Punjab

Ludhiana

CC/19/320

Surinder Malik - Complainant(s)

Versus

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

Surinder Kumar Adv.

11 Oct 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 320 dated 08.07.2019.                                                        Date of decision: 11.10.2022.

 

Surinder Malik aged about 66 years son of Sh. Gulab Ram, resident of H. No.62, Raman Enclave, Near Rishi Nagar, Ludhiana. M: 98152-77047

.…..Complainant.

                                      Versus

1. M/s. United India Insurance Company Ltd., Branch Office 151, Industrial Area-A, Cheema Chowk, Ludhiana through its Branch Manager.
2. M/s. United India Insurance Company Ltd., Regd. Office & Head Office, 24, White Road, Chennai-600 014 through its Chairman/Mg Director/Director/Administrator.
3. M/s. MD India Health Insurance TPT Pvt. Limited, S. No.46/1, E Space, A-2 Building, 3^rd Floor, Pune Nagar, Vadgaonsheri, Pune-411 014 (Mah. through its Chairman/Mg. Director/Director/Administrator/Manager.
4. Prashant Mehra Code No.AG10052425) Agent of United India Insurance Company Limited, Branch Office 151, Industrial Area-A, Cheema Chowk, Ludhiana                                                                                                                                                           …..Opposite parties 

Complaint under Section 12 of the Consumer Protection Act,      1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Surinder Kumar Makkar, Advocate.

For OP1 and OP2          :         Sh. Rajnish Lakhanpal, Advocate.

For OP3 and OP4          :         Complaint against OP3 and OP4 not admitted                                             vide order dated 18.07.2019.

 

ORDER

PER K.K. KAREER, PRESIDENT

 

1.                In brief, the case of the complainant is that he is the holder of medi-claim policy bearing No.2011022817P113506936 issued by OP1. Originally the policy was obtained in the year 2007 and it was got renewed from time to time. The complainant and his wife Neelam Malik  are covered under the insurance policy. During the currency of the policy in the month of November 2018, the complainant suffered eye problem and the doctor advised him eye surgery and implantation of lens. Accordingly, the complainant got himself operated upon and as per doctor’s advice, lens were implanted by the doctor at Anurag Eye enter, Opp. Kali Mata Mandir, Chhotti Haibowal, Hambran Road, Ludhiana on 09.11.2018. The complainant spent a total amount of Rs.37,985/- on his treatment. Thereafter, the complainant lodged a claim of Rs.37,985/- with original bills and receipts but the OPs paid only a sum of Rs.17,000/- to the complainant on 03.01.2019 while the remaining amount of Rs.20,985/- was not paid. This amounts to deficiency of service on the part of the OPs. The complainant got served a legal notice dated 25.03.2019 but despite that the payment of Rs.20,985/- was not made. Hence the complaint whereby it has been requested that the OPs be directed to pay the balance amount of Rs.20,985/- along with compensation of Rs.1,00,000/- and litigation expenses of Rs.20,000/-.

2.                The complaint as against OP3 and OP4 was not admitted as per order dated 18.07.2019.

3.                Upon notice, OP1 and OP2 appeared and contested the complaint.  In the written statement filed by OP1 and OP2, it has been, inter alia, pleaded that the complaint is not maintainable. According to OP1 and OP2, the complainant was informed in advance that any charges over and above the agreed tariff rate with the hospital will be borne by the complainant himself. Even otherwise, the complainant was paid as per the terms and conditions of the insurance policy and agreed tariff rates regarding which the declaration form was duly signed by the complainant himself. Therefore, the complainant is estopped from filing the present complaint. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                In evidence, the complainant submitted his affidavit Ex. CA along with documents Ex. C1 to Ex. C6 and Mark-1 to Mark-9 and closed the evidence.

5.                On the other hand, the counsel for OP1 and OP2 tendered affidavit Ex. RA of Sh. Gurwinder Singh, Assistant Manager of OPs, affidavit Ex. RB of Sh. Pushkar Chandrakant Kulkarni, of MD India Healthcare Services Pvt. Ltd. along with documents Ex. R1 to Ex. R5 and closed the evidence.

6.                We have heard the counsel for the parties and gone through the record carefully.

7.                During the course of arguments, the counsel for the complainant has argued that the OPs are bound to pay the entire amount of Rs.37,985/-  spent by the complainant on his treatment whereas the OPs have paid just an amount of Rs.17,000/- . This clearly amounts to deficiency of service on the part of the OPs. In this regard, the counsel for the complainant has referred to clause 3.22 of the policy Ex. C6 which shows that medical expenses actually incurred for the medical treatment will be paid. According to the counsel for the complainant, partial imbursement of the claim is clearly in violation of clause 3.22 of the policy.

8.                On the other hand, the counsel for OP1 and OP2 has contended that as per clause 3.25 of the policy in case of Preferred Provider Network, reimbursement of expenses incurred in PPN for the procedures listed under PPN package are subject to the rates applicable to PPN package pricing. In this regard, the counsel for the OPs has further referred to declaration Ex. R3 which is signed by the complainant whereby he himself opted to receive imbursement only as per agreed tariff for the treatment and the balance amount was to be borne by him. Counsel for the OPs has further referred to Ex. R5 which shows that Anurag Eye and Maternity Center is an empanelled hospital of the OPs and in this document, for the treatment of cataract a fixed sum of Rs.17,000/- is payable. The counsel for the OPs has further contended that the amount of Rs.17,000/- was payable which stands already paid.

9.                We have weighed the contentions raised by the counsel for the parties and we are of the considered view that as per the clause 3.22 of the policy, in case of preferred provider network, reimbursement for the disease/treatment cover under PPN is supposed to be paid at package rates only which are fixed by insurance company with its empanelled hospitals. As is evident from Ex. R5, hospital where the complainant got himself treated for cataract surgery, a package rate of Rs.17,000/- was only payable which has already been paid. Moreover, the complainant himself signed the declaration form Ex. R3 whereby he agreed for reimbursement as per agreed tariff under PPN rates and the balance amount exceeding package rates was to be borne by him. Therefore, OP1 and OP2 were liable to pay the agreed sum of Rs.17,000/- which has already been paid in accordance with the terms and conditions of the policy and more particularly as per clause 4.22 of the policy Ex. C6. Therefore, it cannot be said to be a case of deficiency of service on the part of OP1 and OP2.

10.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:11.10.2022.

Gobind Ram.

Surinder Malik Vs United India Insurance Co.                         CC/19/320

Present:       Sh. Surinder Kumar Kakkar, Advocate for complainant.

                   Sh. Rajnish Lakhanpal, Advocate for OP1 and OP2.

                   Complaint against OP3 and OP4 not admitted vide order dated                             18.07.2019.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:11.10.2022.

Gobind Ram.