DISTRICT   CONSUMER   DISPUTES   REDRESSAL FORUM,GURGAON-122001

                                                                                                              Consumer Complaint No: 42 of 2014                                                                                                                                                         Date of Institution: 05.02.2014/12.02.2014                                                                                                                                               Date of Decision: 15.02.2016.

Subhash Chandra Sexena Tower-H, Flat No.203, Maple Heights, Sushant Lok-1, Block-C, Gurgaon-122009, Haryana.

                                                                                        ……Complainant.

                                                Versus

The Managing Director, The Oriental Insurance Co. Ltd, A-25/27, Oriental House, Asaf Ali Road, New Delhi-110002.

The Senior Divisional Manager, The Oriental Insurance Co. Ltd, Divisional Office: 215300, IInd Floor, Payal Cinema Complex, Delhi Road, Sector-14, Gurgaon-122001, Haryana.

The Regional Head & DGM, Regional Office, Oriental Bank of Commerce, Plot No.80, Sector-44, Near Ramada Hotel, Gurgaon, Haryana.

The Senor Branch Manager, Oriental Bank of Commerce, Charanjiv Bharti School Extension Counter, Sushant Lok-I, Block-C, Gurgaon, Haryana.

                                                                              ..Opposite parties

Complaint under Sections 12 & 14 of Consumer Protection Act,1986                                                                  

BEFORE:     SHRI SUBHASH GOYAL, PRESIDENT

SMT JYOTI SIWACH, MEMBER

                   SH.SURENDER SINGH BALYAN, MEMBER.

Present:        Shri Subhash Chander Saxena, complainant in person.

                    Shri Arun Yadav, Adv for the opposite party No.1 & 2.

                    Shri Raj Kumar Goyal, Adv for OP-3 & 4.

ORDER       SUBHASH GOYAL, PRESIDENT.

The case of the complainant, in brief, is that he has purchased Oriental Bank Medi-Claim Insurance Policy No.215390/48/2012/1456 from the OP-4 which was valid from 17.01.2012 to 16.01.2013 which was subsequently renewed vide policy No.21530/48/2013/2235 for the period of one year which was effective from 17.01.2013 to 16.01.2014 for ID of Rs. 3 Lacs. The complainant was outraged to see that the policy operational period was incorrectly mentioned as Jan 30,  2013 to Jan 29, 2014 in the policy document . In the meantime his request for provision of cashless facility was denied by Medi-Assist (TPA) at Noida due to Exclusion Clause 4.1 of the policy and for breach in the period of two continuous insurance policies while the complainant was admitted in Paras Hospital, Gurgaon for angioplasty. Initially, a bill of Rs.3, 50,000/- was raised by Paras Hospital on 03.02.2013 at 1.21 pm. Subsequently, after denial of cashless facility a new bill was prepared on Feb 3, 2013 at 6:25 pm the complainant was compelled to pay a total amount of treatment i.e. Rs.3,70, 050/- vide final bill dated 03.02.2015 as per tariffs of Paras Hospital and thus, forced to pay an additional amount of Rs.20,050/- as per the terms and conditions of Paras Hospital  caused by denial of cashless facility. The complainant got rectified the policy documents from the OP-4 and on 13.02.2013 he received the hardcopy of the same mentioning correct period of operation of the policy. The complainant after release from Paras Hospital on 04.02.2013 submitted the claim with the OPs for Rs.3,70,000/- on 09.02.2013 to Medi Assist India TPA Pvt. Ltd, Noida for the treatment he had undergone. After examination of the fact of the issue and all relevant documents the same was resolved and got approved for payment of Rs. 3 Lacs on 15.04.2013. However,  a letter dated 03.01.2014 was received from the Insurance Company repudiating the claim of the complainant in response to the application dated 20.12.2013. Thus, there was deficiency in service on the part of the opposite parties. The complainant prayed that the opposite parties be directed to refund the amount of Rs.20,050/- to the complainant and Rs.75,000/- as compensation. The complainant in support of his claim has filed his affidavit, copy of bank statement (Ann-1), insurance policy (Ann-II),  email correspondence  (Ann-III), letter regarding denial of cashless facility (Ann-IV), terms of payment of Paras Hospital on denial of cashless facility (Ann V), Credit Provisional Bill dated 03.02.2013 (Ann VI), Cash Final Bill dated 03.02.2013 (Ann VII), copy of cash receipts (Ann VIII & IX), claim settlement advice (Ann-X), Policy (Ann XI), correct copy of policy (Ann XII), letter dated 27.05.2013 (Ann XIII & XIV), repudiation letter dated 03.01.2014 (Ann XV) and letter dated 20.12.2013 (Ann XVI).

2                 OP-1 & 2 in their joint written reply have alleged that the OP 1 & 2 have already made the payment whatsoever due to him as per the terms and conditions of the insurance policy and now nothing was remained unpaid and thus, the complaint was liable to be dismissed. It was denied that Paras Hospital raised a bill initially for an amount of Rs.3,50,000/- and thereafter a new bill was prepared on 03.02.2013 for total sum of Rs.3,70,000/- as alleged.

3                 OP-3 & 4 in their written reply have alleged that the matter of policy period was between the complainant and the OP-1 & 2  and thus, the complainant has no cause of action against the opposite parties No.3 & 4 and the complaint was liable to be dismissed against them.

4                 We have heard the the parties and perused the record available on file.

5                 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the parties, it emerges that the complainant has filed the present complaint against the OPs alleging deficiency in service on their part on the ground that  he has purchased Oriental Bank Medi-Claim Insurance Policy No.215390/48/2012/1456 from the OP-4 which was valid from 17.01.2012 to 16.01.2013 which was subsequently renewed vide policy No.21530/48/2013/2235 for the period of one year which was effective from 17.01.2013 to 16.01.2014 for ID of Rs. 3 Lacs and on account of lapse on the part of the opposite parties there was wrong recording of effective date in the said policy and when the matter was represented to the opposite parties then the mistake was rectified. However, on account of said mistake the cash less facility was denied and due to which the complainant had to pay more and had suffered mental harassment. The excess amount was paid on account of hospital charges and if the cash less facility was given then the charges were liable to be paid as per the TPA agreement between the hospital and the TPA authority. On the aforesaid allegations the complainant prayed for refund of excess amount. He has also claimed damages on account of mental harassment and litigation charges.

6                 However, as per the contention of the opposite parties, no doubt due to typographical mistake the effective date of policy was changed due to which the record of OPs showed the discontinuation of the policy and when the said mistake was brought to the notice of the opposite parties the same was rectified and the officer concerned has also tendered apology and the sum insured i.e. Rs.3 Lacs has already been paid to the complainant and as such the complaint was liable to be dismissed.

7                 However, after going through the facts and circumstances of the case and the evidence on file it is evident that the cash less facility was denied by the opposite parties on account of irregularity committed in the effective date of the policy and when the mistake was pointed out by the complainant the same was ordered to be rectified but even then cash less facility was not extended to the complainant and the complainant had to pay the amount from his own pocket. It also emerges that sum insured was Rs. 3 Lacs and the said insurance amount has already been paid by the opposite parties to the complainant and as such ordering of payment of the amount more than the insured amount would tantatmount to violation of terms and conditions of the insurance policy but it is a fact that the cash less facility was denied to the complainant on account of clerical mistake on the part of the opposite parties. Had the cash less facility not been denied to the complainant then the complainant was entitled to be reimbursed as per the GIPSA Rules but for want of cash less facility the complainant had to pay the amount as per the hospital charges.

8                 Therefore, we are inclined to hold that denial of cash less facility without no fault on the part of the complainant tantamount to deficiency in service on the part of the opposite parties and thus, we direct the opposite parties to pay a sum of Rs.20,000/- as compensation for harassment and mental agony as well as litigation expenses with interest @ 9% p.a. from the date of filing of the present complaint i.e. 05.02.2014 till realization. The opposite parties shall make the compliance of the order within 30 days from the date of receipt of the copy of this order.   The parties be communicated of the order accordingly and the file be consigned to the records after due compliance.

Announced                                                                                                                                (Subhash Goyal)

15.02.2016                                                                                                                                    President,

                                                                                                                                             District Consumer Disputes

                                                                                                                                            Redressal Forum, Gurgaon

(Jyoti Siwach)        (Surender Singh Balyan)

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