Haryana

Sonipat

CC/124/2015

1. MUNUSH JAIN,2. SMT. SARIKA JAIN W/O MUNISH JAIN - Complainant(s)

Versus

UNITED INDIA INSURANCE CO. LTD. - Opp.Party(s)

H.C. JAIN

29 Oct 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SONEPAT.

 

                                Complaint No.124 of 2015

                                Instituted on:07.04.2015

                                Date of order:29.10.2015

 

 

1.Munish Jain 2. Smt. Sarika Jain wife of Munish Jain, r/o 2289, Sector 15, near LIC of India office, Sonepat.

                                           ...Complainant.

                        Versus

 

United India Insurance Co. Ltd.  Delhi road, Sonepat through its Branch Manager.

                                           ...Respondent.

 

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. H.C. Jain Adv. for complainant.

           Sh. Ajay Garg Adv. for respondent.

          

          

BEFORE-  NAGENDER SINGH, PRESIDENT.

        SMT.PRABHA WATI, MEMBER.

        D.V.RATHI, MEMBER.

 

O R D E R

 

          Complainants have filed the present complaint against the respondent alleging therein that complainant no.1 had purchased a family medicare insurance policy from the respondent for the period w.e.f. 6.10.2014 to 5.10.2015.  Complainant no.2 was got admitted in Pentamed Hospital, Delhi on 20.12.2014 for her treatment  and intimation in this regard was given to the respondent.  The complainant no.1 lodged the claim  with the respondent after the discharge of complainant no.2 from the hospital for reimbursement of medical expenses of Rs.99,973/-. The complainant no.1 on receipt of  letter dated 24.1.2015 sent e-mail to E-Meditek thereby disagreeing about the deduction of Rs.48,286/- from the total amount of medical expenses. But the said TPA declined the request of the complainant no.1 on the ground that the complainants had opted for a room with rent higher than the entitled category and as such the other charges including consultation charges, nursing charges, OT charges etc. shall be limited to the charges applicable to the entitled category, but this observation of TPA is absolute wrong and without any basis.  The alleged condition was never brought to the notice of the complainants.  If there is any such clause in the insurance policy, then the same is unfair and unreasonable clause.  The complainants have requested the respondent so many times to make the payment of Rs.48286/-, but of no use and that amounts to a grave deficiency in service on the part of the respondent.

2.        In reply, the respondent has submitted that the deduction of Rs.48286/- was legal.  The complainants have opted for a room of higher rent than the entitled category as per the insurance policy and thus, the complainants have violated the terms and conditions of the insurance policy.  The deduction of Rs.48286/- is legal and binding on the rights of the complainants and there is no deficiency in service on the part of the respondent while doing so.

3.        We have heard the ld. Counsel for both the parties at length and we have also gone through the entire relevant material available on the case file carefully & minutely.

          Ld. Counsel for the complainant has submitted that the respondent has wrongly deducted Rs.48286/- from the claim amount of the complainants.

          Ld. Counsel for the respondent has submitted that the deduction of Rs.48286/- was legal.  The complainants have opted for a room of higher rent than the entitled category as per the insurance policy and thus, the complainants have violated the terms and conditions of the insurance policy.

          But we find no force in the contentions raised by the ld. Counsel for the respondent since the respondent has failed to produce any record regarding the rent, for which, the complainants were entitled.  No evidence regarding the rent for comparison of rates has been led by the respondent.  So, in the absence of any record, this Forum is unable to compare the rates of rent and the plea of the respondent that complainants have opted for a room of higher rent than the entitled category as per the insurance policy, remain unproved and thus, we held the deduction of Rs.48286/- to be wrong and illegal. So, we hereby direct the respondent to make the payment of Rs.48,286/- (Rs.forty eight thousand two hundred eighty six) to the complainant within a period of 45 days from the date of passing of this order, failing which, the said amount shall fetch interest at the rate of 09% per annum from the date of passing of this order till realization.  The respondent is further directed to compensate the complainant to the tune of Rs.2000/- (Rs.two thousand) for deficient services, harassment and under the head of litigation expenses.

          With these observations, findings and directions, the present complaint stands allowed.

          Certified copy of this order be provided to both the parties free of cost.

File be consigned to the record-room.

 

 

(Prabha Wati Member) (DV Rathi Member)     (Nagender Singh-President)

DCDRF, Sonepat.      DCDRF Sonepat         DCDRF, Sonepat.

 

Announced: 29.10.2015