CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
ISBT KASHMERE GATE DELHI
CC/145/2014
No. DF/ Central/ Date
Mahesh Kumar Bansal
R/o 109/5, Second Floor, Gautam Nagar,
New Delhi-110049. …..COMPLAINANT
VERSUS
United India Insurance Co. Ltd.
501-503, 5th Floor,
Vikrant Tower,
4, Rajendra Place,
New Delhi-110008.
Medi Assist India TPA Private Limited
B-20, Sector-2, Near Sector-15 Metro Station
Opposite HCL Comnet
Noida, U.P.-201301.
Maharaja Agrasen Hospital,
Punjabi Bagh
New Delhi-110026. …..OPPOSITE PARTIES
Quorum : Ms. Rekha Rani, President
Mr. R.C. Meena, Member
ORDER
Ms. Rekha Rani, President
1. Instant complaint has been filed by Mahesh Kumar Bansal (in short the complainant) under Section 12 of the Consumer Protection Act, 1986 as amended inter-alia pleading therein that he is having policy no. 040400/48/11/97/00002365 of United India Insurance (in short OP). He had taken the said policy in 1998 and the same was continued without any break with enhanced coverage complainant paid the premium regularly. On 24.03.2012 his wife suffered from back pain near abdomen. She was operated in Maharaja Agrasen Hospital for laparoscopic Cholecystectomy and Hysterectomy Abdominal and was admitted from 26.04.2012 to 30.04.2012. Hospital raised a total bill of Rs.1,22,620/- out of which Rs. 80,000/- was settled as cashless and Rs.42,620/- was paid by the complainant from his pocket which OP has refused to pay. Hence, instant complaint was filed seeking direction to OP to pay to the complainant a sum of Rs. 42,620/- with interest @ 18% per annum from the dare of treatment i.e. 30.04.2012, compensation of Rs. 25,000/-, litigation expenses of Rs. 35,000/- and Rs. 5,000/- as misc. and other charges.
2. OP appeared and contested the claim vide its written statement. It is stated that wife of the complainant was admitted at Maharaja Agrasen Hospital with the complaint of Uterine Fibroid with Gall Stone. Her requisition was sent for availing cashless facility for of Rs. 1,22,620/-. It is further stated that there was history of menorrhagia for 5 years and that cashless facility was approved for of Rs. 80,000/- (Rs. 52,000/- as per GIPSA for Laparoscopic Cholecystectomy + Rs. 25,000/- for Hystrectomy % & Rs. 3,000/- for whole blood).
It is further stated that as per liability of maximum amount payable the same had already been paid as per in the policy and that no further amount is payable.
3. Both sides adduced evidence by way of affidavits. We have heard Sh. Ankur Aggarwal, counsel for complainant.
OP has referred to Ex-C1/A wherein clause 1.2 of the Health Insurance Policy is relied on which is reproduced as under:
“Expenses in respect of the following specified illness will be restricted as detailed below:
Hospitalization Benefits | LIMITS per surgery RISTRICTED TO |
Cataract; Hernia, Hysterectomy or surgeries | - Actual expenses incurred or 25% of the sum insured whichever is less.
- Actual expenses incurred or 70% of the sum insured whichever is less.
|
It is submitted by OP that since the disease of the complainant was 5 years old, refund policy of the sum insured under the policy for the year 2006-2007 was Rs.1,00,000/-. 25% of the sum insured was payable to the complainant.
Complainant obtained policy from OP1 from 2006-2007 to 2011-2012. Sum insured for the year 2006-2007 under the policy was Rs. 1,00,000/- and the sum insured under the policy for the period 2011-2012 was Rs. 3,25,000/-.Claim of the complainant was settled under the policy of 2006-2007 on the ground that her disease was 5 years old.Hysterectomy was done during hospitalization from 26.04.2012 to 30.04.2012. So the relevant policy is of the period 2011-2012 in which the sum insured was Rs. 3,25,000/-.25% of Rs. 3,25,000/- is Rs. 81,250/-.In Para 7 Page 2 of the written statement, OP has submitted that bill raised by the hospital for Laparoscopic Cholecystectomy was Rs. 52,000/- which already stands paid by OP.For Hysterectomy only Rs. 25,000/- was paid allegedly as per policy of the year 2006-2007.Bill for Hysterectomy Abdominal/Vaginal was Rs. 67,620/- vide bill no. 12002287 dated 30.04.2012 out of which Rs. 25,000/- has already been paid and Rs. 42,620/- is the remaining balance to be paid.Therefore, OP is directed to pay to the complainant Rs. 42,620/-, Rs. 10,000/- as compensation for causing mental pain, harassment and Rs.10,000/- as litigation expenses.Copy of this order be sent to the parties as statutorily required. File be consigned to record room.
Announced on Day of 2019.
