State Consumer Disputes Redressal Commission
N I C vs Vinod Kumar Singh on 13 July, 2016
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UP C-1 Vikrant Khand 1 (Near Shaheed Path), Gomti Nagar Lucknow-226010 First Appeal No. A/2267/2014 (Arisen out of Order Dated 09/09/2014 in Case No. C/52/2011 of District Ghaziabad) 1. N I C Lucknow ...........Appellant(s) Versus 1. Vinod Kumar Singh Ghaziabad ...........Respondent(s) BEFORE: HON'BLE MR. Udai Shanker Awasthi PRESIDING MEMBER HON'BLE MR. Mahesh Chand MEMBER For the Appellant: For the Respondent: Dated : 13 Jul 2016 Final Order / Judgement RESERVED State Consumer Dispute Redressal Commission, Uttar Pradesh Lucknow Appeal No. 2267 of 2014 National Insurance Company Ltd., .......Appellant Versus M/s Vinod Kumar Singh & Others ......Respondent Present:- Hon'ble Sri Udai Shanker Awasthi, Presiding Member.
Hon'ble Sri Mahesh Chand, Member.
Sri Alok Kumar Singh, Advocate for the Appellant.
Smt. Shuchita Singhfor the Respondent.
Date: 18.07.2016 Judgment Sri Mahesh Chand,Member-This Appeal has been filed by National Insurance Company Ltd. through its Manager, Regional Office, Hazaratganj, Lucknow, against the order dated 9.9.2014, passed by learned District Consumer Dispute Redressal Forum-I,Ghaziabad, in complaint case No 52/2011, Vinod Kumar Singh& OrsVs.National Insurance Company Ltd.In brief the facts of the case are in connection with the dispute regarding the payment of compensation to the complainant who got the insurance cover for medical treatment for himself and the family members under group insurance policy. This policy No 501600/46/09/8500000052 was purchased by complainant's company where he was employed through the opposite party no. 2 of the complaint/Family Health Plan Limited, TPA through Competent Authority. This policy was valid through the period from 1 July 2009 to 30 June 2010. The complainant's wife Smt. Beena Singh was pregnant and at the time of delivery on the advice of consulting doctor, she was admitted in the Hospital, opposite party no.3 on dated 14.4.2010 wherein she delivered a female child through surgical operation under supervision of Dr Monica Agarwal. Smt Beena Singh was discharged from the hospital on 20.4.2010. The complainant paid the bill of Rs 46991/- to the hospital in two installments i.e. Rs23000/- on dated 16.4.2010 and Rs23991/- on dated 20.4.2010.
The complainant submitted the bills for reimbursement to the opposite party no.1. through his company. These bills were to be paid by opposite party no.1 and 2. The complainant continuously pursued his claims with opposite party no.1 & 2 but to avail. The opposite party no. 2 informed the complainant on 7.6.2010 that his claim has been repudiated. When the complainant enquired from the opposite parties no.1 & 2 about the reason of repudiation, they simply told that there was the irregularity in the bills. Being aggrieved with the attitude of the opposite parties no.1 & 2 the complainant filed the complaint before the District Forum, Ghaziabad.
The opposite party no. 1 contested the complaint case before the District Forum by filing the written statement and evidences. In the written statement all the averments of the complaint have been denied and categorically stated that the claims are fabricated and false. It has also been stated in the written statement that as per discharge summary, patient was diagnosed as a case of LSCS with Bilateral Tubual Ligation and as per policy's condition Bilateral Tubual Ligation charges are not payable. It has also been stated that since the premium was paid by Areva T & Co., the employer of the complainant. So the claim should have been filed by Areva T & Co. only. The company has not filed any claim. On these grounds the claim was repudiated.
After hearing the parties and perusing the record on file the learned District Forum allowed the complaint and directed the opposite party no.1 to pay the claim of Rs 46,991/- and Rs 5,000/- as compensation towards mental pain and Rs 2000/- as cost. Thus total amount Rs 53991/- was ordered to be paid within a period of one month failing which 6% simple interest per annum will have to be paid.
Being aggrieved with the order dated 9.9.2014 of the District Forum this appeal has been file before this State Commission under section 15 of Consumer Protection Act 1986. The Appellant have taken the following grounds:-
The District Forum has erred in not considering the fact that the Group Insurance Policy was obtained by Areva T & D (I) Ltd. but in the instant case the company has not filed any claim before the appellant insurance company but by the complainant.
The complainant's bills were false and fabricated and highly inflated.
The patient was diagnosed as a case of LSCS with Bilateral Tubual Ligation and as per policy condition No 4.8 Bilateral Tubual Ligation charges are not payable.
The independent investigator appointed by TPA found several discrepancies in the bills. The hospital was not registered. Hence the bills were rejected.
The respondent/complainant filed the written statement. The respondent/complainant has denied all the allegations made in the appeal. The respondent has stated that all the grounds of the appeal are false and against the record. It has been stated in the reply that the Group Insurance policy was obtained by Areva T & D (India) Ltd for its employees all over India. It covers the family members of the employee also. Appellant has not given any proof regarding fabrication and falseness of the bills. The respondent has also stated that Bilateral Tubual Ligation was done immediately after delivery and no extra charges were paid for this. More over the hospital was duly registered and its renewal was regularly done. The allegations made in the appeal are frivolous and the appeal is liable to be dismissed.
We have heard the arguments of the learned counsels of both the parties and perused the record on file. The contention of the learned counsel of the appellant that the claim should have been filed by Areva T & D (I) Ltd. only then it would have been considered, is not tenable. The complainant has categorically stated that he was paying the premium of the policy through the company. He is the beneficiary of the scheme and not the company. Company is the mediator/facilitator. It is a Group Insurance Policy. Under the policy family members of the subscriber-staffare covered. In the instant case the spouse of the employee/complainant have undergone the surgical operation. The claim was submitted by the insured through the company. He is entitled to file the claim. So far as the condition No 4.8 is concerned that the claim for Bilateral Tubual Ligation is not payable. The Respondent -Complainant has stated that no extra charges have been paid for Bilateral Tubual Ligation. In the instant case surgery was performed for delivery of a child to save the life of the mother and child otherwise normal delivery would have been performed.In the policy surgical delivery of a child is not mentioned in the exclusion list. Hence there is no occasion for declining the claim of LSCS (Lower segment Cesarian section: A Cesarian section in which the surgical incision (cut) is made in the lower segment of the uterus). So far as the inflation of the bills is concerned the appellant has not given any proof of it. Similarly no proof for fabrication of bills or their being false, has been given. In these circumstances the contentions of the appellant are not tenable. There is no force in the appeal and is liable to be dismissed Order In the light of above discussion and observation the Appeal is dismissed. Parties will bear own costs. Hence No order to the costs.
(Udai Shanker Awasthi) (Mahesh Chand) Presiding Member Member S.k. st. c-1 [HON'BLE MR. Udai Shanker Awasthi] PRESIDING MEMBER [HON'BLE MR. Mahesh Chand] MEMBER