| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION PATIALA. Consumer Complaint No. 48 of 11.2.2019 Decided on: 16.6.2021 Milap Kapoor aged 67 years son of Sh.Deep Chand Kapoor, resident of H.no.216, Dalima Vihar,Rajpura-140401 Contact No.8054533895. …………...Complainant Versus - United India Insurance Co. Ltd., Regd. Office 24, White Road, Chennai-600014.
- MD India Healthcare Services TPA Pvt. Ltd., Head Office: S No.46/1, E-space, A-2 Building, 3rd Floor, Pune Nagar Road, Vadgoan Sheri, Pume, 411014 ( Maharashtra)
…………Opposite Parties Complaint under Section 12 of the Consumer Protection Act, 1986. QUORUM Sh. Jasjit Singh Bhinder, President Sh.Y.S.Matta, Member ARGUED BY Sh.Milap Kapoor, complainant in person. Sh.D.P.S.Anand, counsel for OP No.1. Opposite party No.2 ex-parte. ORDER JASJIT SINGH BHINDER,PRESIDENT - This is the complaint filed by Milap Kapoor (hereinafter referred to as the complainant) against United India Insurance Co. Ltd. and another(hereinafter referred to as the OP/s) under the Consumer Protection Act,1986(hereinafter referred to as the Act)
- Briefly the case of the complainant is that the complainant is retired General Manager of the Indian Overseas Bank and got himself insured under medical claim policy bearing No.500100-28-15p-113019799 for total medical cover of Rs.4,00,000/- and the same has been got renewed from time to time.
- It is averred that the complainant got himself treated for senile cataract surgery for right eye from the approved hospital of the OPs at Grewal Eye Institute, Sector 9, Chandigarh. After treatment claim of Rs.96,393/-was submitted by the complainant with TPA MD India vide claim No.C1-261116-740193 by submitting all required documents to the OPs. It is averred that the OPs settled the claim only for Rs.24,500/-instead of full amount and in this regard the complainant wrote number of requests to the OPs but to no effect. Hence this complaint with the prayer to accept the complaint by giving direction to the OPs to make the payment of balance amount of Rs.72,439/- alongwith interest and also to pay compensation and costs of litigation expenses.
- Notice of the complaint was issued to the OPs through registered post. OP No.1 appeared through counsel and contested the complaint by filing written reply though notice of OP No.2 neither received back being unserved nor it appeared to conteste the complaint. Accordingly OP No.2 was proceeded against ex-parte.
- In the written reply filed OP No.1 preliminary objections have been raised to the effect that the complaint is not maintainable as the claim of the complainant has already been settled having paid Rs.24500/- to him as per the terms and conditions of the policy; that after coordinate with the Grewal Eye Institute it has confirmed that the complainant did not declare the insurance policy and paid the treatment charges himself. Further objection is that the claim was settled under PPN package.
- On merits , it is stated that the complainant was issued Tailormade Group Mediclaim Policy for the period from 15.12.2015 to 31.10.2016 in favour of Indian Bank Association covering the risk of retired, resigned employees and their widows of Indian Overseas Bank covering the risk of Rs.4lacs for retired officers and Rs.3lacs for retired clerks and subordinate staff for employee and his spouse. It is averred that the complainant purchased the said policy covering the risk of Rs.4lacs for medical hospitalization charges. Further the OP has reiterated the facts as raised in the preliminary objections which are not repeated for the sake brevity and after denying all other averments made in the complaint, the OP has prayed for the dismissal of the complaint.
- In support of the complaint, complainant has tendered in evidence his affidavit, Ex.CA alongwith documents Exs.C1 to C12 and has closed the evidence.
- The ld. counsel for OP No.1 has tendered in evidence Ex.OPA affidavit of Kanta Dy. Manager alongwith documents Exs.OP1 to OP4 and closed the evidence.
- We have heard the complainant present in person, ld. counsel for parties and have also gone through the record of the case, carefully.
- The complainant who has contested the complaint in person has argued that he has got himself medically insured with the insurance company for Rs.4lac, issued to retiree bank employees and he has retired as General Manager from Indian Overseas Bank. The complainant had undergone senile cataract surgery of his right eye from Grewal Eye Institure, Sector 9 Chandigarh and total expenses of Rs.96,393/- was submitted. The complainant has further argued that the insurance company has sanctioned only Rs.24500/- and they have not sanctioned the remaining amount. The complainant further argued that he also underwent by-pass surgery in the year 2018 so the filing of the complaint was delayed and he has mentioned the same in his affidavit. He has further argued that on 22.2.2019 he was present before the then Ld. President and Members. It is mentioned that the complaint is appearing to be within limitation and the OPs were summoned. The complainant further argued that as the complaint is within limitation so the same be allowed.
- On the other hand, the ld. counsel for the OP No.1 has argued that the amount of Rs.24,500/-was given to the complainant on 7.2.2017 and the complaint was filed on 11.2.2019, so it is time barred. He has relied upon the citation H.P.State Forest Company Ltd. Vs. United India Insurance Co. Ltd. 2009(2)CLT 19.The ld. counsel further argued that the claim was only of Rs.24500/- and that was given to him and was accepted by the complainant.
- To prove his case, the complainant has tendered his Ex.CA and has deposed as per his complaint, Ex.C1 is policy by Tailormade Group Mediclaim Policy for retirees and it was from 5.12.2015 to 31.10.2016.
- On the other hand Sh.Kanta, Deputy Manager of the OP has tendered his affidavit Ex.OPA and has deposed as per the written statement,Ex.C1 is the claim form, Ex.OP2 is also claim form, Ex.OP3 is also claim form,Ex.OP4 is policy.
- In the present complaint admittedly claim of Rs.24500/-has been settled and given to the complainant by the OP.As per Ex.C2, the prescription slip of Grewal Eye Institute Pvt. Ltd. Chandigarh, admittedly in the same it is mentioned that Milap Kappor had been diagnosed as a case of Senile Cataract of left eye and he was admitted on 25.11.2016 and was discharged on the same day. Ex.C3 is the claim form, in which hospital main bill is of Rs.93,000/- and remaining post hospitalization bill of Rs.500/- and pharmacy bill of Rs.913/- has been shown. Exs.C5,C6 and C7 are the various letters written by the complainant.Ex.C9 is acknowledgment of United India Assurance Co. in which the complainant made a complaint with Customer Care department of United India Insurance Company and same is dated 31.7.2017.So it is clear that complainant was corresponding for payment of full amount till 31.7.2017.Ex.C10 is the receipt of Fortis Hospital, which shows that the complainant underwent by-pass surgery at Fortis Hospital and he was admitted on 5.4.2018 and was discharged on 12.4.2018.Ex.C12 is the text message sent by the complainant regarding his grievances to the OPs.
- On the other hand, the OP No.1 tendered claim forms Exs.OP1 to OP3 and Ex.OP4 is policy.
- The main argument of the ld. counsel for the OP is that the complaint is time barred as the complainant has accepted the amount of Rs.24500/- on 7.2.2017 and this complaint was filed on 11.2.2019. Further at the time of filing of this complaint the complainant has mentioned in para no.10 that complainant is enclosing explanation for some delay in approaching CPA. In the affidavit he has mentioned that he has sent Ex.C1 reminder to Insurance company and the customer redressal department and he also underwent bypass surgery in the year 2018.Ex.C9 is the receipt of customer care department of the OP. It is dated 31.7.2017, in which it is mentioned that the OP acknowledged the receipt of the grievance of the complainant and the OP took up the matter for the disposal of the complaint.
- So it is clear that the complainant was corresponding with the OPs for non payment of the bill amount. So when the total bill was not paid, so he has filed the present complaint. At the time of summoning of the complaint on 22.2.2019, the then Ld. President had summoned the OPs and it is mentioned that complaint is within limitation.
- The complainant is senior citizen. He got himself insured for total medical cover of Rs.4lac.He under went senile cataract surgery of right eye and submitted bill of Rs.93000/- but only Rs.24500/-was paid to him.
- So due to our above discussion the complaint is within limitation. There is only delay of four days and that was condoned when complaint was admitted on 22.4.2019.Accordingly the complaint is partly allowed and the OPs are directed to pay the remaining amount of Rs.68500/-to the complainant alongwith interest @6% per annum from 7.2.2017 when he has paid Rs.24500/- till realization. The OPs are further directed to pay Rs.5000/- as compensation for causing mental agony and harassment to the complainant and also to pay Rs.5000/- as costs of litigation expenses.
Compliance of the order be made by theOPs within a period of 45 days from the date of the receipt of the certified copy of this order. ANNOUNCED DATED:16.6.2021 Y.S.Matta Jasjit Singh Bhinder Member President | |
