Chandigarh

StateCommission

A/154/2015

Vinod Kumar Anand - Complainant(s)

Versus

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

Ajmer Lal Pundeer,Adv.

03 Jul 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

                                                      

First Appeal No.	:	154 of 2015
Date of Institution	:	01.07.2015
Date of Decision	:	03.07.2015

 

Vinod Kumar Anand r/o # No.1079, Sector 27-B, Chandigarh.

……Appellant/Complainant

 

V e r s u s

1.      The Oriental Insurance Company Limited, Divisional Office No.2, S.C.O. 48-49, Sector 17-A, Chandigarh (U.T.) through its Senior Divisional Manager.

2.      The Oriental Insurance Company Limited, Regional Manager, S.C.O. 109-110-111, Sector 17-D, Chandigarh through its Chief Regional Manager.

 

              ....Respondents/Opposite Parties

 

Appeal under Section 15 of the Consumer Protection Act, 1986.

 

BEFORE: JUSTICE SHAM SUNDER (RETD.), PRESIDENT.

                MR. DEV RAJ, MEMBER.

                MRS. PADMA PANDEY, MEMBER

 

Argued by:Sh. Ajmer Lal Pundeer, Advocate for the appellant.

 

PER JUSTICE SHAM SUNDER (RETD.), PRESIDENT

            This appeal is directed against the order dated 11.06.2015, rendered by the District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (hereinafter to be called as the District Forum only), vide which, it partly accepted the complaint, filed by the complainant (now appellant) and directed the Opposite Parties (now respondents), as under:-

“For the reasons recorded above, we find merit in the complaint and the same is partly allowed.  OPs are directed :-

(i)     To make payment of balance amount of Rs.67,846/- to the complainant.

(ii)    To make payment of an amount of Rs.10,000/- to the complainant as compensation for harassment on account of deficiency in service.

(iii)   To pay Rs.7,500/- as litigation expenses to the complainant.

This order be complied with by OPs within one month 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 filing of the present complaint till realization, apart from compliance of direction at Sr.No.(iii) above.”

2.       The facts, in brief, are that the complainant had purchased the Insurance Policy, namely Punjab National Bank– Oriental Royal Mediclaim Policy,  Annexure C-4, through PNB Bank, from the Opposite Parties, valid for the period from. 11.08.2013 to 10.08.2014, for the sum assured to the tune of Rs.5 lacs each for himself and his spouse, on payment of premium of Rs.6,830/-. It was stated that the terms and conditions of the Policy, in question, were never supplied to the complainant.
3.       It was further stated that the wife of the complainant developed some eyesight problem, for which she was taken to M/s Grewal Eye Institute, Chandigarh, on 18.04.2014 for check-up. It was further stated that after investigations, it was diagnosed as a case of senile cataract in the right eye of the wife of the complainant. She was advised Robolazr – Monofocal – Right eye. It was further stated that before taking treatment, the complainant approached the office of the Third Party Administrator (TPA), and also the office of Opposite Party No.2, in the matter. It was further stated that, as per the advice of the doctors, Mrs. Promila Anand, wife of the complainant, was admitted to M/s Grewal Eye Institute, on 25.04.2014, where surgery was conducted on the same day. Finally, she was discharged at 5:00 p.m., in the evening. It was further stated that the complainant spent an amount of Rs.1,20,795/-, on the treatment of his wife and submitted claim bill to Opposite Party No.2 on 29.04.2014. 
4.       It was further stated that the Opposite Parties, arbitrarily settled the claim, without the consent of the complainant and allowed reimbursement of Rs.26,154/- only, which amount was credited through NEFT system directly to his (complainant) bank account. It was further stated that aggrieved against the same, the complainant sent a protest letter on 05.07.2014 (Annexure C-12), followed by reminder dated 06.08.2014 (Annexure C-13). It was further stated that finally Opposite Party No.2, vide letter dated 11.08.2014 (Annexure C-14) rejected the genuine request of the complainant. It was further stated that legal notice dated 19.08.2014 (Annexure C-15) was also served upon the Opposite Parties, but to no avail
5.       It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed, directing the Opposite Parties, to reimburse the claim amount of Rs.94,641/-, alongwith interest @18% P.A., from the date of submission thereof; pay compensation, to the tune of Rs.1 lac, for mental agony, physical harassment, deficiency in rendering service and adoption of unfair trade practice; and cost of litigation, to the tune of Rs.22,000/-.
6.       The Opposite Parties, in their joint written version, admitted that the complainant had purchased the Insurance Policy, namely Punjab National Bank– Oriental Royal Mediclaim Policy Annexure C-4, through PNB Bank, from the Opposite Parties, valid for the period from. 11.08.2013 to 10.08.2014, for the sum assured to the tune of Rs.5 lacs each, on payment of premium of Rs.6,830/-. However, it was denied that the terms and conditions of the Policy were not supplied to the complainant. It was also denied that the claim filed by the complainant was settled, in an arbitrary manner. It was stated that the TPA had approved reasonable expenses, as agreed to by the Net Work Hospitals, which were under its panel. It was further stated that the insurer was liable to reimburse the reasonable charges necessarily incurred for surgery/treatment of any illness only.  It was further stated that the complainant had been paid reasonable claim amount, as per the TPA report. It was further stated that neither there was any deficiency, in rendering service, on the part of the Opposite Parties, nor they indulged into unfair trade practice. The remaining averments, were denied, being wrong.
7.       In the rejoinder, filed by the complainant, he repudiated all the averments, contained in the complaint, and repudiated those, contained in the written version of the Opposite Parties.
8.       The Parties led evidence, in support of their case.
9.       After hearing the Counsel for the parties, and, on going through the evidence, and record of the case, the District Forum, partly accepted the complaint, in the manner, referred to, in the opening para of the instant order. 
10.       Feeling aggrieved against the inadequacy of relief, granted by the District Forum, the instant appeal, has been filed by the appellant/complainant, for modification of the order impugned.
11.       We have heard the Counsel for the appellant, at the preliminary stage, and, have gone through the evidence, and record of the case, carefully. 
12.       The Counsel for the appellant, submitted that the appellant and his wife had purchased the Oriental Royal Mediclaim Policy, for the sum insured of Rs.5,00,000/- each,  continuously w.e.f. 11.08.2010 till 2015. He further submitted that according to the terms and conditions thereof, the complainant was entitled to the entire amount of Rs.1,20,795/- spent by him, on the surgery and treatment of right eye of his wife. He further submitted that the District Forum was wrong, in coming to the conclusion, that the complainant was not entitled to the entire amount, spent by him, for the surgery of right eye of his wife and her treatment, but was only entitled to a sum of Rs.94,000/-, out of  which a sum of Rs.26,154/-, already stood paid to him. He further submitted that the order of the District Forum, is, thus, liable to be modified and the amount of reimbursement was liable to enhanced. 
13.       After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the appellant, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed, at the preliminary stage, for the reasons to be recorded hereinafter.  It may be stated here, that the provisions of Clause 1.2 of the Medical Insurance Policy (Annexure R-1), obtained by the complainant and his wife, it reveal that  for room, boarding and nursing expenses, liability under the Policy was not to exceed 1% of the sum insured, per day.  The liability of the Insurance Company, in respect of intensive care unit expenses, was not to exceed 2% of the sum insured per day. The liability of the Company for surgeon, medical practitioner, consultants, specialists fees etc. under domiciliary hospitalization, was not to exceed 10% of the sum insured and maximum of Rs.25,000/- during the Policy period.  However, further perusal of the said Clause reveals  that in respect of Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists fees, Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Material, X-Ray etc., the liability of the Company, under the Policy was, as per the limits of the sum insured.  In the instant case, the limit of the sum insured was Rs.5,00,000/-, in relation to the wife of the complainant, who underwent surgery and treatment of her right eye. The letter dated 22.04.2014 (Annexure C-7) was sent by the complainant, to the Chief Regional Manager of the Opposite Parties. It is evident from this letter that the Opposite Parties were intimated that the wife of the complainant, Mrs. Promila Anand was to be operated upon by Grewal Eye Institute, according to the latest technique of Robo-Lazr, and the cost of the same was Rs.94,000/-. Whereas, the TPA wanted to pay him just Rs.24,000/- under the package, which was much below the cost of the operation. Vide this letter, a request was made by the complainant, to the Chief Regional Manager of the Opposite Parties, for payment of the entire amount of Rs.94,000/-. It is further evident from the letter dated 11.08.2014 (Annexure C-14) that when the complainant enquired from Grewal Eye Institute, if any better treatment was available and when he came to know that better lenses were available, he went ahead with cataract surgery costing Rs.1,20,795/- and opted for premium multi focal lenses, for his wife.  The TPA, no doubt, after taking into consideration the expenses of Rs.1,19,154/-, incurred by the complainant reduced the payable amount to Rs.26,154/-. The basic concept of insurance is that the insured should treat himself/herself, as uninsured.  Had there been no Insurance Policy, would the insured had incurred so much expenses, on treatment of cataract, without consulting other institutes? The answer to such a question, is in the negative. When the complainant himself made a request to the Opposite Parties, vide letter dated 22.04.2014 (Annexure C-7) to pay a sum of Rs.94,000/-, his claim for a sum of Rs.1,19,154/-, on account of the fact that he opted for premium multi focal lenses, could not be accepted.  The TPA, in our considered opinion was wrong in reducing the amount to Rs.26,154/-. The report of the TPA was not in accordance with the provisions of Clause 1.2 of the terms and conditions of the Policy. According to the terms and conditions of the Policy, the complainant was entitled to reimbursement of Rs.94,000/-, which he claimed vide letter dated 22.04.2014 (Annexure C-7) for the surgery and treatment of his wife. The District Forum, was also right, in holding so. The submission of the Counsel for the appellant that the complainant was entitled to the entire amount of Rs.1,20,795/-, as he opted for better treatment  for his wife and that fell within the terms and conditions of the Policy, is devoid of merit. The District Forum was also right in holding that the Opposite Parties were deficient, in rendering service, by not paying the amount of Rs.94,000/-, to the complainant, originally claimed by him, vide letter dated 22.04.2014 (Annexure C-7) and only paying him Rs.26,154/-. The findings of the District Forum, in this regard, being correct, are affirmed.
14.       No other point, was urged, by the Counsel for the appellant.
15.       In view of the above discussion, it is held that the order passed by the District Forum, being based on the correct appreciation of evidence, and law, on the point, does not suffer from any illegality or perversity, warranting the interference of this Commission.
16. '     For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District Forum is upheld.
17.       Certified copies of this order, be sent to the parties, free of charge.
18.       The file be consigned to Record Room, after completion

Pronounced.

03.07.2015

Sd/-

[JUSTICE SHAM SUNDER (RETD.)]

PRESIDENT

 

 

 

Sd/-

(DEV RAJ)

MEMBER

 

 

 

Sd/-

(PADMA PANDEY)

      MEMBER

 

 

Rg