Punjab

Sangrur

CC/207/2018

Bhinderpal Singh - Complainant(s)

Versus

The New India Insurance Company Limited - Opp.Party(s)

Sh.S.S.Dhindsa

28 Feb 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                               

                                                Complaint No.    207

                                                Instituted on:      26.04.2018

                                                Decided on:       28.02.2020

 

Bhinderpal Singh Gosal son of Sh. Nirbhai Singh, resident of House No.313, Hareri Road, Ram Basti, Sangrur, Tehsil and Distt. Sangrur.

                                                        …Complainant

                                Versus

1.     The New India Assurance Co. Ltd. Ranbir College Road, Sangrur through its Branch Manager.

2.     The New India Assurance Co. Ltd. New India Assurance Building, 87, Mahatma Gandhi Road, Fort Mumbai 400 001 through its Managing Director.

3.     Columbia Asia Hospital Bhupindra Road, Near 22 No. Phatak, Patiala through its Manager.

                                                        ..Opposite parties

For the complainant            :       Shri S.S.Dhindsa, Adv.

For Opp.parties 1&2          :       Shri Ashish Garg, Adv.

For OP  No. 3                    :       Exparte.

 

Quorum                                           

Shri Amrinder Singh Sidhu, President

Shri Vinod Kumar Gulati, Member

 

ORDER BY:     

Shri Amrinder Singh Sidhu, President.

1.             Shri Bhinderpal Singh Gosal, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is a consumer of the OPs by purchasing a cashless mediclaim insurance policy bearing number 361300341722800000015 for the period from 10.7.2017 to 09.07.2018 after paying the requisite premium of Rs.9546/- and the complainant is availing the said mediclaim insurance policy from the year 2015 and under this policy the complainant and his wife were insured/covered for any ailment for Rs.3,00,000/-.      The case of the complainant is that during the subsistence of the insurance policy, the wife of the complainant suddenly fell ill due to pain in the abdomen on 18.6.2017 and after thorough investigation, she was diagnosed a case of stone in gallbladder, as such she was operated for the gallbladder in the hospital of OP number 3  and was admitted on 14.4.2018 and the OP number 3 got pre approval for cashless scheme.  Thereafter, the Op Number 3 sent a drafted bill for Rs.59075/- on 16.4.2018 to the OP number 1 and 2, but they approved only Rs.33669/-, then the complainant had got no option except to pay the deducted amount of Rs.25,406/- to the OP number 3.  As such, it is stated that the amount of Rs.25,406/- has been illegally deducted by Ops number 1 and 2.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the amount of Rs.25,406/-  along with interest @ 18% per annum from the date of  drafted bill till realisation and further claimed compensation and litigation expenses.

2.             In reply of the complaint filed by the OP number 1 and 2, it is admitted that the policy in question was issued to the complainant on floater basis for Rs.3,00,000/- for the period from 10.7.2017 to 09.07.2018. It is further admitted that wife of the complainant was admitted on 14.4.2018 at Columbia Hospital Patiala and discharged on 16.4.2018 due to cholelithiasis and lodged the claim for Rs.59075/- and after carefully examining the file, the claim was passed to the tune of Rs.33,669/- and it is further stated that as per the terms and conditions of the policy, the room rent is payable as 1% of the policy including nursing and boarding charges per day or actual whichever is less and charges under the other heads like doctor fee, surgeon fee OT-Anaesthesia fee and investigation were applicable as per entitled room category of Rs.3000/- only. The other allegations levelled in the complaint have been denied.

3.             Record shows that OP number 3 was proceeded against exparte.

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-7 copies of documents and closed evidence. On the other hand, the learned counsel for the OP number 1 and 2 has produced Ex.OP1&2/1 to Ex.OP1&2/4 copies of documents and affidavit and closed evidence.

5.             We have  perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties.

6. The learned counsel for the complainant has contended that complainant is a consumer of the OPs by purchasing a cashless mediclaim policy bearing number 361300341722800000015 for the period from 10.7.2017 to 09.07.2018 after paying the requisite premium of Rs.9546/- and the complainant is running the said mediclaim insurance policy from the year 2015 and under the policy the complainant and his wife were insured/covered for any ailment for Rs.3,00,000/-.      Further case of the complainant is that during the subsistence of the insurance policy, the wife of the complainant suddenly fell ill due to pain in the abdomen on 18.6.2017 and after thorough investigation, she was diagnosed a case of stone in gallbladder, as such she was operated for the gallbladder in the hospital of OP number 3  and was admitted on 14.4.2018 and the OP number 3 got pre approval for cashless scheme.  Thereafter the Op Number 3 sent a drafted bill for Rs.59075/- on 16.4.2018 to the OP number 1 and 2, but they approved only Rs.33669/-, then the complainant had got no option except to pay the deducted amount of Rs.25,406/- to the OP number 3.  As such, it is stated that the amount of Rs.25,406/- has been illegally deducted which should be paid to the complainant.

7.             On the other hand, the learned counsel for the Ops number 1 and 2 has contended that the policy in question was issued to the complainant on floater basis for Rs.3,00,000/- for the period from 10.7.2017 to 09.07.2018. It is further admitted that wife of the complainant was admitted on 14.4.2018 at Columbia Hospital Patiala and discharged on 16.4.2018 due to cholelithiasis and lodged the claim for Rs.59075/- and after carefully examining the file, the claim was passed to the tune of Rs.33,669/- and it is further stated that as per the terms and conditions of the policy, the room rent is payable as 1% of the policy including nursing and boarding charges per day or actual whichever is less and charges under the other heads like doctor fee, surgeon fee OT-Anaesthesia fee and investigation were applicable as per entitled room category of Rs.3000/- only.

8.             It is admitted fact between the parties that the complainant had obtained a health insurance policy from OP number 1 and 2 on 10.7.2017 for the period from 10.7.2017 to 9.7.2018 by paying the requisite premium of Rs.9546/- to the OP number 1 and 2. During the subsistence of the insurance policy, the wife of the complainant suffered from abdominal pain problem and was admitted in the hospital of OP number 3 on 14.4.2018 where she spent an amount of Rs.59075/-, but the OPs paid only an amount of Rs.33669/- and withheld the remaining amount of Rs.25406/-. From the documents submitted by the complainant, we find that the Ops have wrongly and illegally deducted the said amount of Rs.25,406/- as the OP number 3 has raised the bill for the amount of Rs.59075/- for the treatment of wife of the complainant.  As such we are of the considered opinion that the Ops number 1 and 2 are liable to pay to the complainant an amount of Rs.25406/-.

9.             As such, the complaint is allowed with directions to OP number 1 and 2 to pay to the complainant an amount of Rs.25406/- along with interest @ 8% per annum from the date of filing of the complaint i.e. 26.4.2018 till realization. We further direct  OP number 1 and 2 to pay to the complainant an amount of Rs.2000/- as compensation. This order be complied with within 45 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

10.            This complaint could not be decided and order could not be pronounced within stipulated time period because posts of President and Lady Member are lying vacant since 7.8.2018 and 16.09.2018 respectively. The President is doing additional duty only for two days per week.

Pronounced.

                        February 28, 2020.     

 

(Vinod Kumar Gulati)                  (Amrinder Singh Sidhu)

          Member                                    President