BEFORE THE DISTR7ICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 171 of 2015

Date of Institution: 24.3.2015

    Date of Decision:   09.02.2016

Mrs.Amarjit Kaur Wd/o Sh. Dalip Singh R/o 194, Street No.2, Loharka Road, Amritsar

Complainant

Versus

United India Insurance Co. Ltd., Through its Chairman/Managing Director/Principal Officer service through its Branch Office At 283, East Mohan Nagar, Amritsar through its Branch Manager

Opposite Party

Complaint under section 11 and 12 of the Consumer Protection Act, 1986

Present:    For the Complainant                  :  Sh.Deepinder Singh, Advocate

               For the Opposite Party                : Sh.Rajinder Nayyar,Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Sh.Anoop Sharma, Member

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Amarjit Kaur under the provisions of the Consumer Protection Act alleging therein that she obtained health insurance policy from the opposite party vide policy No. 2002042814P104910699 for the period from 7.10.2014 to 6.10.2015 by paying premium of Rs. 10600/-. According to the complainant she fell ill and remained admitted in Fortis Escort Hospital for the period from 4.3.2015 to 7.3.2015 . The complainant incurred Rs. 82318/- on her medical treatment. But the opposite party paid only Rs. 25000/- and the complainant had to pay the remaining amount of Rs. 57318/- from her own pocket. Complainant lodged the claim with the opposite party but the opposite party did not settle the claim for the actual treatment cost 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.57318/- alongwith interest @ 12% p.a. from 7.3.2015 till payment. Compensation of Rs. 40000/- alongwith litigation expenses were also demanded.
2. On notice, opposite party appeared and filed written version in which it was submitted that after getting the information regarding the admission and discharge of the complainant in the hospital, opposite party immediately informed its TPA i.e. Vipul Medcorp TPA Pvt. Service Ltd., which is the authorized agency to deal with the medical insurance and the said TPA after receiving the medical record and bills immediately passed the claim to the tune of Rs. 25000/- as per terms and conditions of the policy and the same was accepted by the complainant without any objection. The complainant is only entitled for Rs. 25000/- as per clause 1.2.1 and 5.12 of the Insurance policy which read as under:-

1.2.1 Expenses in respect of the following specified illness will be restricted as detailed below :

As such the complainant is not entitled for any other amount. While denying and controverting other allegations, dismissal of complaint was prayed.

3.       Complainant tendered into evidence her affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-4.

4.       Opposite party tendered affidavit of Sh. Surinder Singh, Divisional Manager Ex.OP1, copy of claim settlement Ex.OP2, copy of discharge summary/medical record of Fortis Hospital Ex.OP3, copy of Insurance Policy alongwith terms and conditions Ex.OP4, copy of Insurance policy for the period from 2012-13 Ex.OP5.

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 obtained Insurance policy  Ex.C-4 from the opposite party for the period from 7.10.2014 to 6.10.2015 with sum assured Rs. 2 lacs. The complainant fell ill and he remained hospitalized in Fortis Escort Hospital,Amritsar from 4.3.2015 to 7.3.2015 and paid Rs. 82318/- to the aforesaid hospital as per  inpatient bill Ex.C-3 and certificate Ex.C-2. The complainant lodged claim with the opposite party but the opposite party allowed Rs. 25000/- only and did not pay the balance amount Rs. 57,318/- to the complainant. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party qua the complainant.

7.       Whereas the case of the opposite party is that after getting information regarding the admission and discharge of the complainant from the hospital, opposite party informed its TPA i.e. Vipul Medcorp TPA Pvt. Service Ltd. Said TPA after receiving the medical record and bills immediately passed the claim of the complainant  to the tune of Rs. 25000/- under 25% capping of applicable sum assured of Rs. 1 lac for the policy year 2012-13 as per clause 1.2.1 of the policy and policy clause 5.12 (Senior Citizen Policy) because the patient was suffering from this disease from the year 2013. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party qua the complainant.

8.       We have gone through the entire record produced by both the parties particularly the Insurance policy Ex.C-4/OPIV i.e. policy for the period from 7.10.2014 to 6.10.2015.  As per this policy, the complainant was assured to the tune of Rs. 2 lacs . The complainant was admitted in Fortis Escort Hospital on 4.3.2015 with Type IV Large Hiatal Hernia and was operated for the same with laparoscopic approach on 5.3.2015 and was discharged on 7.3.2015. So it is clear that the complainant had undergone surgery for  Hiatal Hernia on 5.3.2015 at Fortis Escort Hospital  for which he remained admitted from 4.3.2015 to 7.3.2015 and he paid Rs. 82,318/- to the said hospital as per bill Ex.C-3. As per clause 1.2.1 of the policy Ex.C-4/OPIV, the complainant is entitled for hospitalization benefit for Hernia to the extent of 25% of the sum assured or the actual expenses incurred which ever is less. 25%  of the sum  assured of this policy comes out to Rs. 50000/- but the opposite party paid only Rs. 25000/- on the ground that in the policy year 2012-13 the complainant was insured to the tune of Rs. 1 lac only  and the complainant was suffering from this disease for the last three years. Opposite party could not produce any evidence that the complainant was suffering from this disease for the last three years. Moreover, the complainant had undergone treatment for Hernia in the year 2015 during the policy period of 2014-15 and during this policy Ex.C-4/OPIV, the complainant was insured to the tune of Rs. 2 lacs and not Rs. 1 lac, as such the opposite party was bound to pay 25% of the sum assured Rs. 2 lacs which amounts to Rs. 50000/- . But the opposite party has paid only Rs. 25000/- which amounts to deficiency of service on the part of the opposite party.

9.       Resultantly we partly allow the complaint with costs and the opposite party is directed to pay the balance amount of Rs. 25000/- to the complainant 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. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

9.02.2016                                                             ( Bhupinder Singh )

President

/R/                                      (Anoop Sharma)               ( Kulwant Kaur Bajwa)

     Member                                        Member