THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR

Consumer Complaint No. 252-14

Date of Institution : 7.5.2014

Date of Decision : 09.04.2015

Mr.Neeraj Aggarwal S/o Sh. Subash Chander Aggarwal R/o 77/17, Kashmir Avenue, Batala Road, Amritsar

...Complainants

Vs.

United India Insurance Co.Ltd through its Chairman/Managing Director/Principal Officer Service through its Branch Office at 57, Railway Link Road, Amritsar through its Branch Manager

....Opp.party

Complaint under section 12/13 of the Consumer Protection Act, 1986

Present : For the complainants : Sh.Deepinder Singh,Adv.

For the opposite party : Ms.Sunita Saini,Adv.

Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member &

Sh.Anoop Sharma,Member

Order dictated by :-

Bhupinder Singh, President

1 Present complaint has been filed by Sh. Neeraj Aggarwal under the provisions of the Consumer Protection Act alleging therein that he has been taking mediclaim policy for himself and his family from last many years. Lastly the complainant has obtained mediclaim insurance policy namely Individual Health Insurance Policy bearing no. 200201/48/13/97/00000388 by making premium of Rs. 8112/- covering the period from 1.8.2013 to 31.7.2014. According to the complainant he fell ill having pain in chest and he was to be hospitalized at Dayanand Medical College & Hospital for the period from 6.3.2014 to 10.3.2014 and incurred an expenditure of Rs. 2,41,000/- on his treatment. However, complainant was insured for the amount of Rs.1,75,000/- plus Rs. 31,250/- as domiciliary hospitalization. The opposite party paid only Rs. 70000/- as cashless advance to the said hospital and the rest of the treatment cost was paid by the complainant to the said hospital. The complainant lodged claim with the opposite party for the remaining amount of Rs. 1,36,250/-, but the opposite party has not paid the genuine claim of the complainant. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to pay the amount of Rs. 1,36,250/- alongwith interest @ 12% p.a from 10.3.2014 till realization. Compensation of Rs. 50000/- alongwith litigation expenses were also demanded.

2. On notice, opposite party appeared and filed written version in which it was submitted that as per the terms and conditions of the policy, reimbursement will be strictly on the agreed rate of the empanelled hospitals. Excess payment, if any will be borne by the patient and as such, a claim of Rs. 70000/- has been settled as per terms and conditions of the policy. While denying and controverting other allegations, dismissal of complaint was prayed.

3. Complainant tendered into evidence his affidavit Ex.C-1, copy of policy Ex.C-2, copy of e-mail dated 17.3.2014 Ex.C-3, copy of discharge summary Ex.C-4, copy of letter dated3.4.2014 and postal receipts Ex.C-5 and Ex.C-6,copy of bill Ex.C-7.

4. Opposite party tendered into evidence affidavit of Sh. Ashok Kumar Sharma,Asstt.Manager Ex.OP1, copy of policy Ex.OP2, authorization letter Ex.OP3, copy of insurance policy Ex.OP4.

5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for the parties.

6. From the record i.e.pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant got mediclaim insurance policy namely (Individual Health Insurance Policy) bearing No. 200201/48/13/97/00000388 for himself and his family from the opposite party to cover risk period from 1.8.2013 to 31.7.2014. The complainant alleges that he fell ill and was admitted in Dayanand Medical College & Hospital on 6.3.2014 from where he was discharged on 10.3.2014 as per discharge summary Ex.C-4 and the complainant spent about Rs. 2,41,000/- on his medical treatment. However, the complainant was insured for Rs.1,75,000/- and Rs. 31250/- for domiciliary hospitalization. Opposite party paid only Rs. 70000/- as cashless advance to the aforesaid hospital authorities for the treatment of the complainant and the rest of the treatment cost was paid by the complainant to the hospital authorities. The complainant filed claim with the opposite party for the remaining amount of Rs. 1,36,250/- to which he is entitled to as per the policy. But the opposite party neither paid nor settled the claim of the complainant regarding the balance amount of Rs. 1,36,250/-, despite so many requests made by the complainant. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party.

7. Whereas the case of the opposite party is that as per terms and conditions of the policy in question reimbursement will be strictly on the agreed rate of the empanelled hospitals. Excess payment , if any will be borne by the patient. Accordingly, the opposite party passed the claim of the complainant to the tune of Rs. 70000/- which was permissible to the complainant as per terms and conditions of the policy. The complainant is not entitled for more compensation. Ld.counsel for the opposite party also produced on record the chart vide which the amount has been deducted from the complainant's claim which is not payable. Ld. Counsel for the opposite party that there is no deficiency of service on the part of the opposite party qua the complainant.

8. From the entire above discussion, we have come to the conclusion that the complainant has obtained mediclaim insurance policy Ex.C-2 from the opposite party for the period from 1.8.2013 to 31.7.2014 and during this period the complainant fell ill and was admitted in Dayanand Medical College and Hospital on 6.3.2014 from where he was discharged on 10.3.2014 as per discharge summary Ex.C-4.The complainant spent Rs. 2,40,671/- on his medical treatment as is evident from the bills issued by the Dayanand Medical College & Hospital, Ludhiana Ex.C-7. But the opposite party paid only Rs. 70000/- as cashless advance to the said hospital as is evident from this bill/voucher Ex.C-7. As per policy Ex.C-2 the insured amount of the complainant is Rs. 1,75,000/- and Rs. 31250/- for domiciliary hospitalization. After discharge from the hospital, complainant lodged claim with the opposite party regarding balance amount of Rs. 1,36,250/- but the opposite party refused to pay the balance amount to the complainant on the ground that as per terms and conditions of the policy , reimbursement will be strictly on the agreed rate of empaneled hospitals and the excess payment, if any, will be borne by the patient/insured. The opposite party did not produce any list of empanelled hospitalization. However, the opposite party produced claim processing module of the complainant which shows that opposite party deducted CABG charges from the claim of the complainant. The complainant paid Rs. 2,08,000/- to the hospital authorities as CABG charges but the opposite party deducted Rs. 1,70,671/- from this amount without any rhyme or reason and paid only Rs. 37,329/- on the ground that the complainant is entitled to maximum 70% of sum assured payable . Here in this case the sum assured payable is Rs. 1,75,000/- + Rs. 31,250/- as domiciliary hospitalization. So as per the plea of the opposite party even the complainant is entitled to 70% of this amount of CABG charges which amounts to Rs. 1,45,650/- . But the opposite party has paid a sum of Rs. 37,329/- only. As such as per the plea of the opposite party even, the complainant is entitled to Rs. 1,08,321/- (Rs.1,45,650/- minus Rs. 37,329/- = Rs.1,08,321/-). Opposite party even as per their own plea has paid Rs. 10,8,321/- less , to the complainant.

9. Consequently we hold that complainant is entitled to this amount of Rs. 1,08,321/-.

10. Resultantly we partly allow the complaint with costs and the opposite party is directed to pay this amount of Rs. 1,08,321/- alongwith interest @ 9% p.a from the date of filing of the complaint till payment is made to the complainant. Opposite party is also directed to pay litigation expenses Rs. 2000/- to the complainant. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.

11. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

09.04.2015 ( Bhupinder Singh )

President

( Kulwant Kaur Bajwa) (Anoop Sharma)

/R/ Member Member