Chandigarh

DF-I

CC/216/2024

NEELAM BANSAL - Complainant(s)

Versus

THE UNITED INDIA INSURANCE COMPANY LIMITED - Opp.Party(s)

PAWAN BANSAL

04 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/216/2024
Date of Institution	:	24/4/2024
Date of Decision	:	4/11/2024

 

Neelam Bansal W/o Sh. Pawan Bansal through her authorized person Sh. Pawan Bansal, Advocate s/o late Sh. H.R.Bansal, resident of House No. 1206, Sector-44B, Chandigarh.

..... Complainant

Versus

 

1. The United India Insurance Company Limited, Registered Office 24 Whites Road, Chennai-600014 through its Managing Director.

2. The United India Insurance Company Limited, Divisional Office, SCO No. 357-358, First Floor, Sector 35-B, Chandigarh through its Bank Manager.

Opposite Parties

 

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Pawan Bansal, Advocate for complainant
	:	Sh. Shubham Jain, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant against the opposite parties  (hereinafter referred to as the OPs). The brief facts of the case are as under :-
   1. It transpires from the averments as projected in the consumer complaint that the complainant  and her husband have been availing family health policy from the OPs  for the last more than 15 years,  with sum insured to the tune of Rs.3,00,000/- each  by paying the premium regularly without any break while renewing the policy No. 11240822P105672361  (hereinafter to be referred as subject policy)  and had paid premium   of Rs.42,076/- on 16.9.2022  and the same was valid w.e.f. 19.9.2022 to 18.9.2023. The complainant had developed some eye problem in her both eyes therefore, consulted many doctors including P.G.I. Chandigarh and all of them had advised the complainant  that Cataract has developed in her eyes which is to be removed through the laser surgery. Since there was nobody to look after the complainant and her husband at Chandigarh so, the complainant decided to get the surgery done at Ludhiana where her daughter is settled. Accordingly the complainant approached the Advanced Center for Eyes Ludhiana (hereinafter to be referred as treating hospital) which is empanelled hospital for the OP's for the said purpose on 28.8.2023 for cataract surgery of the eyes. The attending doctor after thoroughly examining both the eyes of complainant advised to get the Cataract surgery performed through phaco technique on 1.9.2023, to which the complainant had consented. Before that the treating Hospital prescribed some eye drops, blood tests and ECG etc. which were got done by the complainant before the said surgery. The complainant had incurred certain charges for registration, blood tests  and medicines and receipts  of the same are annexed as Annexure C-2 to C-5. Thereafter the treating hospital sent the bill Annexure C-6 of Rs 27,000/- to the TPA but the TPA of the OPs only paid an amount of Rs 25,000/- and the complainant had to pay an additional amount of Rs. 17,000/- in cash, over and above the said amount to the treating hospital. Copy of the said payment receipt is annexed as Annexure C-7. On 1.9.2023, surgery for the right eye of the complainant was performed through the phaco technique and the complainant was kept under observation for about 5 hours in a private room by the doctor in the treating hospital and after thoroughly examining her right eye, the doctor discharged the complainant after prescribing the eye drops mentioned in the discharge slip. On 4.9.2023 as the complainant visited the treating hospital for review of the operated eyes and the doctor after thoroughly checking same was satisfied about the surgery of the right eye and advised the complainant to get the phaco technique surgery of the left eye also done on the same day to which the complainant agreed. For that surgery also the TPA of OPs was contacted by the treating hospital for Cataract surgery (Cashless) and a claim of
      Rs 27,000/- Annexure C-8  was sent  but TPA of OPs recommended only Rs 23,000/- and later, on the insistence of the complainant, again they made the reimbursement of Rs.25,000/- for said eye also. In this manner the aforesaid act of OPs shows that the insured was at the mercy of the TPA of the OPs with whom the complainant has no privity of contract at all. Even when the final bill was raised by the treating hospital for the left eye, the complainant was again compelled to pay Rs.17,000/- for the left eye, which was paid by her vide receipt Annexure C-9. In this manner despite of the fact that the entire treatment of the Cataract surgeries  was  covered under the subject policy, the OPs have wrongly reimbursed only an amount of Rs.50,000/- for both the eyes instead of Rs.88,000/- the total bill amount raised by the treating hospital and the remaining amount of Rs.34,000/-  was paid by the complainant  for the cataract surgeries  whereas the insured is entitled upto 25% of the sum insured or Rs.40,000/- per eye whichever is less and the OPs had only paid even less of the authorized amount  under the subject policy. In this manner, the aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
   2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action suppression of material facts and non- joinder of necessary party. However, it is admitted that the complainant had taken treatment from the treating hospital and the  OPs  have received bills of Rs.27,000/- for each eye and  out of which  after making deductions an amount of Rs.50,000/-  was reimbursed to the complainant which has not been disputed by the complainant. It is however, alleged that in fact the complainant has paid Rs.17,000/- to the hospital on her own accord. Even the treating hospital has given the record showing that the hospital has charged an amount of Rs.27,000/- for each eye. It is further alleged that the  complainant was well aware of the expenses  of the treatment and she herself had given declaration for cashless services and reimbursement of expenses from OPs  and in the said declaration  complete cost of treatment was also mentioned as Rs.27,000/- per eye. Moreover, the complainant has not submitted complete medical record with the OPs rather OPs have collected complete medical bills/record Annexure R-1 (colly) from the treating hospital.    On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
   3. In rejoinder, complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.
2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had got her both the eyes operated for cataract from the treating hospital  and the cashless request was submitted by the treating hospital with the TPA for Rs.27,000/-  per eye,  out of which the OPs had only reimbursed Rs.50,000/- for both the eyes, by making deduction of Rs.4,000/- and the treating hospital has finally raised additional bill of Rs.17,000/- for each eyes i.e. Rs.34,000/- for both eyes which was paid by the complainant from her own pocket  on 1.9.2023 and 4.9.2023  as is also evident from Annexure C-1  and Annexure C-7& C-9, the case is reduced to a narrow compass as it is to be determined if  the OPs are unjustified in not paying the additional amount of Rs.34,000/- to the complainant which was paid by her to the treating hospital for the aforesaid surgery and the complainant is entitled for the relief as prayed for as is the case of the complainant or if the OPs are justified in not paying the additional amount of Rs.34,000/-  paid by the complainant to the treating hospital and the complaint of the complainant being not maintainable is liable to be dismissed as is the defence of the OPs.
   2. In the back drop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around  the subject policy and medical record and the same is required to be scanned carefully.
   3. Perusal of  subject policy Annexure C-1 coupled with Annexure C-10 clearly indicate that  the complainant was covered under the subject policy with sum insured to the tune of Rs.3.00 lakh . Clause 4.1.2 deals with expenses in respect of the cataract  surgery  etc. and the relevant portion of the same is reproduced as under:-

“4.1.2 Expenses in respect of the following specified illnesses will be restricted as detailed below: (Only (Only Applicable for Gold & Senior Citizen Plans only)

Surgery/Illness/Disease/Procedure	Maximum Limits per surgery/hospitalization restrict to
Cataract	Up to 25% of Sum Insured or Rs. 40,000, per eye whichever is less
X x x x	X X X X
X x x	Xx x”

 

4.  From the above documents and evidence, one thing is clear that the expenses in respect of cataract surgery  was payable upto 25% of the sum insured  or Rs.40,000/- per eye whichever is less making clear that, the complainant was entitled for Rs.40,000/- per eye. However, in the case in hand it stands proved on record  that the OPs have  reimbursed Rs.50,000/- i.e. Rs.25,000/- for each eyes  to the treating hospital despite of the fact that it was brought to the notice of the OPs that the complainant had paid an additional amount of Rs.17,000/- for each eye to the treating hospital  for the aforesaid surgery and the claim of the complainant was covered upto Rs.40,000/- as per above referred clause. Thus, the complainant after certain deductions from Rs.17,000/- per eye is certainly entitled for Rs.15,000/- for each eye from the OPs totaling to Rs.30,000/- , which the complainant  has paid from her own pocket to the treating hospital.
5. From the foregoing discussion, as it stands proved on record that the OPs have not paid  remaining claim to the tune of Rs.30,000/- to the complainant the said act of OPs amounts to deficiency in service and unfair trade practice on its part, especially when the entire case set up by the complainant in the consumer complaint as well as the evidence available on record is unrebutted by the OPs. Hence, the instant consumer complaint deserves to be allowed.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under:-
   1. to pay ₹30,000/- to the complainants alongwith interest @ 9% per annum (simple) from the date of institution of the present consumer complaint till onwards
   2. to pay lumpsum amount of ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
5. This order be complied with by the OPs jointly and severally within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 4/11/2024			[Pawanjit Singh] President
mp
			[Surjeet Kaur] Member