Chandigarh

DF-I

CC/408/2017

Devki Nandan Vaid - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

Gaurav Vaid Adv.

19 Apr 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

 

                               

Consumer Complaint No.	:	CC/408/2017
Date of Institution	:	22/05/2017
Date of Decision	:	19/04/2018

 

Devki Nandan Vaid son of Sh. Mool Raj Vaid, Resident of House No.318, Sector 12, Panchkula.

… Complainant

V E R S U S

1.     The Oriental Insurance Company Limited, SCO 48-49, Sector 17-A, Chandigarh – 160017, through its Authorized Signatory.

2.     The Oriental Insurance Company Limited, Regd. and Head Office: A-25/27, Asaf Ali Road, New Delhi – 110002, through its Authorized Signatory.

3.     Medi Assist Insurance TPA Private Limited (Formerly known as Medi Assist India TPA Pvt. Limited), Cabin No.207, Second Floor, SCO 19, Sector 7-C, Chandigarh – 160019, through its Authorized Signatory.

4.     Medi Assist Insurance TPA Private Limited, (Formerly known as Medi Assist India TPA Pvt. Limited), Tower D, 4^th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore – 560029, through its Authorized Signatory.

… Opposite Parties

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

                                 

                          

ARGUED BY	:	Sh. Gaurav Vaid, Counsel for complainant
	:	Sh. J.P. Nahar, Counsel for OPs.

 

Per Rattan Singh Thakur, President

1.         The averments are, complainant is a Senior Citizen and has retired as Chief Manager of Oriental Bank of Commerce. The Complainant and his wife Smt. Minakshi Vaid had a medical insurance cover under Oriental Bank Mediclaim Policy No.231200/48/2015/310 issued by Divisional Office of the Oriental Insurance Company Limited i.e. Opposite Parties No.1 and 2. The Policy was valid from 12.06.2014 to 11.06.2015 and sum insured was Rs.5,00,000/-. The premium of Rs.6830/- was paid and earlier to this, in the preceding years 2013-14, 2012-13, similar policies were also taken. The Third Party Administrator (TPA) of the said Policy was M/s Medi Assist India and during the currency of Oriental Bank Mediclaim Policy, referred to above, Smt. Minakshi Vaid – wife of the Complainant was diagnosed for Cataract of the Right Eye on 13.02.2015, and therefore, she underwent a Femto Cataract Surgery of Right Eye with Multifocal IOL on 16.02.2015 at Mirchia’s Laser Eye Center. The cashless facility could not be availed of. The reimbursement claim of Rs.1,15,067/- was submitted to the Opposite Parties. It was pressed hard and thereafter, a sum of Rs.26,267/- was reimbursed. Per claim of the Opposite Parties, it was reasonable expenses and their permission was not taken before the Surgery was undertaken in the aforesaid hospital. Hence, on these averments, the prayer made to allow reimbursement of remaining amount of Rs.88,800/- along with compensation for undue harassment and mental agony along with expenses of litigation. 
2.         Opposite Parties No.1 & 2 have contested the claim and filed a joint written statement. In nutshell, their line of defence is, before undertaking the operation in the Hospital, permission from Opposite Parties was not taken. Therefore, the total amount of the reimbursement claim was not allowed and reasonable amount of Rs.26,267/- was reimbursed to the Complainant. The existence of the policy in question is not disputed per written statement submitted on behalf of Opposite Parties No.1 and 2.
3.         Learned counsel for the Opposite Parties No.3 & 4 4 has made a statement on 09.01.2018 to the effect that Opposite Parties No.3 and 4 adopts the reply filed by Opposite Parties No.1 and 2. The reply filed by Opposite Parties No.1 and 2 be read as reply of Opposite Parties No.3 and 4 also.
4.         Rejoinder was filed by the complainant and facts mentioned in the consumer complaint were reiterated.
5.         Parties led evidence by way of affidavits and documents.
6.         We have heard the learned counsels for the parties and gone through the record of the case. 
7.         Per record, we derive the under mentioned conclusions for the purpose of disposal of this Consumer Complaint.
8.         Per pleadings of the parties, the undisputed facts are mediclaim policy was in existence on the date of Cataract surgery of the wife of the Complainant. Therefore, we do not feel it relevant to discuss in detail the policy and its Photostat copy has also been placed on record. 
9.         Per record, other admitted facts are as per pleadings of the parties, as well as perusal of Annexures D-4 and D-5 which shows that in Mirchia’s Laser Eye Centre, Smt. Minakshi Vaid was admitted on 16.02.2015 and was discharged on the same day and the diagnosis was Cataract of the Right Eye, as there was blurred vision in the right eye. It is also the admitted case that total amount bill, per receipts Annexure E-1 to E-3 and F-1 to F-2, shows that the claimed amount of Rs.1,15,067/- was paid by the person insured to the Hospital. Even otherwise, these are not disputed facts as per the pleadings of the parties.  
10.         Per record, that is to say the documents produced i.e. Annexure R-3 of M/s Medi Assist India TPA Private Limited shows that on receipt of the Complaint, they had responded on 27.04.2015 and had asked for supply of reasons for no intimation; reasons for not availing cashless facility and other bills. Per this Annexure R-3, it is also the admitted case that the said Hospital is in panel list. This itself shows that the Hospital in which the wife of the Complainant underwent Cataract surgery is approved one for reimbursement by the Insurance Company. In other words, there is no hanky-panky that a fake bill was claimed in connivance with the Hospital, which is own empaneled hospital of the Opposite Parties.   
11.         A meticulous perusal of part of the policy shows that persons insured are Devki Nandan Vaid and Smt. Minakshi Vaid. A recital contained in the policy document shows that insurance under this policy was subject to conditions, clauses, warranties, endorsements and the Policy shall pay for hospitalization expenses for medical/ surgical treatment at any Nursing Home/ Hospital in India as an in-patient defined in the policy. This shows that the Insurance Company had undertaken to reimburse the amount for hospitalization, surgical treatment etc.
12.         The sole ground put forth for repudiating the part of the claim made is, that prior intimation i.e. approval was not taken. Nevertheless, per investigation conducted, it is not the case that reimbursement claim preferred was not genuine one. These are neither the pleadings made on behalf of the Opposite Parties nor any material brought on record. But the claim was partly allowed on the pretext that it was reasonable expenses while the Cataract operation was done from the own empaneled hospital of the Opposite Parties. Thus, it does not lie in the mouth of the Opposite Parties to disallow the remaining part of the claim on the ground of unreasonableness. No facts detailed what is the definition of reasonable claim and what parameters were taken into account while assessing and reimbursing the part of the claim to the tune of Rs.26,267/-. This is arbitrary and is not justifiable as per terms and conditions of the policy which is a bilateral document executed interse the parties.
13.         Admittedly, the Complainant and his wife are Senior Citizens at the wrong side of 70 and their claim ought to have been given top priority by the Opposite Parties who had charged the premium.  The aforesaid material leads to the inference that there was deficiency in service rendered by the Opposite Parties.
14.         In view of the above discussion, we do not find any justification for the repudiation of the part of the claim. Therefore, this Consumer Complaint deserves to succeed and the same is accordingly allowed. The Opposite Parties are directed as under:-

1. To pay amount of Rs.88,800/- i.e. difference of total claim, to the Complainant, along with interest @9% per annum from the date of partial rejection of the claim, till realization.
2. To pay Rs.30,000/- to the complainant as compensation for deficiency in service on their part and for undue harassment and mental agony to the Complainant and his wife;
3. To pay to the complainant Rs.20,000/- as costs of litigation.

15.         This order be complied with by the Opposite Parties 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.
16.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
19/04/2018	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
	Member	Member	President
“Dutt”