Chandigarh

DF-I

CC/483/2023

KANTA - Complainant(s)

Versus

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

04 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/483/2023
Date of Institution	:	03/10/2023
Date of Decision	:	04/06/2024

 

Kanta w/o Sh. Harinder Kumar, H.No.144/2 New Char Chaman, Karnal.

… Complainant

V E R S U S

United India Insurance Co. Ltd., SCO 123/24, Sector 17-B, Chandigarh through Sr. Divisional Manager.

… Opposite Party

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. J.K. Narang, Advocate for complainant
	:	Sh. Satpal Dhamija, Advocate for OP (through VC)

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Smt.Kanta, complainant against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that the husband of complainant had been obtaining Family Medicare Policy from OPs since the year 2013 and also obtained the subject policy (Annexure C-1), valid w.e.f. 26.12.2021 to 25.12.2022, on payment of requisite premium with some insured of ₹3.00 lacs covering the complainant and her husband.  On the advice of doctor, on 15.9.2022, complainant got cataract left eye surgery done from Thakur Eye and Maternity Hospital, Karnal (hereinafter referred to as “Treating Hospital”) and it was having cashless tie up with the OP/insurer.  Before the surgery, initial amount of ₹22,000/- was sanctioned to the Treating Hospital by the TPA with the assurance to the complainant that the remaining amount would be sanctioned after surgery. After surgery, the treating hospital informed the OP about the total amount of ₹30,000/- to be paid for the said surgery, but, the OP had only sanctioned/paid an amount of ₹22,000/- to the Treating Hospital, as a result of which the complainant was compelled to pay ₹8,000/- to it on 15.9.2022 vide receipt No.512.  On 21.9.2022, complainant visited the office of OP and submitted all the documents, but, its officials asked her to submit the documents to the TPA office at Panchkula.  Accordingly, the complainant submitted the said documents on the same day with the TPA.  It was assured by the TPA that the amount of ₹8,000/- would be reimbursed to the complainant within one month.  However, later on, the employees of the TPA informed the complainant that they have closed the claim and the authority to pay the balance claim is only with the OP/insurer. Accordingly, complainant contacted the OP and it was informed to her that it would only be paid by the TPA. Thereafter the complainant sent a written letter to the OP on 8.3.2023, but, till date her claim has not been fully settled.  In this manner, the aforesaid act of the OP amounts to deficiency in service and unfair trade practice. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment of facts and also that the complainant has not approached the commission with clean hands.  However, it is admitted that the complainant had purchased the subject policy, which was valid w.e.f. 26.12.2021 to 25.12.2022 and that she had undergone the medical procedure for cataract surgery for her left eye and prior to that she had applied for cashless authorization through TPA.  It is further alleged that the TPA had approved the cashless facility to the complainant to the extent of ₹22,000/- after making deduction as per terms and conditions of the subject policy and the same was valid upto 30.9.2023.  It is further alleged that, in fact, the complainant had lodged a cashless claim of ₹40,000/- out of which claim of ₹22,000/- was approved as per terms and conditions of the subject policy.   It is further alleged that as the hospital had raised a bill of ₹30,000/- and the OP had paid only ₹22,000/-, the complainant had paid an amount of ₹8,000/- from her own pocket.  As the complainant has not placed on record any treatment record and entire medical bills, except receipt of ₹8,000/-, in the absence of aforesaid record, it cannot be established that there is any deficiency in service or unfair trade practice on the part of OP.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OP.

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.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy from the OP which was valid w.e.f. 26.12.2021 to 25.12.2022, as is also evident from Annexure C-1, and she had undergone procedure for cataract surgery for her left eye from the Treating Hospital on 15.9.2022, as is also evident from the IPD discharge report (available at page 16 with the consumer complaint) and the Treating Hospital had charged an amount of ₹30,000/-, out of which the OP had only approved cashless claim to the tune of ₹22,000/- whereas the remaining amount of ₹8,000/- was paid by the complainant from her own pocket, as is also evident from the claim documents (Annexure C-3) and the receipt (available at page 14 with the consumer complaint), the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in only partially allowing the claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP has rightly approved the claim of the complainant, as per the terms and conditions of the subject policy, and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OP.
   2. In the backdrop of foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around terms & conditions of the subject policy (Annexure C-1/Ex.OP-1) and the same is required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of clause V(1.2) of the subject policy clearly indicates that the expenses in respect of cataract surgeries were restricted to 10% of sum insured subject to maximum of ₹50,000/- per eye.  The relevant portion of the subject policy is reproduced below for ready reference :-

“V.   COVERAGE

The Coverages available under this Policy are described below :

                xxx                    xxx                    xxx

        1.2    Sub-limit :

                a. Cataract Surgery Limited : Expenses in respect of the Cataract surgeries will be restricted to 10% of Sum Insured subject to maximum of Rs.50,000/- per eye.  The limit is applicable per hospitalisation/surgery.

                xxx                    xxx                    xxx”

Thus, one thing is clear from the sub limit as provided above that the expenses in respect of cataract surgery for one eye were restricted to 10% of the sum insured. 

4. In the case in hand, when it is an admitted case of the parties that the sum insured is ₹3.00 lacs, 10% of which comes to ₹30,000/-, and the Treating Hospital had also charged an amount of ₹30,000/-, out of which only an amount of ₹22,000/- was approved and paid by the OP, whereas the complainant was compelled to pay an amount of ₹8,000/- from her own pocket, to our mind it is a clear case where, even as per the terms and conditions of the subject policy, the complainant was entitled to the extent of ₹30,000/- for undergoing the procedure for cataract surgery for her left eye.  Hence, it is safe to hold that the OP/insurer has wrongly and arbitrarily deducted an amount of ₹8,000/- from the total claim and the said act clearly amounts to deficiency in service and unfair trade practice on its part and the present consumer complaint deserves to succeed.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and the OP is directed as under :-

1. to pay ₹8,000/- to the complainant alongwith interest @ 9% per annum w.e.f. 15.9.2022 (i.e. the date when the complainant made the said payment) onwards.
2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹5,000/- to the complainant as costs of litigation.

5. This order be complied with by the OP within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

04/06/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member