Jammu and Kashmir

Jammu

CC/44/2017

Kosar Kabir - Complainant(s)

Versus

Area Manager ICICILombard - Opp.Party(s)

Sarfaraz ahmed

19 May 2018

ORDER

     DISTRICT    CONSUMER     DISPUTES   REDRESSAL  FORUM, JAMMU

                (Constituted under J&K Consumer Protection Act,1987)

                                                         

 Case File  No               334/DFJ         

 Date of  Institution   22-11-2016

 Date of Decision         10 -05-2018

 

 

Dr.Koser Kabir,

W/O Mohd.Mohsin,

R/O( Village Attoli,

Tehsil Mandi Distt.Poonch,

At Present Sector-2 Near Indira

Convent School,Ganga Nagar,

Bantalab,Jammu.

                                                                                                                                                Complainant

                              V/S

1.ICICI Lombard General Insurance Co.Ltd.

Health Care through its Managing Director,

Tower Nanakramguda Gachibowli,Hyderabad-500032.

2.Area Manager,

ICICI Lombard General Insurance Co.Ltd.

Hall No.301-302,3^rd Floor North Block,

Bahu Plaza,Jammu-180001.

3.SDDM Hospital & Research Centre

  Plot NH Sector-2 Channi Himmat Jammu

180015 through its Managing Director.

                                                                                                                                                Opposite parties

     CORAM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Opposite partyCORAM 

                  Khalil Choudhary             (Distt.& Sessions Judge)  President

                  Ms.Vijay Angral                                                              Member

                  Mr.Ghulam Sarwar Chouhan                                      Member

 

In the matter of Complaint under section 10 of J&K Consumer

                              Protection Act 1987.

 

 Mr.Sarfraz Ahmed,Advocate for complainant, present.

Mr.R.S.Durswal,Advocate for Ops 1&2,present.

  Mr.Dheeraj Nanda,Advocate for OP3,present.

 

                                                                    ORDER.

•                     Facts relevant for the disposal of complaint on hand are that: the complainant has obtained Group Mediclaim Insurance Policy from OP2 vide Lot No.176107 for a period of one year w.e.f.25-08-2016 to 24-08-2017 (Annexure-A)and before proceeding further into the matter, it is important to mention that the documents for obtaining the policy were submitted by the complainant through proper channel, but the policy bond and other allied documents pertaining to the policy were not provided to her and only a lot bearing No. 176107 was provided and she was asked to use the said lot as and when required and she was made to believe that she can avail cashless hospitalization from the hospitals empanelled under the scheme. According to complainant before getting herself admitted she inquired from OP2 with respect to the empanelled hospitals in District Jammu and she was told that OP3 falls among the empanelled hospitals in Distt.Jammu and after having told with respect to the empanelled of OP3 she was admitted on 10-09-2016 where she was operate upon as Cesarean (LSCS) and she was blessed with the male baby on,10-09-2016.That complainant remained under the treatment with OP3 till 15-09-2016 when she was discharged, but when she inquired from OP2 with respect to empanelled hospital, she demanded requisite card from OP2,but she was allotted only Lot No. . 176107 with the further intimation that the said lot number can be used for making the claim by concerned hospital .Allegation of complainant is that she got herself admitted in the hospital of OP2 as a beneficiary of Mediclaim Insurance Policy under the aforesaid Lot number,however,at the time of discharge ,OP3 demanded the payment of treatment provided to her on the ground that OP1&2 refused to make the payment as claimed by OP3 and when she contacted OP2 she was told that only Rs.17,000/-has been sanctioned. Since the payment of Rs.82,000/-was to be made to OP3,as such, she was left with no other alternative but to make the entire payment of Rs.82,000/-.Further allegation of complainant is that after discharge from the hospital, she was under treatment and as per the norms of the policy,upto 60 days after operation, the expenses have to be paid by the insurer,however,OP1&2 refused to make payment, which amounts to violation of terms and conditions  and deficiency in service. Complainant further submitted that the policy is still in operation and it was incumbent upon OP1&2 as per terms and conditions of policy to make entire payment incurred in the hospital of OP3 which was empanelled hospital at the time of admission of complainant. Constrained by the act of Ops,complainant served legal notice upon Ops,but the same did not yield any fruitful result and this act of Ops constitutes deficiency in service. Hence the present complaint. In the final analysis, complainant prays for reimbursement of Rs.82,000/-and in addition also prays for compensation of Rs.5.20 lacs including litigation charges.

                 On the other hand,Ops 1&2  filed written version and while denying the allegations of complainant, went on to submit that the Govt.of Jammu and Kashmir tied up with OP for Mediclaim Insurance Scheme, this scheme is valid for network hospitals only and it is purely cashless policy. The scope of reimbursement is not covered under the policy. It is further submitted that Govt.of J&K has also signed a Memo of understanding with the OP,copy of MOU is filed herewith and marked as OA.The Ops 1&2 admitted to the extent that on the basis of a lot No. insured can avail cashless hospitalization from the hospitals empanelled under the scheme. It is submitted that the reimbursement was not covered under the said policy. It is further submitted that claim of complainant has not fall under the purview of the policy and the liability of the OPs strictly lies within the terms and conditions of the policy extended by it and it cannot be held liable for the claims falling outside the scope of such polcy,therefore,there is no deficiency of service or unfair trade practice on the part of OPs,as such the complaint is liable to be dismissed .

               At the same time,OP3 filed written version and denied the allegations in toto.                          

                        Complainant adduced evidence by way of duly sworn evidence affidavit and affidavit of Mohd.Mohsin.Complainant has placed on record, copy of Circular issued by Govt.of J&K Finance Deptt.copies of retail invoice, copy of discharge and follow up record and copy of legal notice.

                   On the other hand,Ops 1&2 have adduced evidence by way of duly sworn evidence affidavit of Apurva Sharma Legal Manager of ICICI Lombard Gen.Insurance Coy Ltd.OP1& 2 placed on record copy of policy schedule and copy of letter issued by OP 1&2 to OP3.

                    We have perused case file and heard L/Cs appearing for the parties at length.

                    Briefly stated case of complainant is that she has obtained Group Mediclaim Insurance Policy from OP2 vide Lot No.176107 for a period of one year w.e.f.25-08-2016 to 24-08-2017,but the policy bond and other allied documents pertaining to the policy were not provided to her and only a lot bearing No. 176107 was provided and she was asked to use the said lot as and when required and she was made to believe that she can avail cashless hospitalization from the hospitals empanelled under the scheme. According to complainant before getting herself admitted she inquired from OP2 with respect to the empanelled hospitals in District Jammu and she was told that OP3 falls among the empanelled hospitals in Distt.Jammu and after having told with respect to the empanelled of OP3 she was admitted on 10-09-2016 where she was operate upon as Cesarean LSCS and she was blessed with the male baby on,10-09-2016.That complainant remained under the treatment with OP3 till 15-09-2016 when she was discharged, but when she inquired from OP2 with respect to empanelled hospital, she demanded requisite card from OP2,but she was allotted only Lot No.176107 with the further intimation that the said lot number can be used for making the claim by concerned hospital .Allegation of complainant is that she got herself admitted in the hospital of OP2 as a beneficiary of Mediclaim Insurance Policy under the aforesaid Lot number,however,at the time of discharge ,OP3 demanded the payment of treatment provided to her on the ground that OP1&2 refused to make the payment as claimed by OP3 and when she contacted OP2 she was told that only Rs.17,000/-has been sanctioned. Since the payment of Rs.82,000/-was to be made to OP3,as such, she was left with no other alternative, but to make the entire payment of Rs.82,000/-.Further allegation of complainant is that after discharge from the hospital, she was under treatment and as per the norms of the policy,upto 60 days after operation, the expenses have to be paid by the insurer,however,OP1&2 refused to make payment, which amounts to violation of terms and conditions  and deficiency in service. Complainant further submitted that the policy is still in operation and it was incumbent upon OP1&2 as per terms and conditions of policy to make entire payment incurred in the hospital of OP3 which was empanelled hospital at the time of admission of complainant. Constrained by the act of Ops,complainant served legal notice upon Ops,but the same did not yield any fruitful result and this act of Ops constitutes deficiency in service.

                        On the other hand,Ops 1&2 came up with the defence that Mediclaim Insurance Scheme is valid for network hospitals only and it is purely cashless policy. The scope of reimbursement is not covered under the policy. It is further submitted that Govt.of J&K has also signed a Memo of understanding with the OP. It is further submitted that claim of complainant has not fall under the purview of the policy and the liability of the OPd  strictly lies within the terms and conditions of the policy extended by it and it cannot be held liable for the claims falling outside the scope of such policy,

                   In order to substantiate her allegations, complainant filed her own duly sworn evidence affidavit and also affidavit of Mohd.Mohsin.The deposition of complainant and her witness is more or less repetition of contents of complaint,therefore,need no reiteration.

                        On the other hand,Ops have also filed evidence affidavit of Apurva Sharma Legal Manager of ICICI Lombard Gen,Insurance Coy Ltd. Again the testimony of witness of OPs is corroborative of version of OPs,therefore,same need no repetition.

                  On the other hand, complainant specifically alleged in the complaint and also lead evidence in support of her case on the point that she informed OPs and completed all requisite formalities, but Ops 1&2 failed to settle the claim. The testimony of complainant went unchallenged, therefore, in our opinion OPs are not justified in denying the claim of complainant, for undisclosed reasons and without intimation to complainant. The claim of complainant is also strengthened by the circular Instructions issued by Finance Deptt. Complainant relied upon estimation details therefore,Ops are duty bound to indemnify the complainant, under the terms of policy.

                      After going through the whole case with the evidence on record what reveals here is the case of complainant is genuinely filed with speaking reasons and merit as being consumers as per the purport of Section 2d of Consumer Protection Act and OP is the service provider having failed in its statutory duty to provide adequate and effective services. The purport of legislation is well defined and statutorily takes care of consumer rights and cannot legally afford to a situation like the one confronted herewith in a manner where they are deprived of their rights as of consumers. The consumers have to come forth and seek for redressal of their grievance. The case of the complainant is also genuinely filed for seeking determination of his right by this Forum.

                       Otherwise also legally speaking it is settled law that the parties are always bound and governed by the terms and conditions of contract and whenever contract is entered into there is proposal made by one party in its unequivocal and unambiguous terms conveyed to the otherside and acted by otherside with the same response and in its understanding and knowledge leaving no scope of any future suspicion and incredibility in mind to come in the way of the said contract afterwards.

                       Further also to make it more clear, as for as the terms of the policy are concerned reliance can be had to judgment in case titled Indraprastha Gas Ltd.V/S New India Assurance Co.Ltd.& Ors. reported in 12015CPJ 279NCwherein the relevant para it is laid down:

        The court has to give material meaning to the document. It is not open to the court to make any addition to or subtraction from the terms and conditions contained in Insurance Policy.

                                     In this view of the matter, we are of the opinion that once Ops 1&2 received premium, contract of insurance become complete and Ops 1&2 cannot subsequently allowed to run from its contractual liability to reimburse the insured for the expenses incurred on the treatment during the currency of policy. Complainant in order to support her claim produced  copies of bills.

                    Therefore, in view of the foregoing reasons the complaint filed by the complainant for redressal of her grievance is allowed and OP1&2 are directed to pay to the complainant an amount to the tune of Rs.82,000(i.e. the expenses incurred on the treatment)alongwith interest  7% per annum w.e.f.15-09-2016 till its realization. The complainant is also entitled to compensation of Rs.10,000/-for causing unnecessary harassment and mental agony and litigation charges of Rs.10,000/-.The Ops 1&2 shall comply the order within one month from the date of receipt of this order. Copy of this order be provided to both the parties as per requirement of the Act. The complaint is accordingly disposed of and file be consigned to records after its due compilation.

Order per President                                     Khalil Choudhary

                                                                (Distt.& Sessions Judge)

                                                                         President

Announced                                            District Consumer Forum

 10-05-2018                                                    Jammu.

 

Agreed by                                                               

      

Ms.Vijay Angral          

  Member                                                                                              

.                

 Mr.Ghulam Sarwar Chauhan

Member