BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMRITSAR.
Consumer Complaint No. 717 of 2019
Date of Institution: 13.9.2019
Date of Decision:28.9.2021
Ramesh Pal S/o Sh. Pritam Chand Aged 57 years, resident of House No. 635, Karampura Navi Abadi Near Rinku Telecom, Amritsar 143001 Punjab M.No. 8360226785
Complainant
Versus
- Aditya Birla Health Insu.Co.Ltd. through its Authorized Signatory 10th Floor, R-Tech Park Nirlon Compound Goregaon- East Mumbai-400063
- Neelkanth Hospital through its Authorized Signatory Near Springdale School, Fatehgarh Churian Road, Bye Pass Amritsar Punjab
Opposite Parties
Complaint under section 11 & 12 of the Consumer Protection Act, 1986 (now u/s 35 of the Consumer Protection Act, 2019)
Result : Complaint Allowed
Case referred
- Hon’ble National Commission, New Delhi in case Aegon Religare Life Insurance Co. Ltd. 2018(1) CLT 310
- Hon’ble State Commission, Chandigarh in case SBI General Insurance Company Limited Vs. Balwinder Singh Jolly 2016(4) CLT 372
- Life Insurance Corporation of India Vs. Ambika Prasad Pandey, AIR 1999 MP 13 and Life Insurance Corporation of India Vs. Narmada Agarwalla, AIR 1993 Ori 103
- Dharmendra Goel Vs. Oriental Insurance Co. Ltd., 2008(3) CPJ 377 (SC
- New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111
Counsel for the parties :
For the Complainant : Sh. Sanjeet Singh,Advocate
For the Opposite Party No.1 : Ex-parte
For the Opposite Party No.2 : Sh. Sarabjit Singh Arora, Asstt. Marketing Manager
CORAM
Mr. Jagdishwar Kumar Chopra, President
Mr.Jatinder Singh Pannu, Member
ORDER:-
Mr. Jagdishwar Kumar Chopra, President :-Order of this commission will dispose of the present complaint filed by the complainant u/s 11 & 12 of the Consumer Protection Act, 1986 (now u/s 35 of the Consumer Protection Act, 2019).
Brief facts and pleadings
1. Brief facts of the case are that on the allurement of the agent of the opposite party, the complainant purchased cashless mediclaim policy in question from the opposite party bearing policy No. GHI-BF-18-IN3540994 for the period from 8.5.2019 to 7.5.2020 for the sum assured of Rs. 5,00,000/- by paying premium of Rs. 10,028/- covering the risk of the complainant as well as his spouse. At the time of taking the policy, the complainant was about 57 years and all the facts about the health of the complainant was stated to the opposite party and the opposite party was duty bound to conduct a through check up of the policy holders. But no medical examination was got conducted by the opposite party. The agent of the opposite party stated that the said policy covered all major diseases .It is pertinent to mention here that the terms and conditions of the policy were never supplied to the complainant till date. . Moreover the complainant was made to sign on dotted and blank lines at the time of signing the forms and other papers without explaining the terms and conditions of the said policy to the complainant. During the policy period the complainant was admitted in Life Care Hospital in emergency condition with chief complaint of loose motion, low blood pressure, pain abdomen and weakness etc on 8.7.2019 and was discharged with DAMA on 9.7.2019 at 6.10 p.m. and same day again admitted to opposite party No.2 hospital on 9.7.2019 at 7.04 p.m for the same problems in emergency conditions and during the admission period the complainant spent Rs. 12,676/- in Life Care Hospital and again Rs. 1,46,151/- in Neel Kanth Hospital i.e. opposite party No.2 on his treatment. He complainant paid Rs. 30000/- out of total treatment of Rs. 1,46,151/- from his own pocket as the opposite party denied the cashless treatment. It is worth to mention here that the opposite party given approval of Rs. 10000/- out of first total cashless claim amount of Rs. 35000/- and immediately thereafter the opposite party rejected the same approved amount without any legal ground. The opposite party No.2 forced the complainant to deposit the entire hospital bill and the son of the complainant have sold his bike and other moveable assets and paid part payment to the hospital. Thereafter the opposite party again forced the complainant to deposit the balance amount . Leaving no option the son of the complainant given the cheque of the balance amount with the undertaking that he cheque will be honoured after clearance of the Insurance amount and on the said assurance the hospital had discharged the complainant after taking undertaking from the son of the complainant. After discharge the complainant made several visits to the opposite party , but the opposite party vide letter dated 9.9.2019 repudiated the claim of the complainant. The act of the opposite party in repudiating the claim of the complainant amounts to deficiency in service, mal practice, unfair trade practice which caused lot of mental tension, harassment, inconvenience besides financial loss to the complainant. Vide instant complaint, complainant has sought for the following reliefs:-
(a) Opposite party No.1 be directed to pay the insured claim amount of Rs. 42,828/- out of total claim amount of Rs. 1,58,828/- alongwith interest @ 18% p.a. from the date of intimation till realization;
(b) Opposite party No.1 be also directed to pay the balance claim amount of Rs. 1,16,000/- to opposite party No.2
(b) Opposite parties be also directed to pay compensation to the tune of Rs. 1 lacs to the complainant alongwith Rs. 10000/- with regard to the personal visits made to the opposite parties.
(c ) Opposite parties be also directed to pay Rs. 5000/- as litigation expenses to the complainant ;
(b) Any other relief to which the complainant is entitled be also awarded to the complainant.
Hence, this complaint.
2. Upon notice, initially opposite party No.2 appeared through Sh. Sarabjit Singh Arora, Asstt. Marketing Manager and filed reply that patient Ramesh Pal had taken treatment from their hospital and given postdated cheque and ensured that he will pay all the due amount as soon as he receives the payment from Insurance company.
3. On the other hand none appeared on behalf of opposite party No.1 and was ordered to be proceeded against ex-parte vide order dated 14.11.2019. Thereafter, on 21.9.2020 Sh. Gaurav Kapoor, Adv. appeared on behalf of opposite party No.1 alongwith application for setting aside ex-parte order dated 14.11.2019 . However, the said application for setting-aside ex-parte proceedings was dismissed vide order dated 19.1.2021 as the same has been filed after a lapse of approximately one year and the only powers to set-aside the ex-parte proceedings rest with the Hon’ble State Commission , Punjab , Chandigarh.
Evidence of the complainant and Arguments
4. Alongwith the complaint, complainant has filed his self attested affidavit Ex.C1/A, copies of treatment bills (1-6 pages) Ex.C-1, copy of approval letter dated 13.7.2019 Ex.C-2, claim form Ex.C-3, discharge summary of patient Ex.C-4, copy of rejection letter dated 20.7.2019 Ex.C-5, copy of rejection mail dated 9.9.2019 Ex.C-6 and closed his evidence.
5. We have heard the Ld.counsel for the complainant as well as representative appearing on behalf of the opposite party No.2 and have carefully gone through the record on the file . We have also gone through the written arguments submitted by the Ld.counsel for the complainant.
Findings
6. From the averments of the complainant, the case of the complainant he purchased cashless mediclaim policy bearing policy No. GHI-BF-18-IN3540994 for the period from 8.5.2019 to 7.5.2020 by paying premium of Rs. 10,028/- for the sum assured of Rs. 5,00,000/- covering the risk of himself as well as his spouse. At the time of taking the policy, the complainant was about 57 years and all the facts about the health of the complainant was stated to the opposite party and the opposite party was duty bound to conduct a through check up of the policy holders. But no medical examination was got conducted by the opposite party. The agent of the opposite party stated that the said policy covered all major diseases .It is pertinent to mention here that the terms and conditions of the policy were never supplied to the complainant till date. . Moreover the complainant was made to sign on dotted and blank lines at the time of signing the forms and other papers without explaining the terms and conditions of the said policy to the complainant. It was the case of the complainant that during subsistence of the policy period he was admitted in Life Care Hospital in emergency condition with chief complaint of loose motion, low blood pressure, pain abdomen and weakness etc on 8.7.2019 and was discharged with DAMA on 9.7.2019 at 6.10 p.m. and during the admission period the complainant spent Rs. 12,676/- in Life Care Hospital and in this regard the complainant has placed on record copy of medical bill of Life Care Hospital Ex.C-1 consisting of (1to 4 pages). Same day again complainant admitted to opposite party No.2 hospital on 9.7.2019 at 7.04 p.m for the same problems in emergency conditions and again spent Rs. 1,46,151/- in Neel Kanth Hospital i.e. opposite party No.2 on his treatment, copy of medical bill is also Ex.C-1 consisting of two pages (5-6) . It was further the case of the complainant that opposite party given approval of Rs. 10000/- out of first total cashless claim amount of Rs. 35000/- and immediately thereafter the opposite party rejected the same approved amount without any legal ground. However, on the asking of opposite party No.2, complainant paid part payment of Rs. 30000/- to opposite party No.2 and also given an undertaking to deposit the balance amount and given the cheque of the balance amount with the undertaking that the cheque will be honoured after clearance of the Insurance amount and on the said assurance the hospital had discharged the complainant after taking undertaking from the son of the complainant. After discharge the complainant made several visits to the opposite party , but the opposite party vide letter dated 9.9.2019 repudiated the claim of the complainant vide email dated 9.9.2019 on the ground of misrepresentation under clause 5 “Duty of Disclosure & Fraudulent Claims”. Ld. Counsel for the complainant contended that the act of the opposite party in repudiating the claim of the complainant amounts to deficiency in service, mal practice, unfair trade practice which caused lot of mental tension, harassment, inconvenience besides financial loss to the complainant. On the other hand the opposite party initially did not opt to put in appearance and was proceeded against ex-parte vide order dated 14.11.2019 . Not only this the application filed by the opposite party No.1 for setting –aside the ex-parte proceedings which was filed after approximately one year from the date of ex-parte order i.e. on 21.9.2020 was also dismissed . So the averments of the complainant remained unrebutted and rather impliedly admitted by the opposite party No.1. Moreover as held by the Hon’ble National Commission, New Delhi in case Aegon Religare Life Insurance Co. Ltd. 2018(1) CLT 310 that non filing of written version to the allegations leveled in the complaint, opposite party impliedly admitted the case of the complainant. As such allegations levelled in the complaint are impliedly admitted by opposite party No.1.
7. Moreover appreciation of the facts and circumstances of the case when we go through the repudiation letter sent by the opposite party No.1 via email dated 9.9.2019 the only ground taken by the opposite party No.1 is misrepresentation as well as duty of disclosures . But we are not agreed with this ground taken by the opposite party No.1 as it was the case of the complainant that at the time of taking policy he was about 57 years and the opposite party was duty bound to conduct a thorough check up of the policy holder as per IRDA of India to thorough check up of policy holder in case the insured was more than 45 years but no medical examination was got conducted by the Insurance company . The averment of the complainant regarding non conducting of medical examination by the Insurance company at the time of taking policy by the complainant remained unrebutted and as such impliedly admitted by the opposite party No.1. Moreover it has been held by the Hon’ble State Commission, Chandigarh in case SBI General Insurance Company Limited Vs. Balwinder Singh Jolly 2016(4) CLT 372 that if Insurance company failed to conduct thorough check up of the policy holder then Insurance company has no right to decline the insurance claim on non disclosure of the facts of pre existing disease when the policy was taken.
8. Moreover there was no bar on the Opposite Party to get the thorough medical check up at the time of issuance of the policy. The Opposite Party was within their right to cancel the policy if it doubted or found any information supplied by the life assured being false or wrong, but this has not been done by the Opposite Party. The investigation has been got done at the time when the claim was lodged by the complainant. It was for the Opposite Party to ensure about the health of the insured before issuance of the policy of such amount. Many times a person may not know himself/ herself if he/ he is suffering from any particular disease. Moreover, prior to issuance of the policy, it was required to check up life assured thoroughly. It was the bounden duty of the Opposite Party to make thorough investigation at the initial stage. It appears that the Opposite Party has different yard stick at the time of accepting the policy for procuring the business and different face at the time of discharge of its lawful liability. The act of the Opposite Party in repudiating the claim on false and frivolous ground amounts to deficiency in service. This is a common practice of the Insurance Companies to repudiate the claim on flimsy grounds without any justification. In this regard, we are supported with the rulings: Life Insurance Corporation of India Vs. Ambika Prasad Pandey, AIR 1999 MP 13 and Life Insurance Corporation of India Vs. Narmada Agarwalla, AIR 1993 Ori 103. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., 2008(3) CPJ 377 (SC) is fully attracted. It was held that
“Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.”
On this point, Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
9. Regarding the quantum of claim, the complainant has placed on record copies of medical bills which he spent on his treatment at Life Care Hospital for Rs. 12676/-, copy of bill is Ex.C-1 containing ( 1-4 pages) which was paid by the complainant from his own pocket as well as bill of Neel Kanth Hospital for Rs. 1,46,151/- Ex.C-1 (containing two pages) and out of which the complainant paid Rs. 30000/- and on the asking of the opposite party No.1 given a cheque of the remaining amount of Rs.1,16,000/- which fact was admitted by opposite party No.2 in its reply , and as such claimed Rs. 1,58,828/- against the sum assured of Rs. 5,00,000/- and prayed that Rs. 42,828/- be paid to the complainant and Rs. 1,16,000/- be paid to opposite party No.2. As the complainant has duly proved his case which remained unrebutted as such the complainant is entitled to the abovesaid amounts which he spent on his treatment and opposite party No.1 is liable to reimburse the abovesaid amount to the complainant as well as opposite party No.2 . However, no case is made out against opposite party No.2, as such complaint against opposite party No.2 stands dismissed.
Relief:
10. In view of the above discussion, we allow the present complaint with costs and direct the opposite party No.1 to pay Rs. 42,828/- as spent by the complainant from his own pocket , to the complainant and the remaining amount of the claim Rs. 1,16,000/- to opposite party No.2 alongwith interest @ 9% p.a. from the date of filing of the complaint till realization of the amount to the complainant as well as opposite party No.2. So far as compensation as claimed is concerned, since the complainant was compelled to knock the door of this Commission and the opposite party No.1 did not bother to redress the grievance of the complainant and had it was redressed at appropriate time, certainly this litigation could have been avoided . As the complainant , has faced lot of harassment due to deficiency in service on the part of the opposite party No.1, as such the opposite party No.1 is liable to pay compensation to the tune of Rs. 10000/- to the complainant. Opposite party No.1 is also directed to pay litigation expenses to the tune of Rs. 3000/- to the complainant .
Compliance of this order be made within 30 days from the date of receipt of copy of this order ; failing which the complainant is entitled to get the order executed through the indulgence of this Commission. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission.
Announced in Open Commission (Jagdishwar Kumar Chopra) President
Dated: 28.9.2021
(Jatinder Singh Pannu)
Member
