District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.209/2021.
Date of Institution: 08.04.2021.
Date of Order: 03.10.2022.
Suresh Chand son of Shri Radha Charan, resident of near Cable office Sagarpur, Tehsil Ballabgarh District, Faridabad, M – 9818543693.
…….Complainant……..
Versus
1. United India Insurance Co.Ltd., (Health Insurance TPA of India Ltd) 2nd floor, Majestic Omnia Building, A-110, Sector-4, Noida (U.P) – 201301.
2. United India Insurance Co. Ltd., (Health Insurance TPA of India Ltd.) Commercial Complex SCO 106, Floor No.2, Green Channel Road, Sector-16, Faridabad.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana…………Member.
PRESENT: Sh. Tejbir Singh , counsel for the complainant.
Sh. A.K.Sharma , counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant had taken the family medicare health policy bearing No. 2221002819P100238786 UHID 1117000000112501 w.e.f. 1.4.2019 as per the provision of the opposite parties and complainant had paid the premium amount pertaining to the above said policy to the opposite parties without any delay. During the mediclaim policy, the complainant was admitted in 25.10.2019 in Fortis Escorts Hospital, Neelam Bata Road, Faridabad on dated 25.10.2019 and was discharged on 27.10.2019 and the hospital had raised the bill amount of Rs.78,700/- and at that time the complainant intimated to the representative of the opposite parties through telephonically call and the representative of the opposite parties paid an amount of Rs,30,000/- in the hospital and remaining amount of Rs.48,700/- could not paid by the representative of the opposite parties by making the alleged query and the amount of Rs.48,700/- was paid by the complainant form his own pocket at the time of discharge of the complainant from the hospital although the amount of Rs.48,700/- was to be paid by the opposite parties. Later on the complainant had sent all related documents regarding the treatment of the complainant as well as bill for getting the imbursement of the mediclaim amount then the representative of opposite parties issued a repudiation letter claim No. 191100189493 on 28.02.2020 in which clear refused to make the payment of Rs.48,700/-. The complainant several times requested to the opposite parties to make the mediclaim amount of Rs.48,700/- but the opposite parties linger on the matter on one pretext to the another. The complainant sent legal notice dated 26.02.2021 to the opposite party but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the mediclaim amount of Rs.48,700/- in respect of the policy bearing No..2221002819P100238786 UHID 1117000000112501 alongwith interest @ 18% p.a. to the complainant which had been beared by the complainant from his own pocket during the insurance mediclaim policy.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties Nos. 1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos. 1 & 2 refuted claim of the complainant and submitted that the complainant neither disclose sum insured in his complaint nor disclose the terms and conditions of the policy in his complaint. As per letter dated 15.11.2019 the complainant was settled his claim for Rs.30,000/- and the opposite parties have deducted Rs.48,700/- for the reason Sub Limited exhausted. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties–M/s. United India Insurance Co. Ltd. & another with the prayer to: a) make the mediclaim amount of Rs.48,700/- in respect of the policy bearing No..2221002819P100238786 UHID 1117000000112501 alongwith interest @ 18% p.a. to the complainant which had been beared by the complainant from his own pocket during the insurance mediclaim policy. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Suresh Chand, Ex.C-1 – repudiation letter, Ex.C-2 – Claim processing sheet,, Ex.C-3 – hospitalization & Domiciliary Hospitalization Benefit Policy, Ex.C-4 – Family Medicare Policy 2014 valid for the period 01.04.2019 to 31.03.2020, Ex.C-5 – identity card, Ex.C-6 – Pre-authorization Query letter dated 20.10.2019, Ex.C-7 – Discharge summary,, Ex.C-8 – Inpatient Detail Bill,,Ex.C-9 to 11 – Deposit Receipt, Ex.C-12 – legal notice, Ex.c-13 – postal receipt, Ex.C-14 – Aadhar card.
On the other hand counsel for the opposite parties strongly
agitated and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Shri Dinesh Kumar, Administrative Officer, United India Insurance Co. Ltd., Faridabad, Ex.R-1 – Hospitalization request claim No. 191100189493.
6. During the course of arguments, counsel for the complainant has placed on record Pre-Authorization Approval letter dated 22,10.2019 vide Annx. X. On the other hand, counsel for opposite party has placed on record Discharge Voucher Cum claim Settlement letter dated 15.11.2019 vide Annx. Y in which the reason for the repudiation was Sub Limit Exhausted.
7. After going through the evidence led by both the parties as well as Pre-Authorization Approval Letter issued by the opposite party in which an amount of Rs.77,900/- has been approved. As per letter dated 15.11.2019 the complainant was settled his claim for Rs.30,000/- and the Opposite parties have deducted Rs.48,700/- for the reason Sub Limited exhausted vide Annx. Y. It is evident from Ex.R1that as per the terms and conditions of the policy the operation/treatment of Hernia is 15% of sum insured. As per policy consumer
insured Rs.2,00,000/- and 15% is Rs.30,000/- so the insurance company is settle the claim Rs.30,000/-.
Total amount : Rs.78,700/-
Company paid : Rs.30,000/-
: Rs.48,700/- not paid.
8. Keeping in view of the above, we are of the opinion that the deduction made by the opposite parties vide Ex.R1 is justified. Hence, no deficiency in service on the part of the opposite parties are proved. Resultantly, the complaint is dismissed, Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on:03.10.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
