State Consumer Disputes Redressal Commission
New India Assurance Co. vs Vinod Alagh on 16 January, 2018
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA First Appeal No : 674 of 2016 Date of Institution: 21.07.2016 Date of Decision : 16.01.2018 The New India Assurance Company Limited, 6 Bahadur Shah Zafar Marg, New Delhi - 110002 and Branch Office at Gurudwara Road, Gurgaon, now through Regional Manager, SCF 36-37, Sector 17-A, Chandigarh. Appellant-Opposite Party Versus Vinod Alag s/o late Shri Jagan Nath Alag, Resident of House No.347, Sector-14, Gurgaon. Respondent-Complainant CORAM: Hon'ble Mr. Justice Nawab Singh, President. Shri Balbir Singh, Judicial Member.
Shri Diwan Singh Chauhan, Member.
Argued by: Shri Vinod Chaudhri, Advocate for appellant. Respondent ex parte. O R D E R BALBIR SINGH, JUDICIAL MEMBER
The New India Assurance Company Limited - Opposite Party is in appeal against the order dated May 20th, 2016 passed by District Consumer Disputes Redressal Forum, Gurgaon (for short 'the District Forum') in Consumer Complaint No.146 of 2010.
2. Vinod Alag - complainant (respondent herein) was provided medi-claim insurance policy bearing No.323200/34/09/11/00001328 (Annexure-A) by The New India Assurance Company Limited (for short 'the Insurance Company')-Opposite Party/appellant, regarding the period from August 02nd, 2009 up to August 01st, 2010. The above mentioned insurance policy in the name of the complainant was renewed on the basis of earlier mediclaim insurance policies purchased by him since the year 2002. On August 09th, 2009 the complainant was got admitted in City Hospital, N.E.A. Pusa Road, New Delhi due to sudden pain in his left leg. Operation was conducted and the complainant remained admitted in hospital up to August 12th, 2009. The complainant submitted his insurance claim before the appellant - Insurance Company against his mediclaim insurance policy claiming an amount of Rs.1,24,241.83 but the Insurance Company made payment only of an amount of Rs.58,606/- and did not make payment of the remaining mediclaim insurance amount Rs.65,636/-.
3. The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 with a prayer that the opposite party - Insurance Company be directed to pay to the complainant balance amount of Rs.65,636/- with interest at the rate of 24% per annum from the date of occurrence; to pay an amount of Rs.25,000/- on account of un-necessary harassment and mental agony; to pay an amount of Rs.25,000/- on account of deficient and inadequate services provided by the Insurance Company; to pay an amount of Rs.5500/- as cost of litigation and Rs.1500/- as miscellaneous expenses.
4. The Opposite Party - Insurance Company in its written version has taken plea that the District Forum, Gurgaon has no jurisdiction to decide this complaint; that the complainant is not covered under the definition of 'Consumer' as provided under the Consumer Protection Act, 1986 and that the complainant is stopped from filing the present complaint by his own acts and conduct. The complainant has concealed material facts. In fact, the complainant was entitled to receive the amount claimed considering rates as mentioned in paragraph No.2 of the mediclaim policy. The rates have been mentioned in insurance policy and the insured can claim only 1% of the total room rent paid. The complainant was entitled to receive only an amount of Rs.58,606/- and that amount has already been paid to the complainant. The complainant is not entitled to receive any other amount as claimed in the complaint. The Insurance Company has prayed that the complaint filed by the complainant be dismissed with costs.
5. Parties adduced evidence in support of their respective claims before the District Forum.
6. After hearing arguments, vide impugned order dated May 20th, 2016 passed by the learned District Forum, the complaint filed by the complainant was allowed directing the opposite party - Insurance Company to pay an amount of Rs.56,345/- as shown in Annexure-C with interest at the rate of 9% per annum from the date of filing of the complaint and to pay an amount of Rs.10,000/- on account of un-necessary harassment, mental agony and litigation expenses. The above mentioned amount was awarded after deducting an amount of Rs.8700/- paid by the complainant as room rent during the period of his treatment.
7. Aggrieved with the impugned order dated May 20th, 2016 passed by the learned District Forum, opposite party - Insurance Company has filed the present First Appeal No.674 of 2016 with a prayer to set aside the impugned order and to dismiss the complaint filed by the complainant.
8. We have heard learned counsel for the appellant-opposite party/Insurance Company and perused the case file. None appeared on behalf of the respondent-complainant despite service and the respondent-complainant was proceeded against ex parte vide order dated November 29th, 2017.
9. During the course of arguments, there was no controversy of any type that the complainant was provided mediclaim insurance policy Annexure-A regarding the period from August 02nd, 2009 up to August 01st, 2010. The above mentioned insurance policy was renewed on the basis of earlier mediclaim insurance policy obtained by the complainant from the opposite party continuously since the year 2002. It is also admitted fact that the complainant, due to sudden pain in his left leg, was got admitted in City Hospital for his treatment on August 09th, 2009. The complainant remained admitted in the hospital up to August 12th, 2009. Operation was conducted and during that period the complainant spent an amount of Rs.1,24,241.83 for his treatment. Regarding treatment provided to the complainant and regarding the amount spent by him as mentioned above, there is no controversy of any type in between both the parties. It is also admitted fact that when the complainant submitted his insurance claim, he was awarded and paid only an amount of Rs.58,606/- in respect of his claim of Rs.1,24,241.83 as mentioned in the hospital Final Bill Annexure-B. As per version of the complainant, he is entitled to receive the remaining amount of Rs.65,636/- which has not been paid by the opposite party with interest.
10. Learned counsel for the appellant-Insurance Company has urged that the awarded amount has been wrongfully calculated by the learned District Forum. The complainant is entitled to receive room rent only qua 1% of the sum insured and only reasonable customary and necessary expenses are reimbursable under the policy, as mentioned in the insurance policy.
11. Learned District Forum has calculated the awarded amount observing that in view of Clause 2.10 of the mediclaim insurance policy, it emerges that the complainant is having Hospitalization Benefit Policy (Zone II) and the case of the complainant is covered under Clause 2.10 (b) according to which the complainant was entitled to 100% reimbursement of the sum insured.
12. We have gone through Clause 2.10(b) as well as Clause 2.3 and 2.4 of the policy. After close perusal of Clause 2.3, 2.4 and 2.10, we have no hesitation in holding that claim of the complainant is covered under Clause 2.10 (b) of the insurance policy wherein it is provided that availing treatment in Zone-II and Zone-III, company's liability will be 100% of the sum insured. In our view, the amount awarded to the complainant has been correctly calculated and the excess room rent amount Rs.8700/- has already been deducted.
13. As a result, as per discussion above in detail, we find that the impugned order dated May 20th, 2016 passed by the learned District Forum does not suffer from illegality and infirmity. Hence, the findings of the learned District Forum stand affirmed and the appeal stands dismissed.
14. The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after expiry of period of appeal/revision, if any.
Announced 16.01.2018 Diwan Singh Chauhan Member Balbir Singh Judicial Member Nawab Singh President CL