Complainant Manohar Lal Sharma has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to pay wrong deduction Rs.1,21,785/- made by the opposite party no.3 should be done away with and his claim be paid without reduction. Opposite parties be further directed to pay Rs.10,000/- as delay and harassment caused, in the interest of justice.

2.       The case of the complainant in brief is that he had got an individual health policy since 17.5.2010 which was renewed from time to time. The last renewal of the policy was renewed vide Policy No.2002022817P102803018 from United India Insurance Co.Ltd., Jalandhar Road, Batala, Gurdaspur from 19.05.2017 to 18.05.2018. He has next pleaded that he was admitted in CAPITOL Hospital, Jalandhar and finally diagnosed as Type II Diabetes Mellitus, Acute Coronary Syndrome - Acute IVVMI, Coronary Artery Disease, Double Vessel Disease PTCA + Stents to RCA and LAD done on 30.07.2017. He was discharged from the hospital on 01.8.2017. The opposite party no.3 settled his claim. The details of settlement of claim are given in the complaint. The deduction of excess charges Rs.70,000/- maximum payable 70% of S.I. have been alleged to be totally illegal, arbitrary and without any justification and not mentioned in the contract. It is clear cut deficiency in service on the part of the opposite parties. Hence this complaint.

 3.          Notice of the complaint was issued to the opposite parties. Opposite party no.1 and 2 appeared through their counsel and filed their written reply taking the preliminary objections that the complainant has no cause of action to file the present complaint; the complaint of the complainant is liable to be dismissed as there is no deficiency in services on the part of the opposite parties.; insurance is a contract between the two parties and both the parties bind with the terms and conditions of the policy and the complainant has not come to the Commission with clean hands and concealed the material facts. On merits, it was submitted that the claim has been raised and the claim of Rs.1,47,845/- after making deductions as per policy terms and conditions has been duly paid to the complainant and as such, there is no further liability of the insurance co. The complainant has filed the present complaint only to harass the opposite party.  It has next submitted that the claim has rightly been settled and deduction has rightly been made as per terms and conditions of the policy.  All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs. 

4.       Notice issued to opposite party no.3 had not been received back. Period of 30 days had already been elapsed. Presumption could be drawn that opposite party no.3 had been served but it was intentionally evading the service of the notice. Case called several times, but none had appeared on behalf of opposite party no.3. Hence, opposite party no.3 was ordered to be proceeded against exparte vide order 03.12.2018.

5.        Alongwith the complaint, complainant has filed his own affidavit  Ex.C-6 alongwith other documents Ex.C-1 to Ex.C-5.

6.       Alongwith the written statement opposite parties no. 1 & 2 has filed affidavit of Sh.Jai Kishan, Divisional Manager Ex.OP-1,2/1-A alongwith copies of documents Ex.OP-1,2/1 to Ex.OP-1,2/4.

7.      Written arguments not filed by the parties.

8.     We have carefully gone through the pleadings of counsel for both the parties; arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the parties for the purposes of adjudication of the present complaint.

9.    The present complaint has been filed by the complainant against wrong deduction from the amount of medical claim settled by opposite party no.3  on behalf of opposite party no.1 & 2 as per Ex.Page 37 and Ex.OP-2. As per claim settlement letter total amount of claim is Rs.2,69,630/- and amount Rs.1,47,845/- has already been paid to the complainant by deducting Rs.84,824/- and Rs.36,961/-. The reasons quoted are as follow:-

         "Rs.1500/- emergency charges deducted: Rs.1500/-       file/admission/registration charges not payable: Rs.1000/- diet charges deducted : Rs.1622/- excess charge: Rs.70000/- maximum payable       70% of S.I. : Rs.9202/- maximum payable 70% of S.I."

It is well admitted by opposite parties in this letter to pay 70% of the sum insured which is clearly mentioned in the terms and conditions  placed at page 113 of Ex. i.e.

b.   Major Surgeries         :          Actual expenses incurred or 70% of the sum                                          insured whichever is less.

As per policy at Ex.OP-1 page 2, the sum insured is Rs.3,00,000/-. Hence the maximum admissible amount @ 70% becomes to Rs.2,10,000/-.

 It is understood that opposite party is equally bound to abide by the terms and conditions of the policy. So as mentioned above complainant is entitled for Rs.2,10,000/-(70% of S.I.) as this amount is less than the total claim amount of Rs.2,69,630/-.

 10.     From the above, we are of the considered view that complainant is entitled for the remaining amount of Rs.62,155/- (2,10,000/- - 1,47,845/-). Moreover, deductions made by opposite party have not been properly explained on justified in their reply with cogent evidences.

11.    In view of the aforesaid discussion considering the facts and circumstances of the case, the present complaint is partly allowed and opposite party no.1 & 2 are ordered to pay the remaining amount of claim of Rs.62,155/- to the complainant within 45 days from date of receipt of copy of order failing which opposite party shall pay this amount with 6% interest till actual realization of the same. Besides this opposite parties no.1 & 2 are directed to pay compensation of Rs.10,000/- in lumpsum for litigation and harassment.

12.        The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

13.    Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.                                                                                                                                                         

             (Naveen Puri)

                                                                            President   

Announced:                                                   (B.S.Matharu)

December 09, 2022                                                 Member

*MK*