Haryana

Yamunanagar

CC/782/2012

Har Parkash s/o shri Rameshwas Dass - Complainant(s)

Versus

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

YC Tyagi

09 Jun 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                             Complaint No… 782  of 2012.

                                                                                             Date of institution: 23.7.2012.

                                                                                             Date of decision:9.6.2015

Har Parkash son of Shri Rameshwar Dass, resident of village Dhanupura, PO Sillikalan, C/o J.M.I.T. Radaur Sub Tehsil Radaur, Tehsil Jagadhri, Distt. Yamuna Nagar.   

                                                                                                           …Complainant.

                                    Versus

 

1. M/s The Oriental Insurance Company Limited, having its Division Office, Opposite Madhu Hotel, Jagadhri Road, Yamuna Nagar-135001 through its Manager.
2. M/s The Oriental Insurance Company Limited, having its Regional Office, LIC Building IInd Floor, Jagadhri Road, Ambala Cantt. through its Manager.        

 

                                                                                                               …opposite parties.

                        Complaint under section 12 of       

                        the Consumer Protection Act.

 

CORAM:         SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

 

Present:  Sh. Y.C.Tyagi, Advocate, counsel for complainant.   

               Sh. Rajiv Gupta, Advocate, counsel for OPs.       

             

 

ORDER

 

                        Brief facts of the present case are that  the complainant is serving as Guard in J.M.I.T. Radaur. In order to enlarge its business, the OP No.1 on behalf of OP No.2 introduced its insurance scheme to the employee of the above College and issued countless insurance policies to provide full financial benefits to the customers under such scheme. Accordingly the complainant also believed upon the oily tongue of the OP No.1 and in the month of January 2012 he obtained a medical benefits/health risk policy (herein referred as ‘insurance policy’) from the OP No.1. The complainant paid an amount of Rs. 450/- as premium on the demand of OP No.1 in cash and OP No.1 issued an Insurance Policy bearing No. 261700/47/2012/468  valid from 21.1.2012 to 20.1.2013 for the sum insured of Rs. 30,000/- covering the health risk of complainant Har Parkash and his wife Reena Rani.  In the month of April 2012 Smt. Reena Rani wife of the complainant suffered sever pain in her abdomen and she was got medically examined by the complainant from S.P. Infertility & Surgical Centre Pvt. Ltd. Opp. Saraswati Vidya Mandir, jagadhri and during medical examination her ultrasound was conducted by Dr. Pardeep Tehlan. In the ultrasound report, it came to the notice of the Doctor that there is a stone/ pathri in the ‘Gal bladder’ of the wife of complainant and in order to remove the same her operation was necessary to be conducted. Complainant being a poor person approached the official of the OP No.1 in its office at Jagadhri Road, Yamuna Nagar and moved an application dated 10.4.2012 and requested them to provide financial help under the said Insurance Policy, so that operation of his wife could be conducted. The official of the OP No.1 received application of the complainant, but did not bother to provide financial help to the complainant and ignored all their assurance given to the complainant at the time of issuance of insurance policy. After arranging the money of Rs. 20,000/- from market at higher rate of interest complainant got operated his wife from the above mentioned hospital and her wife remained admitted in hospital for 3 days w.e.f. 16.4.2012 to 18.4.2012. In this way, the complainant not only suffered the huge mental agony, physical harassment but also suffered huge financial loss on account of operation, ultrasound report, bills of ambulance charges, medicine charges as well as other hospital expenses and spent a sum of Rs. 18523/- on the treatment of his wife Smt. Reena Rani for which the OPs are legally bound to pay the medical benefits assured under the said health insurance policy in question.

                        The complainant had hired the services of the OPs after paying the premium but the OPs failed to provide services by paying the medical benefits and the complainant is entitled to get medical claims of Rs. 18523/- with interest @ 18% per annum till the actual realization as well as compensation of Rs. 50,000/- on account of physical harassment, mental agony and Rs. 7500/- as litigation expenses from the OPs jointly and severally.

2.                     Upon notice, OPs appeared and filed its written statement taking some preliminary objections of maintainability, concealment of material facts and on merit it has been stated that a sum of Rs. 5850/- had been approved subject to the completion of usual formalities of the insurance company and in this regard complainant was duly intimated vide letter dated 4.10.2012 and he was directed to submit discharge voucher duly completed with details of his bank account so that the approved amount be credited in his bank account. It has been further stated that as the complainant had not submitted discharge voucher till date to the insurance company, hence, there is no deficiency in service on the part of OPs and the complaint is without merit and is liable to be dismissed.

3.                     During the pendency, when the complaint was fixed for filing evidence of OPs and arguments, counsel for the OPs moved an application on 13.9.2013 for filing amended written statement and same was allowed vide order dated 12.12.2013 and OPs filed amended written statement on 28.11.2014 mentioning therein that company has re-examined the claim file of the complainant and it has been found that there were certain calculation mistakes while approving the claim of complainant and an amount of Rs. 9450/- was payable instead of Rs. 5850/- which was wrongly calculated, as per terms &conditions of Insurance policy and the Ops are ready to pay the aforesaid amount subject to submission of discharge certificate and details of bank account etc. As the complainant has not submitted the discharge certificate and his account particulars, so the insurance company could not pay the abovesaid amount, hence there is no deficiency in service on the part of OPs and prayed for dismissal of complaint.

3.                     To prove the case, counsel for complainant tendered into evidence affidavit of complainant as Annexure CX and documents such as Annexure C-1 Photo copy of Cover Note, Annexure C-2 Photo copy of ultrasound report,  Annexure C-3 Photo copy of application dated 10.4.2012, Annexure C-4 to C-7 Photo copies of medical treatment record, Annexure C-8 to C-16 Photo copy of bill of medicines and hospital charges, Annexure C-17 Photo copy of claim form and closed the evidence on behalf of complainant. On the other hand, counsel for the OPs tendered affidavit of Sh. R.S.Kalra, Divisional Manager, Oriental Insurance Company, Yamuna Nagar as Annexure RX and affidavit of Sh. Gurmej Singh, Deputy Manager, Oriental Insurance Company, Yamuna Nagar as Annexure RY and tendered documents such as Annexure R-1 Copy of letter dated 4.10.2012, Annexure R-2 Insurance policy with terms and conditions and closed the evidence on behalf of OPs. 

4.                     We have heard the counsels of both the parties and have gone through the pleadings as well as documents placed on the file carefully and minutely. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OPs reiterated the averments made in the reply and prayed for dismissal of complaint.

                         It is admitted fact that the complainant and his wife was insured under the medical benefits/ health risk policy bearing No. 261700/47/2012/468 valid from 21.1.2012 to 20.1.2013 for the sum insured of Rs. 30,000/-. It is also admitted fact that wife of the complainant Smt. Reena Rani got her treatment from S.P. Infertility & Surgical Centre Pvt. Ltd. Opp. Saraswati Vidya Mandir, jagadhri for removal of the stone/ Pathri from the gal bladder and submitted her medical and hospital bills which was to the tune of Rs. 18523/-. It is also admitted fact that complainant moved an application on 10.4.2012 to the opposite parties for providing financial help under the said policy of insurance. Counsel for the complainant argued that Smt. Reena Rani remained admitted in the hospital for three days from 16.4.2012 to 18.4.2012 and has spent a sum of Rs. 18523/- under the various head including medicines purchased vide Annexure C-8 to C-16 and as such the present complaint has been moved praying therein to direct the OPs to pay Rs. 18523/- to complainant.  

                        From the perusal of Annexure R-2, Insurance policy, it is evident that complainant is entitled to get the benefits as per column ‘A’ up to 5% of the sum insured per day on account of room boarding expenses, as per column ‘B’ up to 15% of the sum insured on account of Surgeon Anesthetist, medical practitioner, consultants, specialists fees, nursing expenses and as per column ‘C’ up to 15% of sum insured per illness on account of Anesthesia, Blood, Oxygen, Operation threatre charges surgical appliances, medicines & Drugs. Diagnostic materials and x-ray dialysis chemotherapy, Radiotherapy costs of pacemaker, Artificial limbs & cost of organs and similar expenses i.e. as per column A, B, C, the complainant is entitled for Rs. 450/- for room charges etc. for three days @ 150/- per day and Rs. 4500/- for surgeon fee, nursing expenses etc. and Rs. 4500/- for diagnostic material, x-ray, Medical bills etc. totaling Rs. 9450/-.

                        Initially the OPs passed the claim only for Rs. 5850/- and the complainant was therefore compelled to move the present complaint and therefore OPs were deficient in providing service to the complainant.

                        In view of the facts & circumstances of the case, we partly allow the present complaint and direct the OPs to pay a sum of Rs. 9450/- alongwith interest at the rate of 9% per annum from the date of filing of complaint till its realization within 30 days to the complainant and further OPs are directed to pay Rs. 3000/- as compensation for mental agony & harassment as well as Rs. 2500/- as litigation expense.       

                         The aforesaid directions must be complied with by the OPs within the stipulated period failing which the complainant shall be entitled to invoke the jurisdiction of this Forum as per law. The complaint is partly accepted accordingly in the above terms. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court.

Dated: 9.6.2015.                 

                                                                                    (ASHOK KUMAR GARG )

                                                                                    PRESIDENT,

                                                                                     

 

                                                                                    (S.C.SHARMA )

                                                                                     MEMBER.

All the 1 to 6 pages of this judgment

are checked and signed by me.  

 

 

 

President

9.6.2015.