DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.295/16
Mr. Parveen Budhiraja
S/o Shri (late) O.P. Budhraja
R/o J 3/77, Flat No.R5 Second Floor
Khirki Extension Malviya Nagar
New Delhi. .…Complainant
VERSUS
The New India Assurance Co. Ltd.
22 Mothers House 2nd Floor
Yusuf Sarai Commercial Complex
Near Green Park
New Delhi-110016. ….Opposite Party
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Date of Institution: 12.09.2016
Date of Order : 10.05.2023
President: Ms. Monika A Srivastava,
The complainant is seeking Rs. 68,894/- with 12% interest along with the sum of Rs. 50,000/- compensation towards physical strain, harassment and mental agony and Rs. 10,000/- as legal costs.
- It is the case of the complainant that he was having a mediclaim policy from the OP vide policy no. 31150234142800000642 from 12.12.2014 till 11.12.2015 for coverage of Rs. 8,00,000/- and at premium of Rs. 18,765/- was paid by the complainant to the OP.
- It is the case of the complainant that on 11.09.2015 he was diagnosed with the medical problem of haemorrhoids and fissures and was advised surgery. Complainant was admitted to an empanelled hospital of the OP at Batra hospital was treated and his stay in the hospital was from 17.09.2015 till 23.09.2015.
- It is stated by the complainant that initially he deposited an amount of Rs. 10,000 at the hospital on 17.09.2015 and the total bill of the hospital was Rs. 1,43,374/- but the TPA paid only Rs. 74,480/- to the hospital out of the total bill of Rs. 1,43,374/-.
- It is the case of the complainant that despite being sick he had to somehow gather the balance amount to be paid to the hospital by taking private loans from the relatives and it became a very shameful situation for him.
- It is the case of the complainant that despite having cashless mediclaim yet he had to pay Rs. 10,000/- in the hospital and thereafter also a small amount was reimbursed to him and he was denied the entire payment.
- In their reply it is stated that they have already paid the sum of Rs. 74,480/- to the complainant which was due and payable under the terms and conditions of the policy and no further amount is due and payable to the complainant. Therefore, the complaint is without any cause of action and is liable to be dismissed.
- It is further stated by the OP that there has been no deficiency of service on the part of the OP and that the complainant has not come to this Commission with clean hands and is guilty of suppressing material facts.
- It is stated by the OP has not caused any mental agony to the complainant and that there has been no deficiency in service.
- In its rejoinder, the complainant has mostly denied all the above made by the OP in their reply.
Both the complainant as well as the OP have filed their respective evidence affidavits as well as written submissions. Oral arguments have been heard and this Commission has gone through the entire material on record.
It is seen from the record that no such defence has been taken by the OP in their reply and it is only in evidence that they have stated that the sum of Rs. 6,577/- was deducted proportionately from charges incurred at hospital, except medicines, since insured opted for room rent higher than the entitlement as per policy terms and same is not payable. It is further stated that a sum of Rs. 21,438/- was deducted for stapler which is part of hemorrhoidectomy package but has been charged separately by hospital.
In the written submissions, the complainant have clarified that this amount of Rs. 21,438/- had been denied by the hospital as doubly charged.
It is seen from the record that the OP is basing its defence on the terms and conditions provided in the policy which states as under:
“2.7 Continuous coverage means uninterrupted coverage with us till the date of commencement of period of insurance of the insured person under family floater mediclaim policy(2007) or under family mediclaim 2012 policy or New India Floater Mediclaim policy from time to time The coverage incepted under any of these policies. A break in insurance for a period not exceeding 30 days shall not be reckoned as an interruption in coverage for the purposes of this clause. In case of change in sum insured during such uninterrupted coverage, the lowest sum insured would be reckoned for determining continuous coverage.”
At the time of final arguments, on being asked the counsel for the OP could not explain the reason for the clause in case of uninterrupted coverage the lowest sum insured would be reckoned for determining continuous coverage.
This Commission is of the view that such a term is unfair trade practice on the part of the OP and misleads the complainant to believe and pay higher premium in the hope that in case of any adversity, the insured would be getting a better medical coverage. Therefore, the OP is held liable for indulging in unfair trade practice.
It is also seen from the record of the case that vide order dated 26.07.2017, the OP had paid a sum of Rs. 40,879/- to the complainant and the balance amount of Rs. 28,015/- is what is left to be paid to the complainant. However, this amount includes the cost of the stapler which should have been provided by the hospital. Therefore, this Commission directs the OP to pay a sum of Rs. 6,577/-to the complainant along with interest at 5% per annum from 23.09.2015 till realisation within 3 months from the date of this order failing which the OP shall be liable to pay this amount with interest at 7 % per annum from the said date till realization. The OP is further liable to pay a sum of Rs.20,000/- as compensation to the complainant within 3 months from the date of this order.
File be consigned to the record room after giving copy of the order to the parties as per rules.
