, Amritsar on 08.05.13 and she remained admitted in the hospital uptil 15.05.13. The complainant submitted mediclaim in pursuance of the insurance policy to the tune of Rs.1,01,220/- on account of expenses incurred on treatment of Smt.Shakuntla Devi Gupta. However, the opposite parties granted claim to the tune of Rs.64,372/-, while the remaining amount claimed by the complainant was declined. In our opinion, the claim was declined to the tune of Rs.36,050/- in view of the provisions of clause 1.0 of the insurance policy. Clause 1.0 of the insurance policy has been reproduced in the arguments addressed on behalf of the opposite parties which need not to be reproduced for avoiding repetition. The expenses which were not allowable as per the terms and conditions of the insurance policy have been rightly deducted from the mediclaim amount claimed by the complainant. There is absolutely no deficiency in service on the part of the opposite parties. The complainant has already been granted the claim allowable as per the terms and conditions of the insurance policy. Instant complaint is nothing, but an abuse of the process of law. There is no force in the complaint and the same deserves to be dismissed. Consequently, the instant complaint is ordered to be dismissed accordingly. Copies of the order be sent to the parties free of cost immediately and thereafter the file be consigned to the record room.

 

                   (Bhupinder Kaur)          (Vinod Bala)        (S.S. Panesar)

                    Member                         Member                   President

 

Announced in Open Forum.

Dated:13.08.2015.