Delhi

North

CC/84/2020

AJAY SURI - Complainant(s)

Versus

UNITED INDIA INSURANCE COMPANY LTD. - Opp.Party(s)

02 Dec 2024

ORDER

 

 

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Consumer Complaint No. 84/2020

In the matter of

Sh.Ajay Suri                                                             

43, Rajpur Road, Civil Lines

Delhi-110054                                                                                      …      Complainant

                                                                               

Versus

United India Insurance Company Ltd.

503-504, Kailash Building, K.G.Marg

New Delhi-110001                                                                             …     Opposite Party

 

 

ORDER
02.12.2024

Ms.Harpreet Kaur Charya, Member

            The present Complaint has been filed by Sh. Ajay Suri, against United India Insurance Co.Ltd., New Delhi as OP under Section 35 of the Consumer Protection Act, 2019.  

1. Facts necessary for the disposal of the present complaint are that the complainant purchased a Family Medicare Policy bearing No.0408002818P109934520 for the period 25.11.2018 to 24.11.2019.  It has been stated by the complainant that he has been continuing the policy since 25.11.2011.
2. On 19.06.2019, cashless claim for ‘Coronary Artery Disease’ was rejected.  A claim for reimbursement along with all documents was filed on 02.07.2019.  After passing of more than one month OP issued a query letter dated 08.08.2019 for providing the page -2 and 3 of hospital breakup bill.   The complainant has alleged that the same stood submitted with the original claim filed on 02.07.2019 which was also confirmed by customer Care of OP. 
3. After several reminders and personal visits, the OP paid partial amount of Rs.1,80,077/- instead of total claim amount of Rs.3,01,869/-.  OP also shared the processing sheet showing the deduction as follows:-

Explanation of benefits:

Category	Sub category	Billed amount (in Rs.)	Deducted amount (INR)	Approved amount (INR)	Remarks
Investigation	Investigation			0.00	Rs. 1200/- DEDUCTED AS THESE INVESTIGATIONS ARE PART OF ANGIOPLASTY PACKAGE
Others	Others			0.00	Rs.500/- MRD CHARGES
Medicines And consumables	Consumables	83269.00	35692.00	45577.00	RS.35692/- DEDUCTED AS ALL THESE CONSUMABLES EXCEPT STENT AND BALLOON CHARGES ARE PART OF ANGIOPLASTY PACKAGE
Package charges	Package charges	216900.00	84400.00	132500.00	Rs.84400/- DEDUCTED AS PER REASONABLE AND COSTOMARY CLAUSE

4. The complainant has further stated that as per the explanation provided by the OP the deduction have been made under a ‘reasonable and customary clause’ which are not their policy terms and conditions. 
5. Online complaint was filed in November, 2019 with OP, however even after lapse of a period of more than five months, OP has refused to pay balance amount. The complainant has again alleged that he was not aware whether   reasonable and customary clause ever existed in his Health Policy Contract.
6. Complainant requested OP to share the item-wise details for the other deductions for consumable, forming part of the Angioplasty package for which he was charged by the hospital but not paid in the claim amount.
7. The complainant has stated that OP did not pay the hospital bills despite receiving hefty premium.  The policy was procured for taking care of hospital bills in the complainant’s old age and deteriorating health condition.  Being the sole earning member of the family he had to undergo harassment from OP, hence, the present complaint with the prayer for directions to OP to pay Rs.1,21,792/- and Rs. 10,000/- as compensation towards mental and financial harassment.  
8. The complainant has annexed the policy documents for the period 25.11.2018 to 24.11.2019; premium receipt issued by OP date 31.10.2018; Claim Processing Sheet ; copy of the passport of the complainant; printout from the grievance portal of OP; email dated 28.02.2020 and  24.04.2020 have been annexed with the complaint.
9. Notice of the present complaint was issued to OP.  Written statement was filed on their behalf. They have raised preliminary objections such as the present complaint is bereft of merit; treating hospital and TPA are the necessary parties whereas same have not been made a party to the dispute.  It is the case of overcharging by the hospital. 
10. It has been submitted that there is mutual understanding between the hospitals on panel of OP and charges for different tests/treatment are fixed and payable accordingly and the same are reasonable and customary charges.
11. It has been further submitted by OP that consumable are not covered as per Clause 4.20 of the Policy, therefore, complainant is not entitled for the same. Clause 3.32 deals with reasonable and customary charge in the policy terms and conditions and deductions are made accordingly. 
12.  It is the hospital that has overcharged and OP has paid the claim according to the terms and conditions.  The remaining amount in dispute has been overcharged by the hospital and OP is not liable to pay the excess amount.  Rest of the contents have been denied with the prayer for dismissing the complaint with cost.  OP has annexed copy of policy documents alongwith terms and conditions dated 25.11.2018 to 24.11.2019.
13. Rejoinder to the written statement was filed by the complainant reiterating the facts of the complaint and denied those of the written statement.  It has been denied that the treating hospital and TPA are necessary party and as the dispute does not arise out of overcharging by the hospital. It has been submitted that the deductions made by OP are arbitrary and without any rationale.  It has been denied that hospital has arbitrarily charged for investigations and others which are included in package. 
14.  We have perused the material placed on record and heard the submission made by the Authorised Representative of the complainant and Ld. Counsel for OP.   
15. Perusal of the order-sheets dated 22.09.2022, 11.11.2022 and 09.01.2023 reveal that despite several opportunities neither complainant nor OP has filed their evidence by way of affidavit.      
16. In absence of evidence by way of affidavit in support of his pleadings, the complainant has failed to prove his complaint, being so; the present complaint is dismissed without orders to cost.
17. Office is directed to supply the copy of this order to the parties as per rules. Order be also uploaded on the website.  Thereafter, file be consigned to the record room.

 

 

(Harpreet Kaur Charya )         Member

(Ashwani Kumar Mehta)                               Member

                                        (Divya Jyoti Jaipuriar)

                                                                                                 President