Punjab

Patiala

CC/17/458

Jaswinder Singh - Complainant(s)

Versus

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

Sh. Arun Bansal

22 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

 

                                     

Consumer Complaint No.	:	CC/458/2017
Date of Institution	:	13.12.2017
Date of Decision	:	22.3.2023

 

 

Jaswinder Singh aged 46 years son of Sh.Bawa Singh, resident of Quarters, Gurudwara Dukhniwaran Sahib, Patiala

 

                                                                   …………...Complainant

                                      Versus

 

1. United India Insurance Co. Ltd., Leela Bhawan Market, Patiala through its Manager.
2. Medsave Health Insurance TPA Limited SCO-66, Second Floor, Sector 40-C, Chandigarh, Punjab-160036 through its Manager.

 

                                                                   …………Opposite Parties

 

Complaint under the Consumer Protection Act

 

 

QUORUM

                                      Hon’ble Mr.S.K.Aggarwal, President

                                      Hon’ble Mr.G.S.Nagi, Member        

 

 

PRESENT:                   None for the complainant

                             Sh.D.P.S.Anand, counsel for OP No.1.

                             Opposite party No.2 ex-parte.                            

 ORDER                                          

1. The instant complaint is filed by Jaswinder Singh   (hereinafter referred to as the complainant) against United India Insurance Co. Limited and another (hereinafter referred to as the OP/s) under the Consumer Protection Act (for short the Act).
2. The averments put forth by the  complainant are as follows:

That complainant is working as clerk with Gurudwara Shri Dukhniwaran Sahib Patshahi 9^th, Patiala. He was insured by OPs through employer i.e. Gurudwara Shri Dukhniwaran Sahib Patshahi 9^th, Patiala and mediclaim policy was issued to him vide card No.52001170026803 Z. Wife of complainant namely Kuldeep Kaur was also insured under this card number.

Kuldeep Kaur, wife of complainant admitted in Columbia Asia Hospital, Patiala for treatment due to abdomen disorder. She remained admitted in said hospital from 3.4.2017 to 4.4.2017. An amount of Rs.28179/- spent on her treatment. At the time of admission of his wife, intimation was given to OPs for cashless treatment but the same was refused and the complainant was forced to pay the said amount from his own pocket.

Wife of complainant again suffered gastro problem. She was again admitted in Columbia Asia Hospital, Patiala on 28.8.2017 and remained admitted upto 30.8.2017. Rs.25,924/- spent on her treatment, which was paid by the complainant from his own pocket. Thereafter, complainant approached OPs and filed two separate claim forms. He also submitted all relevant documents for reimbursement of Rs.28,179/- and Rs.25,924/- totaling Rs.54103/- but they flatly refused to pay the said claims. Various letters were written by the employer of the complainant to the OPs for releasing the said amount but of no avail. Complainant also sent legal notice dated 15.11.2017 upon the OPs. Instead of releasing full amount of Rs.54103/- OPs released only an amount of Rs.17753/- , which amounts to deficiency in service and unfair trade practice on their part. Consequently, prayer has been made for acceptance of complaint.

3. Upon notice, OP No.1 appeared through counsel and filed written statement, whereas notice issued to OP No.2 through registered post neither received back unserved nor any person appeared on its behalf and was accordingly proceeded against ex-parte vide order dated 26.4.2018.
4. In the written statement filed by OP No.1, it raised various preliminary objections.
5. On merits, it is submitted that OP No.1 has issued Taylor Made Group Health Policy, in favour of Manager, Gurudwara Sri Dukhniwaran Sahib, Patiala for the period 4.1.2017 to 3.1.2018 and Medsave Health Insurance was the Third Party Administrator. It is submitted that claim of the complainant for the treatment of period 3.4.2017 to 4.4.2017 had already been settled in accordance with the SGPC Uniform Code of conduct and deductions, for a sum of Rs.17573/- against claimed amount of Rs.38459/-, as was recommended by the Medsave Health Insurance TPA Ltd..Second claim of the complainant of Rs.25924/-was closed as no claim, for want of completion of deficiencies by the complainant and the OP is still ready to settle the same only after necessary compliance of deficiencies. There is no deficiency in service on the part of OP. After denying all other averments, this OP prayed for dismissal of complaint.
6. To prove the case, ld. counsel for complainant tendered in evidence,Ex.CA, affidavit of complainant alongwith documents, Ex.C1 copy of envelop issued by the OP, Ex.C2 copy of policy card,Ex.C3 discharge summary dated 4.4.2017,Ex.C4 copy of invoice dated 4.4.2017, Ex.C5 copy of patient bill, Ex.C6 discharge summary dated 30.8.2017,Ex.C7 patient bill dated 30.8.2017,Ex.C8 copy of invoice dated 28.8.2017,Ex.C9 copy of invoice dated 29.8.2017, Ex.C10 to Ex.C13, copies of letters issued by Gurudwara Sahib to the OP,Ex.C14 legal notice,Exs.C15 &C16 postal receipts and closed evidence.
7. On the other hand, ld. counsel for OP No.1 has tendered in evidence Ex.OPA affidavit of Kanta Devi, Manager of OP No.1, Ex.OPB, affidavit of Dr.Arvin Bakshi alongwith documents,Ex.OP1 copy of discharge summary dated 4.4.2017,Ex.OP2 copy of claim approval note,Ex.OP3 copy of discharge summary dated 30.8.2017,Ex.OP4 copy of bill of Columbia Asia dated 30.8.2017,Ex.OP5 copy of insurance policy with conditions, Ex.OP6 copy of letter dated 21.5.2017 of Med Save,Ex.OP7 copy of letter dated 14.11.2017 and closed evidence of OP No.1.
8. None appeared on behalf of the complainant. We have heard the ld. counsel for OP No.1 and have also gone through the record of the case, carefully.
9. The complainant was insured through his employer Gurudwara Dukhniwaran Sahib, Patiala against mediclaim policy and was issued card No.520011700286803Z alongwith his wife under the said card. Wife of the complainant was hospitalized from 3.4.2017 to 4.4.2017 due to abdomen pain in Columbia Asia Hospital, Patiala and an amount of Rs.28179/- was spent on her treatment under bill No.053 dated 4.4.2017 for Rs.3900/- and bill No.25105 dated 4.4.2017 for Rs.24279/-issued by the said hospital. Again wife of complainant suffered gastro problem and was admitted in Columbia Asia Hospital, Patiala from 28.8.2017 to 30.8.2017. An amount of Rs.25,924/-was spent on her treatment. Due intimation was given to the OPs at the time of her admission and claim was subsequently lodged after her discharge from the hospital. However, a total amount of Rs.54103/-for the treatment on both the above occasions was paid by the complainant from his own pocket, as the OPs failed to honour the cashless treatment. The matter was also taken up by the employer of the complainant with the OPs as per letters, Exs.C10 to Ex.C13 but the claim was not settled. Legal notice, Ex.C14 was also served upon the OPs but not fruitful purpose was served. However, an amount of Rs.17573/- has been subsequently reimbursed against the claim of Rs.54103/-.
10. OP No.1 in its written statement has submitted that the first claim for the period of admission from 3.4.2017 to 4.4.2017 has already been settled for Rs.17573/- against the claim amount of Rs.38459/-in accordance with SGPC Uniform Code of conduct and deductions. However, the second claim of Rs.25924/- for the period 28.8.2017 to 30.8.2017 has been closed due to non compliance of requirements made by the complainant. It is further submitted that OP is ready to settle this claim also after the compliance of deficiencies is made by the complainant.
11. The OP No.1 has  produced on record copy of the insurance policy,Ex.OP5.As per Serial No.50 & 51 of the said policy, complainant and his wife Kuldeep Kaur were covered for sum assured of Rs.4,00,000/-. OP has also placed reliance on Clause 1.2(a) of the policy, as per which room, boarding and nursing expenses as provided by the hospital/nursing home should not extend to 1% of the sum insured or the actual amount whichever is less. This will also include nursing care, RMO charges, fluid/blood transfusion, injection administration charges and similar expenses. The OPs have also produced copy of settlement of claim for first admission from 3.4.2017 to 4.4.2017, as per which the room rent ofRs.7800/- was claimed whereas a deduction of Rs.6675/- had been made and room rent of Rs.1125/- was allowed. However, a study of the rent clause as above clearly indicates that room rent of Rs.4000/-per day was admissible to the complainant and as such the said deductions have been wrongfully made by the OPs.
12. The complainant has placed on record bill Ex.C4 for Rs.3900/- and Ex.C5 for Rs.24279/-against claim No.1 which was settled for Rs.17573/-by the OPs. The OPs have argued that the complainant was not entitled for the said claim on the grounds that he was not entitled for the treatment from Columbia Asia Hospital. However, OPs have failed to place on record any such exclusion clause for getting treatment at Columbia Asia, Hospital. We, therefore, direct the OPs to settle the claim of the complainant of Rs.28179/-after making a deduction of Rs.3125/- as per the policy conditions and Rs.17573/- already paid to the complainant.
13. We further find that the bill of Rs.25924/- (Rs.17694/-Ex.C7) Rs.4330/-, Ex.C8 and Rs.3990/-, Ex.C9 have been submitted by the complainant against which no reimbursement had been made by the OPs. We, therefore, direct the OPs to settle the claim of the complainant for Rs.25924/- and Rs.25054/- after deducting Rs.17537/-already paid to the complainant with regard to first claim. The complaint is accordingly partly allowed. Compliance of the order be made by the OPs within 30 days from the date of receipt of certified copy of this order, failing which they shall pay interest @9% on the awarded amount from the date of filing of complaint i.e.13.12.2017  till realization.  
14. The instant complaint could not be disposed of within stipulated period due to Covid protocol and for want of Quorum from long time.
85109252238716.  
85109252238717.  

 

                                              G.S.Nagi                           S.K.AGGARWAL

                                              Member                          President