DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/15

Date of Institution : 05.01.2018/29.11.2021

Date of Decision : 19.07.2022

Vijay Kumar Aggarwal s/o J.C. Aggarwal R/o 27, Green Avenue, Amritsar.    …Complainant

Versus

1. United India Insurance Co. Ltd., 24 Whites Road, Chennai Through its Manager/Director/Overall Incharge. 

2. United India Insurance Co. Ltd., through its Divisional Manager/ Senior Divisional Manager/Person Over All Incharge, Lawrence Road, Amritsar.

3. Vipul Medcorp Insurance TPA Pvt. Ltd., through its Director/Manager Over All Incharge Branch, Court Road, Amritsar.

…Opposite Parties

 

Complaint U/S 11 and 12 of The Consumer Protection Act 1986 as amended up to date

Present: Sh. Amit Bhatia Adv counsel for the complainant.

Sh. Sandeep Khanna Adv counsel for opposite parties No. 1 and 2.

Opposite party No. 3 exparte. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Smt. Urmila Kumari : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    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 filed the present complaint under Section 11 and 12 of the Consumer Protection Act against United India Insurance Company Limited, Chennai and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant was obtaining mediclaim insurance policy from the opposite parties No. 1 and 2 since the year 1998 paying requisite premium to the opposite parties No. 1 and 2. The complainant further submitted that during the tenure of policy issued on 13.2.2017 valid up to 12.2.2018 the complainant was admitted to Altec Laser and Super Specialty Centre for diagnosis of BHP on 29.7.2017 and discharged on 2.8.2017. He was admitted there with the C/O Prostomegaly Stage-II with Urinary Urgency with Frequency of Urination with Mild Pain while passing urine. During the admission period he was also operated. During the said period he paid a sum of Rs. 73,730/- to the said hospital for his treatment. Further, before getting the said treatment the complainant intimated the opposite parties about his admission vide letter dated 28.7.2017 which was duly received in the office of opposite parties. After getting the requisite treatment from the said hospital the complainant lodged his claim vide letter dated 8.8.2017 received by opposite parties on 9.8.2017. But the opposite party paid only a sum of Rs. 20,000/- to the complainant for his claim of Rs. 73,730/- and remaining amount has not been disbursed by the opposite parties on the ground that in the listed hospitals for the said treatment amount of Rs. 20,000/- is sufficient. In this regard the complainant also received an email from the opposite party No. 3. The excuse of the opposite party is baseless as it is the complainant to see which is the best person to take the treatment and complainant is taking regular treatment from the said hospital. The complainant is taking the mediclaim policy from the opposite party for the last about 20 years and at present the complainant is approximately 70 years of age and opposite party is harassing the complainant by withholding the genuine claim of the complainant. The ground taken by the opposite party is illegal and complainant never received any terms and conditions of the policy. In this way the act of the opposite parties is clear cut deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay remaining amount of Rs. 53,730/- alongwith interest at the rate of 18% per annum.    

2) To pay Rs. 50,000/- on account of harassment. 

3) To pay Rs. 11,000/- as cost of legal expenses.

4) Any other relief to which the complainant is found entitled. 

3. Upon notice of this complaint, the opposite parties No. 1 and 2 filed written version taking preliminary objections on the grounds that the complainant has violated the basic terms and conditions of the policy in question so present complaint is not maintainable. As per clause 1.1 of the insurance policy The company will pay the amount of expenses which are medically necessary and reasonable charges. Further, as per clause 3.33 of the policy Reasonable and customary charges are the charges for service or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for the identical or similar services, taking into account the nature of illness/injury involved. Further, the opposite parties enrolled certain hospitals on its network and opposite party has negotiated packages for various surgeries including TURP procedure undergone by the complainant. However, in the present case the complainant has not availed the cashless facility at any network hospitals which are enrolled with the opposite party rather preferred the reimbursement mode of claiming expenses which are otherwise exaggerated and unreasonable. In the light of these provisions the payable amount of Rs. 24,000/- was duly approved and same was paid to the complainant and claim of complainant fully satisfied and nothing remains due towards the complainant. Further, the complainant not approached this Commission with clean hands and concealed the material facts.  

4. On merits, the opposite parties No. 1 and 2 not denied the obtaining of policy by the complainant. However, the liabilities under the said policy are strictly covered as per terms and conditions and exclusion clauses of the said policy. Further, the opposite parties No. 1 and 2 repeat the contents as mentioned in preliminary objections so there is no need to reiterate the same. However, lastly the opposite parties No. 1 and 2  prayed for the dismissal of the present complaint against the opposite parties No. 1 and 2 with costs. 

5. The opposite party No. 3 did not appear before this Commission despite service, so the opposite party No. 3 was proceeded against exparte.  

6. In support of his complaint, the complainant tendered into evidence his affidavit Ex.CW-1/A, copies of cover notes of policies Ex.C-1 to Ex.C-14, copy of order passed by DCF, Amritsar dated 2.6.2017 Ex.C-15, copy of letter dated 28.6.2017 Ex.C-16, copy of letter Ex.C-17, copy of email Ex.C-18, copy of email Ex.C-19, copy of letter dated 8.8.2017 Ex.C-20, copy of discharge summary Ex.C-21, copy of bill dated 2.8.2017 Ex.C-22, copies of receipts Ex.C-23 and Ex.C-24, copies of bills Ex.C-25 to Ex.C-30, copies of cover notes of policies Ex.C-31 and Ex.C-32 and closed the evidence. 

7. To rebut the case of the complainant, the opposite parties No. 1 and 2 tendered in evidence affidavit of Sat Pal Assistant Manager Ex.OP-1.2/1, copy of insurance policy alongwith terms and conditions Ex.OP-1.2/2, copy of email Ex.OP-1.2/3 and closed the evidence. 

8. We have heard the learned counsel for the parties and have gone through the record on the file carefully.

9. The opposite parties admitted all the contents regarding purchase of policy, validity of policy, sum insured and treatment taken by the complainant from Altec Laser and Super Speciality Centre. The only dispute between the parties is regarding the quantum of claim given by the opposite parties to the complainant. The complainant admitted in his complaint that the opposite parties have paid the amount of Rs. 20,000/-  on account of insurance claim with regard to the expenses on the treatment of the complainant. 

10. The opposite parties No. 1 and 2 submitted in their written version that as per clause 1.1 of the insurance policy the company will pay the amount of expenses which are medically necessary and reasonable charges. Further, as per clause 3.33 of the policy Reasonable and customary charges are the charges for service or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for the identical or similar services, taking into account the nature of illness/injury involved. Further, the opposite parties enrolled certain hospitals on its network and opposite party has negotiated packages for various surgeries including TURP procedure undergone by the complainant. However, in the present case the complainant has not availed the cashless facility at any network hospitals which are enrolled with the opposite party rather preferred the reimbursement mode of claiming expenses which are otherwise exaggerated and unreasonable, so the opposite parties No. 1 and 2  deducted Rs. 53,730/- from the total claim of Rs. 73,730/-. They mentioned that they have deducted this amount on the basis of document Ex.OP-1.2/3 in which the opposite parties have given the comparison of treatment expenses of the complainant with other hospitals. But opposite parties have not produced any document to prove that the deduction is  reasonable as the complainant had submitted the entire medical bills with the opposite parties which was charged by the hospital. The opposite party wrongly deducted amount of Rs. 53,730/- from the medical bills of the complainant which is not justified and unreasonable. The opposite parties No. 1 and 2 made the above mentioned deduction from the claim of the complainant but they have not tendered any document or affidavit of any hospital mentioned in the comparison chart Ex.OP-1.2/3 in their evidence vide which they have made these deductions. In this way the opposite parties failed to rebut the case of the complainant with any convincing and reliable evidence and act of the opposite parties is deficiency in service and unfair trade practice. 

11. In view of the above discussion, present complaint is partly allowed against the opposite parties No. 1 and 2 and opposite parties No. 1 and 2 are directed to pay the amount of Rs. 53,730/- to the complainant on account of balance amount of insurance claim alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite parties No. 1 and 2 are also directed to pay Rs. 3,300/- to the complainant as compensation for mental tension and harassment and Rs. 2,200/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Both the opposite parties No. 1 and 2 jointly and severally liable to comply with the above mentioned order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        19th Day of July 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member