DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.
Complaint Case No : RBT/CC/2018/134
Date of Institution : 21.02.2018/29.11.2021
Date of Decision : 16.08.2022
Sh. Pavittar Thukral C/o Pharma Loyed, Verka Majitha Bye Pass, Majitha Road, District Amirtsar.
…Complainant Versus
United India Insurance Co. Ltd., Rayya District Amritsar through its Manager.
…Opposite Party
Complaint Under Section 12 of Consumer Protection Act, 1986. As Amended Upto Date.
Present: Ms. Harsimrandeep Kaur Adv counsel for complainant.
Sh. S.S. Batra Adv counsel for opposite party.
Quorum:-
1. Sh. Ashish Kumar Grover : President
2.Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):
1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 (as amended upto date) against United India Insurance Co. Ltd.,(hereinafter referred as opposite party).
2. Brief facts of the case are that the complainant is having insurance policy No. 2002052817P102015946 and in the said policy persons covered i.e. complainant, Mamta Thukral (wife), Satya Anchal Thukral (daughter unmarried) and Mrs. Satya Parpati Thukral (daughter unmarried). It is further alleged that the wife of the complainant fell ill and went to the doctor for examination and doctor advised her operation and she was admitted in the Hospital Altec Super Specialty Center having his head office 295, Gopal Nagar, Majitha Road, Amritsar and the complainant submitted a claim for insurance to the opposite party worth Rs. 64,188/- and also submitted all the bills and other relevant documents. The opposite party has released only Rs. 32,000/- and the remaining amount of Rs. 32,188/- the opposite party put of the matter on one pretext or the other in spite of repeated requests made by the complainant. The complainant approached the opposite party number of times to get the amount of Rs. 32,188/-, but of no use. Thus, alleging deficiency in service on its part. Hence, the present complaint is filed for seeking the following reliefs.-
i)To pay the claim amount of Rs. 32,188/- alongwith interest @ 18% from the date of submission till realization.
ii)To pay Rs. 50,000/- as compensation for mental tension and harassment suffered by the complainant alongwith Rs. 10,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite party appeared and filed written statement by taking preliminary objections interalia on the grounds of maintainability, complainant has not come with clean hands. It is alleged that the complainant had obtained the Individual Health Policy of the opposite party under the settled terms and conditions. It is further alleged that the patient Mrs. Mamta Thkural was hospitalized at Altec Laser Super Specialty Hospital (Non PPN Hospital) from 7.10.2017 to 10.10.2017, she was diagnosed as a case of “Multiple Fibroid Uterus” for which she underwent total laparoscopic hysterectomy and after treatment the complainant filed a claim for reimbursement for an amount of Rs. 64,188/-, which was processed under the settled terms and conditions of the policy as the insured was covered under UI-Gold Policy clause 1.1 provides the company will pay the amount of expenses which are medically necessary and reasonable charges & further policy clause 3.33 has specifically stated that reasonable and customary charges as the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account of nature of illness/injury involved. It is further alleged that the list of hospitals for cashless facility was also provided to the complainant, as such as per the policy the claim of the complainant was considered and settled Rs. 32,000/- which satisfied the norms of expenses as necessary reasonable and customary & compared with the charges of empaneled hospital. On merits, the opposite party denied the case of the complainant and prayed for the dismissal of complaint.
4. In order to prove the case the complainant tendered into evidence his own affidavit Ex.C-1, copy of the policy schedule Ex.C-2, copy of the letter dated 23.10.2017 Ex.C-3, copy of the discharge voucher Ex.C-4 and closed the evidence.
5. To rebut the case of complainant the opposite party tendered into evidence affidavit of Sh. Dilbagh Singh Deputy Manager Ex.O.P1, copy of the insurance policy Ex.O.P2, copy of the mail Ex.O.P3 and closed the evidence.
6. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties. Written arguments filed by the parties.
7. Ld. Counsel for complainant argued that the complainant is having insurance policy No. 2002052817P102015946 i.e. Ex.C-2 and in the said policy persons covered i.e. complainant, Mamta Thukral (wife), Satya Anchal Thukral (daughter unmarried) and Mrs. Satya Parpati Thukral (daughter unmarried). It is further argued that the wife of the complainant fell ill and went to the doctor for examination and doctor advised her operation and she was admitted in the Hospital Altec Super Specialty Center and the complainant submitted a claim for insurance to the opposite party worth Rs. 64,188/- i.e. Ex.C-3 and also submitted all the bills and other relevant documents. It is argued that the opposite party has released only Rs. 32,000/- Ex.C-4 and for the remaining amount of Rs. 32,188/- the opposite party put of the matter on one pretext or the other in spite of repeated requests made by the complainant.
8. On the other hand, Ld. Counsel for the opposite party argued that the complainant had obtained the Individual Health Policy of the opposite party under the settled terms and conditions i.e. Ex.O.P2. It is further argued that the patient Mrs. Mamta Thkural was hospitalized at Altec Laser Super Specialty Hospital (Non PPN Hospital) from 7.10.2017 to 10.10.2017, she was diagnosed as a case of “Multiple Fibroid Uterus” for which she underwent total laparoscopic hysterectomy. It is argued that after treatment the complainant filed a claim for reimbursement for an amount of Rs. 64,188/-, which was processed under the settled terms and conditions of the policy as the insured was covered under UI-Gold Policy clause 1.1 provides the company will pay the amount of expenses which are medically necessary and reasonable charges & further policy clause 3.33 has specifically stated that reasonable and customary charges as the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account of nature of illness/injury involved. It is further argued that the list of hospitals for cashless facility was also provided to the complainant, as such as per the policy the claim of the complainant was considered and settled Rs. 32,000/- which satisfied the norms of expenses as necessary reasonable and customary & compared with the charges of empaneled hospital.
9. In order to prove his the complainant has placed on record copy of Individual Health Policy Schedule Ex.C-2 which is not disputed between the parties. The complainant has further placed on record letter dated 23.10.2017 Ex.C-3 which was written to the Manager, United India Insurance Company Limited, Rayya, District Amritsar, to settle the medical claim of Rs. 64,188/- spent by the complainant on the treatment of his wife. The complainant has also placed on record Discharge Voucher Cum Consent Letter Ex.C-4 which shows that the complainant has received Rs. 32,000/- and Rs. 32,188/- has been deducted by the opposite party. On this, Ld. Counsel for opposite party has argued that the opposite party has deducted the amount of Rs. 32,188/- out of Rs. 64,188/- as per clause 1.1 and clause 3.33 of the insurance policy Ex.O.P2. The opposite party has placed on record copy of mail Ex.O.P3 vide which it is mentioned that with these hospitals, we have negotiated packages for various surgeries including Laparoscopic Hysterectomy undergone by the patient at Adlakha Hospital, Amritsar and packages with other prominent hospitals as under;-
Sr. No. Name of hospital Package
1 Apollo hospital Rs. 20,000/-
2 A P hospital Rs. 20,000/-
3 Beri Maternity Centre Rs. 24,000/-
4 Carewell hospital Rs. 24,000/-
5 Sanjevan hospital Rs. 24,000/-
It is further mentioned in Ex.O.P3 that the insured has not availed cashless facility at any of these hospitals. But we are of the view that the opposite party has failed to produce any cogent evidence to prove this fact that the above mentioned hospitals charged as per the schedule mentioned by the opposite party in document Ex.O.P3. It is admitted case of the opposite party that the complainant has lodged his claim of Rs. 64,188/- alongwith original bills and vouchers. Neither the opposite party has produced any official document of the above mentioned hospitals nor filed any affidavit to prove its version. The opposite party has repudiated the claim of the complainant on un-reasonable and un-justified grounds which is clear cut deficiency in service on the part of the opposite party.
10. In view of the above discussion, the present complaint is partly allowed and the opposite party is directed to pay the remaining claim amount of Rs. 32,188/- to the complainant alongwith interest @ 6% per annum from the date of filing the present complaint till realization. The opposite party is further directed to pay Rs. 5,000/- on account of compensation and Rs. 3,300/- on account of litigation expenses to the complainant. Copy of order will be supplied to the parties by District Consumer Commission, Amritsar as per rules.
File be sent back to District Consumer Disputes Redressal Commission, Amritsar.
ANNOUNCED IN THE OPEN COMMISSION:
16th Day of August, 2022
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
