Haryana

Sonipat

CC/112/2016

Satyapal Chauhan S/o Jaswant Singh Chauhan - Complainant(s)

Versus

United India Insurance Co. Ltd. - Opp.Party(s)

Ravi Shanker Garg

21 Dec 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

               

 

                                Complaint No.112 of 2016                                             Instituted on:21.04.2016

                                Date of order:21.12.2016

 

1.Satya Pal Chauhan son of late Jaswant Singh Chauhan, resident of H.No.159/20, Atlas road, Opp. Bulbul Hotel, Sonepat.

2.Smt.Sudha Rani wife of Satya Pal Chauhan, resident of H.No.159/20, Atlas road, Opp. Bulbul Hotel, Sonepat.

…Complainants.   

Versus

 

1.United India Ins. Co. Ltd. GT Delhi road, Lakhmi Piau, Kundli, distt. Sonepat.

2.E-Meditek (TPA) Services Pvt. Ltd., Corporate office plot o.577, Udyog Vihar, Phase V, Gurgaon, 122016.

                                                     …Respondents.

 

 

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh.Ashish Garg      Advocate for complainant.

           Sh.Kuldeep Solanki  Advocate for respondent no.1.

           Respondent no.2 ex-parte.

 

Before-    Nagender Singh-President.

Prabha Wati-Member.

J.L. Gupta-Member.

 

O R D E R

 

          Complainants have filed the present complaint against the respondents alleging therein that they are the medi claim policy holders (Gold Individual Health Insurance policy) for Rs.3,50,000/-.  On 27.1.2016 due to some illness i.e. Endometroid Adenocarcinoma, complainant no.2 was admitted in Bhatia Global Hospital and Endusurgery Instt. Paschim Vihar, New Delhi, for which, prior intimation was given to the respondents and the respondents have given the approval to the said hospital for treatment of complainant no.2.  The complainant no.2 submitted the claim form with estimate of treatment given by the said hospital i.e. Bhatia Global Hospital. The respondent no.2 sent a letter dated 26.1.2016 to respondent no.1  regarding the requirement of documents.  Operation of the complainant no.2 was conducted on 28.1.2016 and she was discharged on 31.1.2016.  The said hospital has raised a bill of Rs.1,28,016/- which was to be paid by the respondent no.1 to the hospital directly.  But the respondent no.1 has paid only Rs.43750/- to the hospital and the complainants requested the respondent no.1 for the reimbursement of the balance amount of Rs.84266/-, but of no use and that amounts to a grave deficiency in service on the part of the respondents. So, they have come to this Forum and has filed the present complaint.

2.        The respondent no.1 has appeared and filed the written statement, whereas respondent no.2 was proceeded against ex-parte.

          The respondent no.1 in its reply has submitted that the complainant did not supply all the relevant documents to the respondent no.1. The respondent on.1 has released the amount as per terms and conditions of the policy to the complainants. The complainants are not entitled for any other amount which has been claimed by them by way of present complaint and thus, prayed for the dismissal of the present complaint.

3.        We have heard the arguments advanced by the learned counsel for both the parties at length.  All the documents have been perused very carefully and minutely.

          In the present case, the complainants have submitted that they have spent Rs.1,28,016/- on the treatment of the complainant no.2. But the respondent no.1 has only paid Rs.43750/- to the hospital thereby with-holding an amount of Rs.84266/-.

          We have perused the written statement and affidavit filed by the respondent no.1 very carefully.  In the written statement & affidavit, it has not been mentioned anywhere by the respondent no.1, why they have with-held the amount of Rs.84266/- from the total medical bill of Rs.1,28,016/-.  NO calculation or any other reason regarding with-holding an amount of Rs.84266/- is mentioned by the respondent no.1 in the written statement or affidavit.  Rather in para no.8 of the reply, the respondent no.1 has submitted that the insurance company has released the amount as per terms and conditions of the insurance policy.  In our view, there is a grave deficiency in service on the part of the respondent no.1 and with-holding of an amount of Rs.84266/- amounts to deficiency in service. Thus, we hereby direct the respondent no.1 to make the payment of Rs.84266/- (Rs.eighty four thousand two hundred sixty six only) to the complainants within a period of 60 days from the date of passing  of this order, otherwise, the said amount shall fetch interest at the rate of 09% per annum from the date of passing of this order till its actual realization.

           With these observations, findings and directions, the present complaint stands allowed qua respondent no.1.

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

File be consigned to the record-room.

 

 

(Prabha Wati)(J.L.Gupta)                   (Nagender Singh-President)

Member DCDRF  Member DCDRF                   DCDRF, Sonepat.

 

Announced:21.12.2016.