Chandigarh

DF-I

CC/207/2018

Ms. Sunita Bhalla - Complainant(s)

Versus

The New India Assurance Co. Ltd. - Opp.Party(s)

N.K. Bhalla

07 May 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                               

Consumer Complaint No.	:	CC/207/2018
Date of Institution	:	08/05/2018
Date of Decision	:	07/05/2019

 

Ms. Sunita Bhalla resident of house No.345, MDC, Sector 4, Panchkula-134109, Haryana.

… Complainant

V E R S U S

1.     The New India Assurance Company Limited, Regd. & Head Office, 87, M.G Road, Fort, Mumbai-400001 through its Managing Director.

2.     The New India Assurance Company Ltd., SCO 37-38, Sec.17-C, 160017, through its Divisional Manager.

3.     Vidal Health Insurance TPA Pvt. Ltd., B-25, 1^st Floor, Sector 1, Noida through its Manager, Branch Operations & Services. 

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                             

      

ARGUED BY	:	Sh. N.K. Bhalla, Counsel for complainant
	:	Sh. Sukaam Gupta, Counsel for OPs 1 & 2
	:	OP-3 ex-parte.

Per Rattan Singh Thakur, President

1.         The allegations in brief are, husband of the complainant had purchased New India Flexi Floater Group Mediclaim Policy from OP-2 as per particulars given in para 1 of the consumer complaint.  Complainant’s case is, she suffered from illness and was admitted in Fortis Hospital, Mohali on 6.10.2017 and discharged on 7.10.2017. The hospital had raised a bill of Rs.1,29,947/- which was paid by the complainant as the OPs did not accord approval for the cashless treatment, though the policy of cashless treatment was taken.  Her case is, bill was submitted to OP-3 and an amount of Rs.99,632/- only was transferred to her account and when she sent a legal notice to OP-2, further amount of Rs.15,025/- was transferred in her account without giving any reference, but the remaining amount of Rs.15,292/- was not transferred from the total amount of Rs.1,29,947/-. In spite of cashless policy taken, approval was not accorded though assurance was given on phone that approval for cashless will be given shortly.  Since no approval was received, complainant was put to humiliation and on bill being raised she had paid the entire amount to the hospital. Hence, the present consumer complaint for directing the OPs to refund the balance amount of Rs.15,292/-, pay Rs.20,000/- as compensation and Rs.21,000/- as litigation expenses.
2.         OPs 1 & 2 had contested the consumer complaint and, inter alia, raised preliminary objections of consumer complaint being not maintainable.  Crux of their reply is, deductions were made as per terms and conditions per clause 3.1 (A), (C) and (D).  Their case is, there was capping in the room rent and was limited to boarding and nursing expenses actually incurred or 1% of the sum insured per day whichever is less; Rs.1,500/- as against admission charges; Rs.168/- deducted as against consultation charges; Rs.350/- deducted as against consumables and disposables; Rs.1,836/- deducted being non-medical expenses; Rs.492/- deducted against laboratory investigations; Rs.1,275/- deducted against miscellaneous charges; Rs.500/- deducted being excess amount and Rs.19,960/- was deducted against surgeons charges. On these lines, the cause is sought to be defended.
3.         OP-3 did not appear despite due service, therefore, vide order dated 25.6.2018, it was proceeded against ex-parte. 
4.         Rejoinder to the written reply of OPs 1 & 2 was filed and averments made in the consumer complaint were reiterated.
5.         Contesting parties led evidence by way of affidavits and documents.
6.         We have heard the learned counsel for the contesting parties and gone through the record of the case. After perusal of record, our findings are as under:-
7.         Per pleadings of the parties, the admitted facts are, complainant had actually got herself treated in Fortis Hospital as indoor patient from 6.10.2017 to 7.10.2017 and hospital had raised bill of Rs.1,29,947/-. These facts are not at all disputed by the OPs.  Their claim is, deductions were made as per terms and conditions of the policy.
8.         Perusal of the record further shows, first installment of Rs.99,632/- was deposited in the account of the complainant and thereafter another amount of Rs.15,025/- was deposited in her account.  The payment was not by way of cheque, but, through NEFT and, therefore, there was no chance with the complainant to lodge protest to say full claim not reimbursed. It was a case of direct transfer, therefore, there was no opportunity to protest its deposit.  How this was released in piecemeal is not understandable and no clarification on this score has been given by the OPs. 
9.         Perusal of the pleadings of the parties shows, OPs had not denied the claim that it was a cashless facility. If it was so, then why the approval was not accorded for cashless facility is not understandable.
10.         Even the pleadings and evidence led by the complainant shows, when the assurance of approval for cashless facility was given by the OPs, the hospital had calculated the patient’s share of Rs.3,250/- and rest was to be cashless.  There is no explanation on this point of fact why the approval for cashless facility was not accorded particularly so when the policy was as such.  The OPs themselves did not follow the terms and conditions of the cashless facility. At the most Rs.3,250/- i.e. the patient’s share could have been deducted and no other amount.
11.         Per allegations made in the consumer complaint as well as in the rejoinder furnished, followed with the affidavits, OP-3 i.e. Vidal Health Insurance TPA did not opt it proper to contest the consumer complaint meaning thereby allegations levelled therein by the complainant were not disputed at all. 
12.         In view of the above discussion, the present consumer complaint deserves to succeed and the same is accordingly partly allowed.  OPs are directed as under :-

1. To refund the balance claim amount of Rs.12,042/- (Rs.15,292 – Rs.3,250) to the complainant alongwith interest @ 9% per annum from the date of making the first payment i.e. 4.12.2017 till realization.
2. To pay an amount of Rs.10,000/- to the complainant as compensation for causing mental agony and harassment to her;
3. To pay Rs.5,000/- to the complainant as costs of litigation.

13.         This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
14.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
07/05/2019	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President