Punjab

Nawanshahr

CC/89/2016

DAVINDER SINGH - Complainant(s)

Versus

Chola Mandalam - Opp.Party(s)

In Person

13 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SHAHEED BHAGAT SINGH NAGAR

 

                     Consumer Complaint No.  89 of 30.09.2016

                      Date of Decision             :   13.11.2017

 

 

Dawinder Singh S/o Sh.Mohan Lal Resident of Dr.Ambedkar Basti, Rahon, Tehsil Nawanshahr, District Shahid Bhagat Singh Nagar.

                                                          ….Complainant

Versus

1. Cholamandalam MS General Insurance Company Limited, 2^nd Floor, “Dare House” No.NSC Bose Road, Chennai – 600001, India, through its Managing Director.
2. Cholamandalam MS General Insurance Company Limited, S.C.O. 2463-2464, II Floor Sector-22-C, Chandigarh – 160022, through its State General Manager.
3. Harbans Lal, Agent of Cholamandalam MS General Insurance Company Limited/Rural Area Sales Executive of Lovely Autos, Chandigarh Road, Nawanshahr.

                                                          ….Opposite Parties

                      Complaint under Section 12 of the

 Consumer Protection Act, 1986

cOUNSEL FOR THE PARTIES:

For complainant             :         Sh.Harinder Chauhan, Advocate

For OP No.1&2             :         Sh.B.P.S. Panesar, Advocate

For OP No.3                 :         Sh.P.S. Bakshi, Advocate

 

QUORUM:

S.KARNAIL SINGH, PRESIDENT

S.KANWALJEET SINGH, MEMBER

ORDER

S.KARNAIL SINGH, PRESIDENT

1. This complaint is presented by complainant wherein it is alleged that complainant has availed the vehicle loan from Cholamandalam MS General Insurance Company Limited and OP-3 has insured his health policy bearing No.2842/00114005/000/00 after received Rs.3348/- as premium on 23.06.2015, under the policy of the Cholamandalam MS General Insurance Company Limited.  So M/s Cholamandalam Investment and Finance Company Limited has issued Membership Card No.A2135231A alongwith a certificate of Insurance on 25.06.2015 under Family Floater type of policy for a sum of Rs.75,000/- for the period from 22.06.2015 to 21.06.2016.  The complainant has physical weakness so went to Raja Hospital Nawanshahr on 20.05.2016, where he admitted in hospital by Dr.Ajay Dhawan and under health insurance policy with cash less facility. Hospital staff emailed to the Insurance Company that what is the cost on his treatment of Rs.26,000/- and said request was approved under cash less policy under the above said policy.   Then after sent the email to the hospital the above said company sent authorized letter dated 22.05.2017 with approval of Rs.10,000/- that you can start the treatment.  The complainant remained admitted in Raja Hospital, Nawanshahr from 20.05.2016 to 24.05.2016.  After the completion of treatment the said hospital send email to Cholamandalam MS Insurance Company to approve for the final discharge, then the Insurance Company said that this treatment is not covered under the policy.  Whensoever the above company has already certified with Dr.Ajay Dhawan that the treatment was under the policy and also approved Rs.10,000/- as per their letter.  But after completion of treatment and at the time of discharge how Insurance Company said that treatment is not under the cover of the Insurance Policy.  After receiving the cashless denial letter dated 24.05.2016, the hospital recovered an amount of Rs.17,880/- from complainant.  As complainant has already paid premium of Rs.3348/- and as per terms and conditions of the concerned Company in regard to his health policy.  However, the company taken the premium money but inspite of his request to pay the expenses of his treatment, the concerned company rejected the health treatment claim.  Thereafter, the complainant contacted the customer care helpline number and also send his documents again by post but claim of the complainant was rejected vide letter dated 17.06.2016.  As such, there is deficiency in service on the part of OPs and accordingly instant complaint filed with prayer that complaint of the complainant may be accepted and OPs be directed to pay the expenses of his treatment under health policy and also pay the compensation to the tune of Rs.10,000/-.  
2. Notice of the complaint was given to the OPs and accordingly, the OP No.1&2 filed joint written reply and contested the complaint of the complainant, taking preliminary objections that complaint is not maintainable in the present form and further averred that the complainant has no locus standi to file the present complaint.  It is further alleged that complainant has no cause of action against the answering OPs.  On the perusal of the documents, it was observed that the complainant had taken treatment for psychological/psychiatric illness, which is not covered under the scope of the policy issued by the OPs to the complainant.  It was also made clear to the complainant at the time of issuance of insurance policy to the complainant when complainant availed the loan for vehicle, from the M/s Cholamandalam , hence the claim is inadmissible as the diagnosis falls outside the scope of the cover as defined under the policy clause B-15, where in illness does not mean mental illness and accordingly it was also informed that the even the previous Authority Letter dated 22.05.2016 stood Null & Void, vide cashless denial letter to the hospital dated 24.05.2016.  It was also intimate to the Raja Hospital and the complainant that denial of the cashless access is not to be considered in any way as a denial of treatment.  The insured could send a request for consideration through reimbursement within stipulated period i.e. on 02.06.2016 with all his claim documents.  But, after the scrutiny of the claim documents, it was observed by OPs that the claim of the complainant is not admissible for the same reason as stated in the cashless denial letter to the hospital dated 24.05.2016 and further averred that this Forum has no jurisdiction to entertain and try the present complaint.  On merits, it is admitted that complainant get insured his vehicle and alongwith insurance of the vehicle, a Health Insurance Policy was also given for the period from 22.06.2016 to 21.06.2016 and further admitted that an authorization letter was sent to the Hospital on 22.05.2016, whereas Rs.10,000/- was approved for admission of the complainant but later on the said authorization was cancelled.  All other averments made in the complaint are categorically denied.  Lastly prayed that the complaint of the complainant is without merits and same is liable to be dismissed.
3. The OP-3 also filed written reply cum affidavit, wherein took preliminary objections that the complaint is not maintainable against answering OP-3.  It is nothing but a sheer abuse of process of law and has been filed simply to harass and pressurize the answering OP.  Answering OP has wrongly shown as agent of OP No.1&2.  He is not in any manner concerned with the business activities of the said Insurance Company – M/s Cholamandalam General Insurance Company Limited nor responsible for any of the transaction of the said Insurance Company.  Rather, answering OP-3 is an employee of M/s Lovely Autos Limited, Chandigarh Road, Nawanshahr and other allegations as made in the complaint are categorically denied and lastly prayed that complaint of the complainant qua OP-3 may be dismissed.    
4. In order to prove the case, authorized Rep. of complainant, has tendered affidavit of complainant Ex.CW1/A alongwith photocopies of documents Ex.C-1 to Ex.C-10 and closed the evidence.  Similarly, counsel for OP No.1&2, has tendered affidavit of Shubhanshu Jain, Assistant Manager Ex.OP1/A alongwith photocopies of documents Ex.OP1/1 and then evidence of OP-1&2 closed by order vide order dated 17.01.2017.  Then, Counsel for OP-3, has also tendered into evidence affidavit of Harbans Lal Ex. OP3/A alongwith documents Ex.OP3/1 to Ex.OP3/2 and closed the evidence.
5. We have heard the learned counsel for respective parties and also gone through complaint file alongwith documents very minutely.
6. Before imparting with main issue in dispute, we have to adjudge whether there is any liability of OP-3 in this complaint.  The complainant alleged that OP-3 is agent of Cholamandalam MS General Insurance Company i.e. OP No.1&2, but OP-3 categorically deposes in his written reply that he is not the agent of OP No.1&2.  Rather, he is employee of Lovely Autos, in order to establish that the OP-3 is the agent of OP No.1&2, the complainant has not brought on file any documentary evidence, so by simply stating that OP-3 is agent is not sufficient, so we accordingly find that no claim against OP-3 is made out.  And as such, complaint of the complainant qua OP-3 is dismissed.
7. Coming to the main issue as levelled in this complaint, as per version of the complainant that he got insurance of his vehicle, the Insurance Company also gave Health Insurance Policy with Cashless facility to the complainant for that the complainant has paid premium of Rs.3348/- and period of the said insurance is 22.06.2015 to 21.06.2016 for total insured amount of Rs.75,000/-.  The factum in regard to Health Insurance Policy in the name of the complainant is not denied by the Op No.1&2.  Rather, this fact has been admitted.  The question is only remain that the claim of the complainant as cashless has been rejected by the Op No.1&2 vide letter dated 24.05.2016 Ex.C-4 by referring the policy clause B-15 that the disease for which the complainant get treatment is not covered under aforesaid clause.  For that purpose, the Op No.1&2 brought on file Rules and Regulation as Ex.OP1/1, wherein clause B-15 is available, admittedly at the time of getting admission by the complainant in Raja Hospital Nawanshahr, an approval was obtained by official of said hospital by sending email that the total cost of treatment is Rs.26,000/- and accordingly Op No.1&2 gave approval for admission of the complainant and approved an amount of Rs.10,000/- vide letter dated 22.05.2016 Ex.C-3 and thereafter as per version of OP No.1&2, the claim of the complainant was repudiated vide letter dated 24.05.2016 Ex.C-4 as well as vide another letter dated 17.06.2016 but the said letter is not brought on file by either of the parties.  We considered the version of the Op No.1&2, whether relevant terms and conditions as prescribed in the documents Ex.OP1/1 is binding upon the complainant or not, if the complainant make aware about the said terms and conditions at the time of inception of Insurance Policy, then obviously the complainant is bind by the said terms and conditions, but in this case the OP No.1&2 failed to establish in this file by way of documentary evidence that when the said terms and conditions was brought to the notice of complainant.  And further whether the said terms and conditions was supplied to the complainant at the time of issuance of policy, so if terms and conditions are not in knowledge of the complainant and the same have not been supplied to the complainant, then the same is not binding upon the complainant.  Moreover, the claim of the complainant has been approved for cashless treatment vide letter dated 22.05.2016 Ex.C-3 and once cashless treatment is approved it cannot be withdrawn because the hospital sent the detail of expenditure, name of the disease as well as treatment and these factum has been considered by the Insurance Company i.e. Op No.1&2 then approved the cashless treatment to the complainant and thereafter make self made story on the basis of one clause of the terms and conditions and there upon claim of the complainant cannot be rejected.  So with these observations, we are of the considered opinion that claim of the complainant illegally and wrongfully rejected by OP No.1&2. Whereas, the complainant is entitled for the recovery of the amount so spend on treatment.
8. In the light of above detailed discussion, the complaint of the complainant succeeds and same is partly accepted and OP No.1&2 are directed to pay hospital treatment charges of the complainant to the tune of Rs.17882/- alongwith interest @9% P.A. from the date of rejection of claim i.e. 24.05.2016 till realization and OP-1&2 further directed to pay compensation for mental harassment to the complainant to the tune of Rs.7,000/-.
9. Entire compliance be made by the OP No.1&2 within a period of 30 days from the date of receipt of copy of this order.
10. Complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be sent to the parties, as permissible, under the rules.

Dated 13.11.2017                                                         

 

                                     

(Kanwaljeet Singh)                (Karnail Singh)

Member                                  President