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

 

Complaint Case No : RBT/CC/2018/156

Date of Institution   : 27.02.2018/29.11.2021

Date of Decision    : 01.09.2022

Sh. Vinod Kumar aged 65 years son of Sh. Puran Chand resident of 1013, Ranjit Avenue, Housing Board Colony Sector 3, Amritsar.  

                 …Complainant Versus

1.United India Insurance Company Limited having its Branch Office at 57, Railway Link Road, Amritsar through its Branch Manager/Divisional Officer.

2.Smt. Paarvati Devi Hospital U/T Rai Bahadur Kishore Chand Maheswari Charitable Trust A Block, Rnajit Avenue, Amritsar through its Authorized Representative. 

              …Opposite Parties

Complaint Under Section 11 & 12 of Consumer Protection Act, 1986 as Amended Upto Date.

 

Present: Sh. Vikram Puri Adv counsel for complainant.

Sh. Sandeep Khanna Adv counsel for opposite party No. 1.

Sh. Updip Singh Adv counsel for opposite party No. 2.

 

 

Quorum:-

1. Sh. Ashish Kumar Grover : President

2.Sh. Navdeep Kumar Garg : Member 

 

2.(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 Company Limited and others (hereinafter referred as opposite parties).

2. Brief facts of the case are that the complainant obtained one individual health policy bearing No. 2002012816P117753000 for a period of one year commencing from 21.3.2017 to 20.3.2018 from the opposite party No. 1 against the premium of Rs. 7,239/- covering the risk of himself and his wife for a sum of Rs. 1,00,000/- each. It is alleged that at the time of taking the above said policy the opposite party No. 1 assured that it will be a cashless policy and in case of health problem and in the event of hospitalization of the complainant, he will not have to make any payment out of his pocket. The complainant was fit at the time of purchasing the above said policy. It is further alleged that during the policy period on 15.10.2017 the complainant suffered some health problem and felt severe pain in his stomach and started loose motions and he was taken to opposite party No. 2, where the doctor told the complainant that he will have to be admitted in th ICU as certain tests and ultrasound needs to be done. The doctor of opposite party No. 2 further told the complainant that to deposit at least Rs. 8,000/- with the reception and complainant deposited Rs. 8,000/- in cash and the opposite party No. 1 was accordingly informed by the complainant. It is further alleged that on 15.10.2017 certain tests were conducted and later on the basis of reports and ultrasound, the doctor recommended the complainant for proper treatment and the complainant remained admitted in the hospital from 15.10.2017 to 18.10.2017. The officials of the opposite party No. 2 compelled the complainant to pay the total amount of Rs. 42,610/- (including Rs. 4,000/- as visiting charges of Dr. G.S. Chhina who is a Ortho doctor) without issuing the proper medical bills. The complainant contacted the officials of the opposite party No. 1 telephonically and requested that the policy in question was a cashless policy and it was the duty of the opposite party No. 1 to clear the dues of the hospital and the officials of the opposite party No. 1 told the complainant to issue the cheque on his behalf and later on they will look into the matter. But the complainant was not having cash or cheque book and the close relative of the complainant Sh. Vikas Bhatia issued the cheque No. 002442 dated 19.10.2017 on behalf of complainant. In the meanwhile the complainant lodged his claim with the opposite party No. 1 and submitted the relevant documents but the complainant has received one e-mail dated 7.11.2017 from Mr. Dushyant Passan TPA that the opposite party No. 1 has approved the meager amount of Rs. 19,558/- out of total bill of Rs. 42,610/-. It is alleged that the opposite party No. 1 cannot reject the genuine claim of the complainant on flimsy grounds. It is further alleged that now the complainant has received a legal notice dated 13.2.2018 from the counsel of opposite party No. 2 Under Section 138 of the N.I.Act on the ground that the cheque No. 002442 for a sum of Rs. 42,610/- issued by the relative of the complainant has been dishonoured. The complainant had already deposited Rs. 8,000/- in cash with the opposite party No. 2 on 15.10.2017 and opposite party No. 1 approved and cleared the amount of Rs. 19,558/- but the opposite party No. 2 has wrongly issued the legal notice for excessive amount of Rs. 42,610/-, actually the pending disputed amount with the opposite party No. 2 is Rs. 29,278 including Rs. 500/- as a registration charges which the opposite party No. 1 is duty bound to clear the dues to the opposite party No. 2. Thus, alleging deficiency in service on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.- 

i)The opposite party No. 1 clear the pending outstanding amount of Rs. 29,278/- of the complainant to the opposite party No. 2 for medical treatment.  

ii)To pay Rs. 30,000/-  as compensation for mental tension and harassment suffered by the complainant alongwith Rs. 5,000/- as litigation expenses.   

3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version by taking preliminary objections interalia on the grounds of consumer, not come with clean hands etc. It is alleged that the present claim has already been approved and paid as per clause 1.2 of the mediclaim policy in question. It is further alleged that the hospital bill was for Rs. 48,326/- wherein room rent availed was Rs. 3,000/- per day and ICU charges availed were Rs. 6,000/- per day and the sum insured qua the present insurance cover was Rs. 1 lac and the maximum payable room rent and ICU charges are 1% and 2% of the sum insured respectively. However, the complainant availed high category room and other expenses which are subject to proportionate deduction as per clause 1.2. Accordingly, the claim in question was approved for an amount of Rs. 17,462/- which was duly paid to the complainant in accordance with the provisions of policy in question. On merits, the opposite party No. 1 denied the case of the complainant and prayed for the dismissal of complaint. 

4. The opposite party No. 2 filed written version by taking preliminary objections interalia on the grounds of no consumer dispute, maintainability, complaint is gross abuse of the process of this Forum, no locus-standi, etc. On merits, the opposite party No. 2 denied the case of the complainant. It is submitted that the complainant was given proper required treatment by the doctors of the opposite party No. 2. It is further denied that any false or excessive medical bill was raised by the opposite party No. 2 and the patient was made to pay for the amount over and above the claim to be settled by the insurance company, but the complainant failed to pay the amount over. Thus, there is no deficiency in service on its part and prayed for the dismissal of complaint. 

5. In order to prove the case the complainant tendered into evidence his own affidavit Ex.C-1, copy of the insurance policy containing 3 pages Ex.C-2, copy of discharge summary issued by Smt. Parvati Devi Hospital Ex.C-3, copy of the patient discharge bill issued by Smt. Parvati Devi Hospital Ex.C-4, copy of the legal notice dated 12.2.2018 Ex.C-5 and closed the evidence.   

6. To rebut the case of complainant the opposite party No. 1 tendered into evidence affidavit of Sh. Dilbagh Singh Asstt. Manager Ex.O.P1/1, copy of the policy and terms and conditions Ex.O.P1/2, copy of the e-mail Ex.O.P1/3, copy of the detail of the approval of claim amount Ex.O.P1/4, copy of the details of deductions as per policy Ex.O.P1/5 and closed the evidence.  

7. The opposite party No. 2 tendered into evidence affidavit of Sunil Handa Ex.O.P2/A, copy of resolution Ex.O.P2/1 and closed the evidence.

8. 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 complainant. 

9. Ld. Counsel for complainant argued that the complainant obtained one individual health policy bearing No. 2002012816P117753000 for a period of one year commencing from 21.3.2017 to 20.3.2018 from the opposite party No. 1 against the premium of Rs. 7,239/- covering the risk of himself and his wife for a sum of Rs. 1,00,000/- each i.e. Ex.C-2. It is alleged that at the time of taking the above said policy the opposite party No. 1 assured that it will be a cashless policy and in case of health problem and in the event of hospitalization he will not have to make any payment out of his pocket. It is further argued that during the policy period on 15.10.2017 the complainant suffered some health problem and felt severe pain in his stomach and started loose motions and he was taken to opposite party No. 2, where the doctor told the complainant that he will have to be admitted in th ICU as certain tests and ultrasound needs to be done and the doctor of opposite party No. 2 further told the complainant to deposit at least Rs. 8,000/- with the reception and complainant deposited Rs. 8,000/- in cash and the opposite party No. 1 was accordingly informed by the complainant. It is further argued that the complainant remained admitted in the hospital from 15.10.2017 to 18.10.2017 Ex.C-4 and the officials of the opposite party No. 2 compelled the complainant to pay the amount of Rs. 42,610/- (including Rs. 4,000/- as visiting charges of Dr. G.S. Chhina who is a Ortho doctor) without issuing the proper medical bills. It is also argued by the Ld. Counsel for complainant that the close relative of the complainant Sh. Vikas Bhatia issued the cheque No. 002442 dated 19.10.2017 on behalf of complainant and in the meanwhile the complainant lodged his claim with the opposite party No. 1 and submitted the relevant documents but the complainant has received one e-mail dated 7.11.2017 from Mr. Dushyant Passan TPA that the opposite party No. 1 has approved the meager amount of Rs. 19,558/- out of total bill of Rs. 42,610/-. It is argued that the opposite party No. 1 cannot reject the genuine claim of the complainant on flimsy grounds. It is further argued that now the complainant has received a legal notice dated 13.2.2018 Ex.C-5 from the counsel of opposite party No. 2 Under Section 138 of the N.I.Act on the ground that the cheque No. 002442 for a sum of Rs. 42,610/- issued by the relative of the complainant has been dishonoured. It is also argued that the complainant had already deposited Rs. 8,000/- in cash with the opposite party No. 2 on 15.10.2017 and the opposite party No. 1 approved and cleared the amount of Rs. 19,558/-, but the opposite party No. 2 has wrongly issued the legal notice for excessive amount of Rs. 42,610/-, actually the pending disputed amount with the opposite party No. 2 is Rs. 29,278 including Rs. 500/- as a registration charges which the opposite party No. 1 is duty bound to clear the dues to the opposite party No. 2. 

10. On the other hand, Ld. Counsel for opposite party No. 1 argued that the present claim has already been approved and paid as per clause 1.2 of the mediclaim policy in question Ex.O.P1/2. It is further argued that the hospital bill was for Rs. 48,326/- wherein room rent availed was Rs. 3,000/- per day and ICU charges availed were Rs. 6,000/- per day and the sum insured qua the present insurance cover was Rs. 1 lac and the maximum payable room rent and ICU charges are 1% and 2% of the sum insured respectively but the complainant availed high category room and other expenses which are subject to proportionate deduction as per clause 1.2 and the claim in question was approved for an amount of Rs. 17,462/- which was duly paid to the complainant in accordance with the provisions of policy in question. 

11. Ld. Counsel for opposite party No. 2 argued that the complainant was given proper required treatment by the doctors of the opposite party No. 2. It is further argued that no false or excessive medical bill was raised by the opposite party No. 2. 

12. In order to prove his case the complainant has placed on record copy of insurance policy Ex.C-2 which is not disputed between the parties. The complainant has further placed on record Discharge Summary Ex.C-3 to prove that the complainant was admitted in the hospital of opposite party No. 2 from 15.10.2017 to 18.10.2017. The complainant has also placed on record Patient Discharge Bill Ex.C-4 to prove that the complainant has spent Rs. 48,326/- on his treatment. Ex.C-4 further shows that the complainant has paid 6,000/- as advance on 18th October 2017 to the hospital and the balance payment shows as Rs. 42,326/-. On this, Ld. Counsel for opposite party No. 1 has argued that the opposite party No. 1 has paid the amount of Rs. 17,462/- as per clause 1.2 of the insurance policy Ex.O.P1/2 which is as under;-

“In the event of any claim (s) becoming admissible under this scheme, the co. will pay through TPA to the Hospital/Nursing Home or the insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably and necessary incurred thereof by or on behalf of such insured person, but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.

A. Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing Home upto 1% of the sum insured per day. This also includes Nursing Care, RMO Charges, IV Fluids/Blood Transfusion/Injection Administration charges and similar expenses. 

B. If admitted in IC Unit, the company will pay 2% of the sum insured per day or actual amount whichever is less. 

13. The opposite party No. 1 in support of its case has also placed on record copy of email Ex.O.P1/3, which shows that the opposite party No. 1 has settled the claim of the complainant as per clause 1.2 of the insurance policy in question Ex.O.P1/2. However, Ex.O.P1/3 further shows that the opposite party No. 1 has disallowed the room charges for an amount of Rs. 8,400/- from the amount of Rs. 11,400/- and approved the amount of Rs. 3,000/- on account of maximum room rent  Rs. 1,000/day payable including nursing charges and the opposite party No. 1 has also disallowed the ICU charges for an amount of Rs. 3,000/- from the amount of Rs. 5,000/- and approved the amount of Rs. 2,000/- on account of maximum ICU room rent 2000/day payable including nursing charges. Ex.O.P1/3 further shows that the opposite party No. 1 has deducted proportionately the other charges. But we are of the view that the opposite party No. 1 has failed to produce any cogent evidence to prove this fact that how the opposite party No. 1 has deducted proportionately the other charges except the amount of Rs. 11,400/- as per policy. The amount of Rs. 11,400/- was rightly deducted by the opposite party No. 1. Rest amount was deducted by the opposite party No. 1 on un-reasonable ground. The opposite party No. 1 has place on record Ex.O.P1/3 i.e. calculation sheet vide which the opposite party No. 1 wrongly deducted Rs. 30,864 instead of Rs. 11,400/-. 

14. In view of the above discussion, the present complaint is partly allowed and the opposite party No. 1 is directed to pay an amount of Rs. 19,464/- (i.e. after deducting Rs. 11,400 from Rs. 30,864/- as per Ex.O.P1/3) 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. 3,000/- on account of compensation and Rs. 2,000/- on account of litigation expenses to the complainant. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of order will be supplied to the parties by District Consumer Commission, Amritsar as per rules.  

ANNOUNCED IN THE OPEN COMMISSION:

       1st Day of September, 2022 

 

            (Ashish Kumar Grover)

            President             

 

(Navdeep Kumar Garg)

Member