Punjab

Faridkot

CC/17/95

Gurmail KAUR - Complainant(s)

Versus

BRANCH MANAGER Oriental Insurance co. Ltd. - Opp.Party(s)

NARESH KUMAR AGGARWAL

18 Aug 2017

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     95

Date of Institution: 20.03.2017

Date of Decision :  18.08.2017

 

1. Gurmail Kaur aged about 65 years wife of late Gurdev Singh,
2. Rupinder Singh aged about 33 years s/o late Gurdev Singh,
3. Maninder Kaur aged about 31 years d/o late Gurdev Singh,

All residents of Street No. 3, Gurjeet Provisional Store, Kotkapura Road, Jaitu, Tehsil Jaitu District Faridkot.                                           

 

                                                                           .........Complainant

Versus

1.  Oriental Insurance Company ltd. Old Grain Market, Kotkapura, Tehsil Kotkapura. District Faridkot through its Branch Manager.
2. Oriental Insurance Company ltd. Shop No.6-A, First Floor, Nehru Market, Faridkot Tehsil and District Faridkot through its Manager.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Sh P Singla, Member.

 

Present: Sh Amit Mittal, Ld Counsel for Complainant,

              Sh Vinod Monga, Ld Counsel for OPs.

(Ajit Aggarwal, President)

                                             Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make payment of insurance claim  with interest and for further directing OPs to pay Rs.1,00,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.55,000/-.

2                                   Briefly stated, the case of the complainant is that complainant is wife of Gurdev Singh and complainant no. 2 and 3 are son and daughter of complainant respectively. It is submitted that husband of complainant retired from District Education Office, Faridkot and was getting pension. He was covered under Punjab Government Employees and Pensioners Health Insurance Scheme having ID No.MD15-09814043268. As per policy, husband of complainant was entitled for cashless treatment and OPs are liable to pay the insurance claim. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant or her husband. It is further submitted that on 2.08.2016, husband of complainant fell ill and was got admitted in Global Healthcare Hospital, Bathinda and died  on 3.08.2016. complainant made payment of Rs.2,93,610/-to hospital authorities and when she came to know that as per government scheme, her husband was entitled for cashless treatment, she lodged claim with OPs. After several requests and efforts made by complainant, OPs paid amount of Rs.1,09,000/-and withheld the remaining amount. Complainant further made requests to OPs to making payment of remaining amount of Rs.1,84,610/-, but they kept delaying the matter on one pretext or the other without disclosing any reason. All this amounts to deficiency in service and has caused harassment and mental tension to complainant. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                                         The counsel for complainant was heard with regard to admission of the complaint and vide order dated 28.03.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                                         On receipt of the notice, the OPs filed written statement wherein asserted that there is no privity of contract between complainant and OPs and complainants never purchased the policy in question from them. It is averred that there is no deficiency in service on the part of OPs as after considering and processing the claim of complainant, they have already made payment of Rs.1,09,254/-to OPs. As per terms and conditions and package rate of policy, complainant has been paid the amount admissible to her as reimbursement of expenses incurred by her on treatment of her husband. It is admitted by OPs that husband of complainant was covered the policy in question. She is not entitled for more amount as sought by her. It is reiterated that there is no deficiency in service on the part of OPs. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                                        Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-47 and then, closed their evidence.

6                                                          In order to rebut the evidence of the complainant, Counsel for OPs tendered in evidence affidavit of Ashwani Kumar Ex OP-1 and document Ex OP-2 and then, closed the evidence.  

7                                                          We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

8                                                        Ld Counsel for complainant vehementally argued that complainant is wife of Gurdev Singh and complainant no. 2 and 3 are son and daughter of complainant respectively. It is submitted that her husband retired from District Education Office, Faridkot and was getting pension. He was covered under Punjab Government Employees and Pensioners Health Insurance Scheme having ID No.MD15-09814043268. As per policy, husband of complainant was entitled for cashless treatment and OPs are liable to pay the insurance claim. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant or her husband. On 2.08.2016, husband of complainant fell ill and was got admitted in Global Healthcare Hospital, Bathinda, where he died on 3.08.2016. Complainant made payment of Rs.2,93,610/-to hospital authorities and when she came to know that as per government scheme, her husband was entitled for cashless treatment, she lodged claim with OPs. After several requests and efforts made by complainant, OPs paid amount of Rs.1,09,000/-and withheld the remaining amount. Complainant further made requests to OPs to making payment of remaining amount of Rs.1,84,610/-, but they kept delaying the matter on one pretext or the other without disclosing any reason. All this amounts to deficiency in service and has caused harassment and mental tension to complainant. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

9                                                        To controvert the allegations of complainant, ld counsel for OPs asserted that there is no privity of contract between complainant and OPs and complainants never purchased the policy in question from them. It is averred that there is no deficiency in service on the part of OPs as after considering and processing the claim of complainant, they have already made payment of Rs.1,09,254/-to OPs. As per terms and conditions and package rate of policy, complainant has been paid the amount admissible to her as reimbursement of expenses incurred by her on treatment of her husband. It is admitted by OPs that husband of complainant was covered the policy in question. She is not entitled for more amount as sought by her. It is reiterated that there is no deficiency in service on the part of OPs. Prayer for dismissal of complaint is made.

10                                                       The case of the complainant is that being a retiree from Education Office, husband of complainant was insured under the policy in question. He fell ill, got admitted in hospital and died there on next day. Though as per policy in question, he was entitled for cashless treatment, but her wife paid Rs.2,93610/-for his treatment to hospital. Thereafter, she lodged claim with OPs and after several requests OPs paid Rs.1,09,00/-and did not pay the remaining claim amount of Rs.1,84,610/-. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of remaining claim amount to them, which amounts to deficiency in service. She has prayed for accepting the complaint. In reply, OPs have stressed mainly on the point that they have already paid the amount admissible as per rules, terms and conditions and package rate of policy and nothing is due towards them. Complainant is not entitled for further relief of claim amount as sought by her.

11                                                          From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of husband of complainant with OPs. Ops have themselves admitted that he was insured with them as per Cashless Health Insurance Scheme launched by Punjab Government. OPs argued that as per policy terms and conditions and scheduled rate for the treatment under policy in question, the complainants are entitled only for Rs.1,09,000/-as reimbursement for the treatment of deceased Gurdev Singh. As per scheduled  rate they are not entitled for any other amount than this and this amount has already been paid to them and now, they are not entitled for anything. OPs have made payment of Rs.1,09,000/-to complainant, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement that how they calculated this amount on their own. Admittedly, the complainants spent Rs.2,93,610/- for the treatment of her deceased husband Gurdev Singh and paid this amount to hospital, the Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the persons.

12                                                            Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The 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 the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

13                                                    From the above discussion and case law produced by the complainant, we are of considered opinion that Ops have wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy  out of entire amount, spent on treatment by complainant, which was covered under the Mediclaim insurance policy. The present complaint is hereby accepted. Ops are directed to payRs.1,84,610/-to complainant, which was wrongly deducted by them out of amount spent by her on treatment of her deceased husband Gurdev Singh alongwith interest at the rate of 9 % per anum from 19.12.2016 when they made less payment till final realization. Ops are further directed to pay Rs.5,000/-to complainant as compensation for harassment and mental agony suffered by him besides Rs.2000/- as litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 18.08.2017

                                                Member                   President

                                                          (P Singla)              (Ajit Aggarwal)