Haryana

Ambala

CC/303/2013

BHARAT BHUSHAN - Complainant(s)

Versus

UII CO. LTD. - Opp.Party(s)

V. P.S DUGGAL

18 Apr 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 303 of 2013

                                                          Date of Institution         : 20.11.2013                                                                 

                                                         Date of decision   : 18.04.2017

 

          Bharat Bhushan son of Shri Dharma Nand, resident of house No. 537,    Sector-7, Ambala City.  

 

……. Complainant.

 

 

1.       Branch Manager, United India Insurance Co. ltd. polytechnic chowk bal Bhawan Road, Ambala city.

2.       E-Meditech (TPA) Services Limited, corporate Office, Plot No.577, Udyog        Vihar, Phase-V, Gurgoan, Haryana-122016, through its Managing Director.

 

 

….…. Respondents.

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER         

                   Ms. ANANMIKA GUPTA, MEMBER               

 

Present:       Sh. VPS Duggal, counsel for complainant.

                   Sh. Deepak Sharma, counsel for Ops.  

 

ORDER:

                   In nutshell, brief facts of the present complaint are that the complainant is a regular medi-claim policy holder from the OP and in pursuance of the same the complainant got a policy vide cover Note No.958394, dated 07.08.2012 for a sum of Rs.2,25,000/- for a period from 10.08.2012 to 09.08.2013. Further submitted that during the indemnified period i.e. from 10.08.2012 to 09.08.2013, the complainant suffered a very acute knee problem and was referred to Fortis Heart & multi-specialty hospital Mohali for the replacement of the knee which was operated/replaced on 04.04.2013 and the medical bill of Rs.2,13,114/- was submitted by the Fortis Hospital as treatment charges of the complainant and the said amount was originally paid by the complainant on the assurance of the OP that they will reimburse the total amount spent by the complainant. Further submitted that the complainant against the total bill of Rs.2,13,114/- i.e. the amount paid by the complainant to Fortis Hospital Mohali as treatment charges, the OP paid only a sum of Rs.1,05,000/-, although the complainant was insured/indemnified for a sum of Rs.2,25,000/- as the complainant had paid the premium on it, as such the amount of Rs.1,05,000/-paid by OPs/towards the total amount of Rs.2,13,114/- was highly insufficient, arbitrary and illegal as such there is a clear cut case of deficiency of service on the part of the OP as well as unfair trade practice committed by the Ops. Hence, the present complaint.

2.                Upon notice, OPs appeared and filed written statement submitting that  the complainant was insured to the sum of Rs.2,25,000/- against the premium paid by him. Further submitted that the sum insured in the year 2008-2009 was Rs.1,50,000/- and accordingly the claim of the complainant was settled considering clause No.1.2.1 and 4.4 of the policy and the complainant was entitled as per the sum insured in the year 2008-2009 and not in terms of the policy period 10.08.2012-09.08.2013. The OP never assured the complainant that total medical bills will be paid by them and the complainant was paid admissible amount of claim as per the terms & conditions of the policy. Under clause of the policy i.e. Exclusions:-the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:4.4 during the first four years of the operation of the policy the expenses related to treatment of Joint Replacement due to Degenerative Condition and age-related Osteoarthritis and Osteoporosis are not payable. The inception date of the first policy was 2008-2009 and the present policy in question is w.e.f. 10.08.2012 to 09.08.2013.

3                 To prove his version complainant has tendered affidavit as Annexure C-X alongwith documents as Annexure C-1 to annexure C-3 and closed his evidence. Counsel for OP has also tendered affidavit as Annexure R-X alongwith documents Annexure R-1 to Annexure R-5 and closed his evidence.

4.                We have heard learned counsel for the parties and carefully gone through the case file. It is admitted fact that the complainant had purchased the medi-claim policy in the year 2008 and same was renewed from time to time & lastly renewed for the period of 10.08.2012 to 09.08.2013 for a sum insured of Rs.2,25,000/-. During the policy period, the complainant suffered acute knee problem and same was got replaced on 04.04.2013 and medical bills of Rs.2,13,114/- were submitted by the complainant for reimbursement. It is also admitted fact that OP has paid only sum of Rs.1,05,000/- instead of indemnifying the medical expenses incurred by the complainant. The moot question involved in this case is that whether the sum insured at the time of taking the policy for the first time in the year 2008 is to be considered or the sum insured during the relevant policy period i.e. 10.08.2012 to 09.08.2013 is to be considered.

                   It is not disputed that the sum insured during the policy period w.e.f. 10.08.2012 to 09.08.2013 is Rs.2,25,000/- and 70% of the total insured value or actual expenses incurred is payable to the complainants after the expiry of 4 years from the date of commencement of policy. It is also not disputed that the complainant got replaced the knee after expiry of 4 years from the date of first commencement of the policy in the year 2008. We are of considered view that the OP has wrongly calculated the amount of medical claim on the basis of Rs.1,50,000/- instead of Rs.2,25,000 sum insured. So, the complainant is entitled for 70% of sum insured during the relevant period which is Rs.2,25,000 which comes to Rs.1,49,179/- & the OP had paid Rs.1,05,000/- as per terms and conditions of the policy. So, the OPs are deficient in service by making less payment to the complainant to the tune of Rs.44,179/-. Accordingly, the present complaint is allowed with costs and direct the Ops to comply with the following direction within thirty days from receipt of copy of the order:-

1. To pay Rs.44,179/- to the complainant with interest @ 9% from the date of the complaint till its realization.
2. Also to pay a sum of Rs. 3,000/- cost of litigation.

                   Copy of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room.

Announced on :18.04.2017                                            (D.N. ARORA)

                                                                                                 President

 

    

           (PUSHPENDER KUMAR)

                                                                                                          Member

 

 

                    (ANAMIKA GUPTA)

                                                                                                 Member