| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION PATIALA. Consumer Complaint No. 304 of 10.8.2017 Decided on: 23.1.2023 Rajesh Kumar Bansal S/o Sh.Prem Chand Bansal, resident of Kothi No.124, Ekta Kunj, Near State Bank of India, New Officers Colony, Patiala. …………...Complainant Versus The New India Assurance Co. Ltd.,Leela Bhawan, Patiala. …………Opposite Party Complaint under the Consumer Protection Act QUORUM Hon’ble Mr. S.K.Aggarwal, President Hon’ble Mr. G.S.Nagi,Member PRESENT: Sh.Bhart Virdi, counsel for complainant. Sh.Sanjiv Kumar Garg, counsel for OP. ORDER - The instant complaint is filed by Rajesh Kumar Bansal S/o Sh.Prem Chand Bansal (hereinafter referred to as the complainant) against New India Assurance Co. Ltd. (hereinafter referred to as the OP/s) under the Consumer Protection Act (for short the Act).
- The averments of the complainant are as follows:
That the complainant is holder of mediclaim policy No. 36150034162800000373, for the period from 22.1.2017 to 22.1.2018.He admitted for a planned surgery in Sir Ganga Ram Hospital, New Delhi on 16th June,2017 and was discharged after surgery on 21.6.2017. Before surgery OP was informed well in time, who wrote letter dated 21.6.2017 to the said hospital. The complainant spent Rs.3,11,129/- on his treatment but the OP approved only Rs.1,29,529/- and the balance amount of Rs.1,81,600/- was paid by the complainant from his own pocket. In this regard, complainant lodged claim with the OP but it failed to pay any heed. Complainant also got served legal notice dated 12.7.2017 upon the OP for settlement of claim who gave vague reply to the notice. As such there is deficiency in service on the part of the OP. Hence this complaint with the prayer for giving a direction to the OP to pay the balance outstanding amount alongwith interest and costs of litigation expenses. - Upon notice, OP appeared through counsel and filed the written statement raising various preliminary objections.
- On merits, it is it is submitted that the policy in question was a New India Floater Medical Policy for Rs.3,00,000/-and the OP has made full and final payment to the complainant of his claim, as per the terms and conditions of the insurance policy. After denying all other averments of the complainant, the OP has prayed for the dismissal of the complaint.
- In support of his complaint, ld counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant, Ex.C1 original insurance policy, Ex.C2 copy of legal notice and closed the evidence.
- On the other hand, ld. counsel for the OP has tendered in evidence,Ex.OPA affidavit of Smt.Gurveen Kaur, Sr.Divisional manager of OP, Ex.OP1 copy of reply to legal notice, Ex.OP2 copy of complete insurance policy alongwith terms and conditions (Page 1 to 33), Ex.OP3 copy of claim settlement voucher, Ex.OP4 copy of letter dated 27.6.2017 and closed the evidence.
- The ld. counsel for the parties have advanced the arguments as per their respective pleadings and the evidence adduced on record.
- After going through the record of the case, it transpires that complainant is holder of New India Floater Mediclaim insurance policy, Ex.C1 valid for the period from 21.1.2017 to 21.1.2018, with the total sum insured of Rs.3,00,000/. The complainant had undergone surgery during this period and spent Rs.3,11,129/- out of which OP paid Rs.1,29,529/-.These facts have not been denied by the OP. The grievance of the complainant is that balance amount of Rs.1,70,471/- has not been paid by the OP. In this regard he has also issued legal notice dated 12.7.2017 Ex.C2, upon the OP.
- Initially, the OP calculated the payable amount as Rs.94,839/-vide Ex.OP3, which was further revised to Rs.1,30,529/-(Ex.OP4), when OP has relied upon Clause 3.1 of terms and conditions of the policy,Ex.OP2, according to which reimbursement value has been calculated after making the deductions.As per the said term, the room rent to be payable is included but not limited to boarding and nursing expenses, actually incurred or 1% of the Sum Insured per day, whichever is less.
- The complainant had purchased a policy for Rs.3lac(Ex.C1) and as per the said condition, the room rent payable was Rs.3000/- per day.The complainant remained admitted in the hospital for the period from 16.6.2017 to 21.6.2017 ( 6 days).As such room rent would be Rs.18000/-. However, claim of Rs.45000/- has been made by the complainant. As such Rs.27000/-in excess of the eligibility have been claimed by the complainant, which are not payable. However, the other expenses of which deductions have been made include the actual medical expenses, incurred by the complainant, as per Ex.OP3. We are thus, of the opinion that the OP is not justified to deduct the amount actually paid by the complainant qua medical expenses as no element of luxury is involved. Moreso, it is not forgotten that the complainant took the policy of mediclaim to the tune of Rs.3,00,000/-.
- In view of our above discussion, we partly allow the complaint with a direction to the OP to settle the claim of the complainant for Rs.1,43,471/-after making deduction of Rs.27000/-paid in excess of eligibility on account of room rent and Rs.1,29,529/- already paid to the complainant against a total sum insured of Rs.3,00,000/-. Parties are left to bear their own costs. Compliance of the order be made by the OP within 30 days from the date of the receipt of certified copy of this order.
- The instant complaint could not be disposed of within stipulated period due to heavy rush of work, Covid protocol and for want of Quorum from long time.
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G.S.Nagi S.K.AGGARWAL Member President | |
