State Consumer Disputes Redressal Commission
Amrit Pal Garg vs United India Insurance Company Limited on 17 September, 2015
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No.282 of 2015
Date of Institution : 12.03.2015.
Date of decision : 17.09.2015.
Amrit Pal Garg s/o Late Megh Raj Garg, resident of H.No.41/2C,
Atam Nagar, Model Town, Ludhiana.
......Appellant/Complainant.
Versus
1. M/s United India Insurance Company Limited, 24, Whites
Road, Chennai -600014.
2. The Managing Director M/s United India Insurance Company
Limited, 24, Whites Road, Chennai - 600014.
3. M/s United India Insurance Company Limited, III, Gulmor
Hotel Building, Ferozepur Road, Ludhiana, through its
Brancyh Manager.
4. The Branch Manager, M/s United India Insurance Company
Limited, III, Gulmor Hotel Building, Ferozepur Road,
Ludhiana.
...Respondents/Opposite parties.
First Appeal against the order dated
28.01.2015 of the District Consumer
Disputes Redressal Forum, Ludhiana.
Quorum:-
Hon'ble Mr. Justice Gurdev Singh, President
Sh.Baldev Singh Sekhon, Member
Sh.Vinod Kumar Gupta, Member Present:-
For the appellant : Sh. Rahul Rampal, Advocate For respondent : None SH.VINOD KUMAR GUPTA, MEMBER This appeal has been preferred by the appellant/complainant against the order dated 28.01.2015 passed by District Consumer Disputes Redressal Forum, Ludhiana (in short, "District Forum"), vide which the complaint filed by him was dismissed. First Appeal No.282 of 2015 2
2. As per the allegations made in the complaint, the complainant purchased one health insurance policy for himself and for his wife, vide Insurance policy bearing No.200900/48/13/97/00000973, which was valid upto 27.07.2014, from opposite party No.1, through opposite party No.3 after paying the premium to opposite parties. Unfortunately, the wife of the complainant; namely, Meena Garg, had undergone Cataract Surgery from Thind Eye Hospital, Jalandhar on 13.02.2014 and was discharged on 14.02.2014. He submitted all the relevant papers and two bills of Rs.90,000/-, each, dated 13.02.2014 and 14.02.2014 for the expenses incurred by him on the treatment of his wife, to the opposite parties. But, they paid only a partial amount of Rs.44,000/- instead of Rs.1,80,000/-, without any reason, to him. Legal notice dated 13.05.2014 was served upon them through his counsel Davinder Gupta. That notice was duly received by them, but they neither replied nor complied with the same. The complainant suffered a lot of mental pain, agony tension and financial loss. He prayed for issuance of directions to the opposite parties; to pay the amount of Rs.1,86,000/-, along with the interest on account of mental pain agony, tension as well as financial loss suffered by him and Rs. 22,000/- as litigation expenses.
3. The complaint was contested by opposite parties by filing written reply, before the District Forum. Preliminary objections were taken, that the complaint was not maintainable; complaint was false and frivolous and was bad for non-joinder and mis-joinder of the necessary parties; the complainant had not come First Appeal No.282 of 2015 3 to the District Forum with clean hands and had suppressed the material facts; the intricate questions of facts and law were involved in the case which cannot be summarily decided under the Act. On merits, it was pleaded that the parties were governed by the terms and conditions of the insurance policy. The due service was rendered by them and there was no lapse or deficiency in service on their part. It was further pleaded that such type of cases were being dealt with by M/s Alankit Healthcare TPA Ltd. on behalf of opposite parties. The case of wife of the complainant was also dealt with by aforesaid TPA. The competent doctors minutely scrutinized the bills of her treatment and considering all the facts they worked out amount of Rs.22,000/- on two occasions and paid the amount of Rs.22,000/- twice i.e. Rs.44,000/- to the complainant. It was further pleaded that he and his wife were not entitled to any other amount. The Alankit Health Care (TPA) has specifically worked out on the payable amount and also given the reason for not allowing the other alleged amount on treatment of Mrs.Meena Garg. There is no deficiency in services on their part. Other allegations of the complaint were denied and opposite parties prayed for dismissal of the complaint.
4. Both the sides produced evidence in support of their respective averments before the District Forum, which after going through the same and hearing learned counsel for both the parties dismissed the complaint of the complainant, vide impugned order dated 28.01.2015.
5. We have heard the learned counsel for the appellant as none has appeared on behalf of the respondent at the time of final First Appeal No.282 of 2015 4 arguments. We have carefully gone through the records of the case.
6. It was submitted by the learned counsel for the appellant/complainant that the District Forum failed to consider that there was nothing on record produced by the respondent/Opposite parties to prove or show that the appellant/complainant was only entitled for Rs.44,000/- and there was no explanation as to what was the excessive medical procedure, which had undertaken by Meena Garg and which was not covered under the terms and conditions of the policy. No witness was examined by respondent/opposite party to prove that due to some contract, appellant/complainant was not entitled for full expenses of treatment undergone at Thind Eye Hospital. It was prayed that the appeal be accepted and the order of the District Forum be set- aside.
7. The complainant purchased one health insurance policy bearing No.200900/48/13/97/00000972 Ex. C-1 from opposite parties for the period 28.07.2013 to 27.07.2014 after paying the premium of Rs.13,109/- under which he and his wife Meena Garg were covered. The complainant has wrongly mentioned the policy No. 200900/48/13/97/00000973 in the complaint. It is also admitted fact that the wife of the complainant was admitted in Thind Eye Hospital, Jalandhar on 13.02.2014 and discharged on 14.02.2014, for Cataract Surgery. From the Discharge Summary dated 14.02.2014 Ex.R-14, it was diagnosed "PSEUDOPHAKIA in Right Eye, ISC in Left Eye". The complainant submitted two bills Ex.C-2 and Ex.C-3 to opposite First Appeal No.282 of 2015 5 parties amounting to Rs.90,000/- each for the expenses incurred on the treatment of his wife. We have perused the terms and conditions of the policy Ex.C-1. The relevant condition is reproduced as under:-
1.2.1 Expenses in respect of the following specified illnesses will be restricted as detailed below:-
Hospitalization Benefits LIMITS per surgery RESTRICTED TO a. Cataract, Hernia, a. Actual expenses incurred or 25% of b. Hysterectomy the sum insured whichever is less. c. Major surgeries* b. Actual expenses incurred or 70% of the Sum Insured whichever is less.
8. It is clear from summary of bill Ex. R-11 that the wife of the complainant had obtained special treatment from Thind Eye Hospital for Cataract Surgery with multifocal IOLI; which is not only a cataract surgery but in addition to cataract surgery some more procedure was performed on her which is not covered under the policy. For simple surgery an amount of Rs. 22,000/- for each surgery was permissible.
9. We have perused the medical bills vide Ex.C-2 & C-3 submitted by the complainant. We are unable to find out what actual expenses had been incurred on Cataract Surgery on both eyes and what amount was paid for multifocal IOLI. No detail has been given for cataract surgery and multifocal IOLI surgery. There is an agreement dated 05.09.2007 Ex.R-5 between Alankit Health Care Ltd. and Thind Eye Care, according to which for cataract surgery the hospital was to charge only Rs. 22,000/-. From this agreement it can easily be concluded that the hospital from which the wife of the complainant got herself operated for cataract First Appeal No.282 of 2015 6 charged Rs. 22,000/- for each of the operations and the balance amount was for the other procedure.
10. The District Forum has rightly appreciated these documents and righty allowed a sum of Rs. 44,000/- for cataract surgery of two eyes. We do not see any illegality in the order of the District Forum and same is hereby upheld.
11. Sequel to the above discussions, there is no merit in the appeal. Appeal filed by the appellant/complainant is dismissed. The order of the District Forum is affirmed and upheld.
12. The arguments in this case were heard on 03.09.2015 and the order was reserved. Now the order be communicated to the parties as per rules.
13. This appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE GURDEV SINGH) PRESIDENT (BALDEV SINGH SEKHON) MEMBER (VINOD KUMAR GUPTA) MEMBER September 17, 2015 Lb/-