Haryana

Karnal

CC/408/2019

Chander Bhan - Complainant(s)

Versus

Cholamandalam MS General Insurance Company Limited - Opp.Party(s)

S.S. Moonak

01 Mar 2023

ORDER

bBEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No.408 of 2019

                                                        Date of instt.15.07.2019

                                                        Date of Decision:01.03.2023

Chander Bhan, aged 59 years, son of Shri Mitter Sain, resident of house no.32-A, Chaman Garden, Karnal. Aadhar no.3218 9247 8345.

 

                                               …….Complainant.

                                              Versus

 

1.     Cholamandalam MS General Insurance Company Limited through its General Manager, 2^nd floor, Dara house, NSC Bose Road, Chennai-600001.

 

2.     Cholamandalam MS General Insurance Company Limited through its Branch Manager, (Claims Department) SCO 2463-64, 1^st floor, Sector-22-C, Chandigarh 160022.

 

3.     Dr. S.R. Ajmani, c/o Ajmani General and Maternity hospital, opp. Civil Hospital Karnal.

 

4.     National Insurance Co. Ltd. through its Divisional Manager, Karnal. (Policy no.420501491810000007).

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary…..Member

          

 Argued by: Shri S.S.Moonak, counsel for the complainant.

                    Shri Vineet Rathore, counsel for the OPs no.1 &2.

                    Shri Baljeet Chauhan counsel for the OP no.3.

                    Shri Pankaj Malhotra, counsel for the OP no.4.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that  complainant had obtained a Group Health Insurance Policy (Medi-claim) from the OPs for himself alongwith the other beneficiaries including his son Himanshu Goyal, wife Sunita Rani, vide policy no.2842/00168356/0003/000/00 dated 01.02.2019 for a sum of Rs.5 lakhs. A sum of Rs.16637/- was paid as premium through the bank account of the complainant. In the month of March 2019, complainant fell ill and the complainant was admitted in Ajmani General and Maternity Hospital, Karnal on 11.03.2019 due to high fever and congestion in the chest etc. The complainant remained admitted in the said hospital for five days i.e. four days in ICU and one day in private ward. Complainant spent Rs.50,000/- on his treatment, medicines, hospitalization attendant and transportation etc. After discharge from the hospital, complainant submitted the claim form and original bills to the OPs and requested the OPs to settle the claim but OPs did not pay any heed to the request of complainant and lingered the matter on one pretext or the other and lastly repudiated the claim of the complainant, vide letter dated 29.05.2019 on the false and frivolous grounds. In this way there is deficiency in service on the part of the OPs. Hence this complaint.

2.             On notice, OPs no.1 and 2 appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that on receipt of claim intimation, OP asked for required documents for processing the claim and appointed investigator in order to reveal out the actual facts. On investigation, it was found that this was an early claim within one month of purchase of policy. It is also revealed that all records are maintained in handwritten and overwritten and manipulated and ICU room was not available in the hospital and there is no IPD details maintained. As per the record submitted by complainant and treatment record, it was clearly established that complainant was treated on daycare basis only. It clearly transpires that claim was made for undue claim benefits due to which claimant has manipulated the documents misleading the court by giving false bills and statement and insured has violated the policy condition of utmost good faith by giving false and misleading facts. As such, the claim of complainant was repudiated, vide letter dated 29.05.2019. It is further pleaded that as per bills and other expenses submitted the claim amount to the tune of Rs.38410/- but same was repudiated being non-genuine. There is no deficiency in service on the part of the OPs no.1 and 2. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.3 filed its separate written version raising preliminary objections with regard to maintainability and concealment of facts. On merits, it is pleaded that complainant had purchased the insurance policy from OPs no.1 and 2 and he had raised the claim for amount spent by him on his treatment and the insurance company repudiated his claim. There is no allegation in the complaint regarding the treatment given by the answering OP to the complainant nor there is any complaint regarding the amount charged by OP as such present complaint liable to be dismissed on this ground against the answering OP. The answering OP was insured with National Insurance Company and as such the said insurance company is liable to be impleaded in the present complaint.

4.             OP no.4 in its written version stated that present complaint is not maintainable as the complainant has taken the policy in question from the OPs no.1 and 2 and there are no allegations in the complaint regarding the treatment given by the doctor nor there is any complaint regarding the amount charged by the doctor. The OP no.4 has no concern with interse dispute between the complainant and the Cholamandlam and prayed for dismissal of the complaint.

5.             Parties then led their respective evidence.

6.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of insurance policy Ex.C1, copy of repudiation letter Ex.C2, copy of discharge summary Ex.C3, copy of details of bills Ex.C4, copy of receipt of bills Ex.C5, copy of bank copy
Ex.C6, copy of statement of account Ex.C7, copy of medical bills Ex.C8 to Ex.C18 and closed the evidence on 22.01.2020 by suffering separate statement.

7.             On the other hand, OPs no.1 and 2 has tendered into evidence affidavit of Sujeet Kumar Sahu Manager Ex.OP1/A, affidavit of Dr. Sunil, Insurance Claims Investigator Ex.OP1/B, copy of claim form Ex.OP1, copy of claim form part-B Ex.OP2, copy of investigation report Ex.OP3, copy of computation sheet Ex.OP4, copy of repudiation letter Ex.OP5, copy of hospital record Ex.OP6/A to Ex.OP6/H, copy of insurance policy Ex.OP7 and closed the evidence on 05.01.2022 by suffering separate statement.

8.             Learned counsel for the OP no.3 has tendered into evidence affidavit of Dr. S.R. Ajmani Ex.OP3/A, copy of treatment record Ex.OP3/1, copy of insurance policy Ex.OP3/2 and closed the evidence on 11.01.2023 by suffering separate statement.

9.             Learned counsel for the OP no.4 has tendered into evidence affidavit of Reena Basak Assistant Ex.OP4/A and closed the evidence on 01.12.2022 by suffering separate statement.

10.           We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

11.           Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued complainant had purchased a Group Health Insurance Policy from the OP no.2. On 11.03.2019, complainant fell ill and the complainant was admitted in Ajmani General and Maternity Hospital, Karnal and remained admitted in the said hospital for five days. Complainant spent Rs.50,000/- on his treatment. After discharge from the hospital, complainant submitted the claim to the OPs and requested the OPs to settle the claim but OPs did not pay any heed to the request of complainant and lastly repudiated the claim of the complainant, vide letter dated 29.05.2019 on the false and frivolous grounds and lastly prayed for allowing the complaint.

12.           Per contra, learned counsel for the OPs no.1 and 2, while reiterating the contents of written version, has vehemently argued that on receipt of claim intimation. OP appointed investigator in order to reveal out the actual facts. On investigation, it was found that all records are maintained in handwritten, overwritten, manipulated and ICU room was not available in the hospital and there is no IPD details maintained. As per the record, complainant was treated on daycare basis only. The claim of the complainant has been repudiated, vide letter dated 29.05.2019 being non-genuine and lastly prayed for dismissal of the complaint.

13.           Learned counsel for the OP no.3, while reiterating the contents of written version, has vehemently argued that complainant had purchased the insurance policy from OPs no.1 and 2 and he had raised the claim for amount spent by him on his treatment but the insurance company repudiated his claim. There is no allegation in the complaint, regarding the treatment given by the OP to the complainant nor there is any complaint regarding the amount charged by OP and lastly prayed for dismissal of the complaint qua OP no.3.

14.           Learned counsel for OP no.4 argued that there are no allegations in the complaint regarding the treatment given by the doctor nor there is any complaint regarding the amount charged by the doctor and lastly prayed for dismissal of the complaint qua OP no.4.

15.           We have duly considered the rival contentions of the parties.

16.           Admittedly, complainant purchased Group Health insurance policy from the OPs no.1 and 2. It is also admitted that during the subsistence of the insurance policy, complainant was hospitalized in Ajmani General and Maternity Hospital, Karnal.

17.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C2/Ex.OP5 dated 27.04.2019 on the grounds, which reproduced as under:-

“On scrutiny of the claims documents submitted, we observed that the claim is not admissible for the following reason:

On perusal of the documents and hospital visit report, it is observed that there are several discrepancies observed in terms of hospitalization bills/clinical features. Exaggeration of bills, clinical features, medication without indications and without genuine hospitalization which confirming misrepresentation of documents in order to claim which does not cover under the scope of policy under general condition 4.9 which reads as No indemnity is available or payable for claims directly and indirectly caused by, arising out of or connected to if you shall make or advance any claim knowing the same to be false or fraudulent in amount or otherwise, this policy shall be void. All claims or payments due shall be forfeited and all payments made shall be repaid in full by you who shall be jointly and severally liable for the same.

While expressing our inability to pay this claim due to above mentioned reason, we reiterate our obligation to pay all admissible claim fairly and promptly”.

18.           The claim of the complainant has been repudiated by the OPs no.1 and 2 on the ground of misrepresentation of facts. Moreover, if there is any overwriting in the medical record for that complainant cannot be blamed for the wrong act of the doctor. For the sake of gravity, if it is presumed that complainant had violated the terms and conditions of the insurance policy, in that eventuality, the claim of the complainant cannot be repudiated in toto.  In this regard, we can rely upon the case laws cited in Revision Petition no.1870 of 2015(NC) decided on 14.08.2018 titled as New India Assurance Co. Ltd. Versus Thirath Singh Brar,  and authority of our own Hon’ble State Commission in First Appeal no.717 of 2016 decided on 6.4.2017 titled as United India Insurance Company Limited and others Versus Anshul Bansal.  In both judgments it was held that in case of any breach of warranty/condition of the policy the insurer is liable to pay 75% of admissible claim on non-standard basis.

19.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

                “It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

20.           Keeping in view the ratio of the law laid down in the abovesaid authorities and the facts and circumstances of the present complaint, we are of the considered view that the act of the OPs no.1 and 2 amounts to deficiency in service and unfair trade practice while repudiating the claim of the complainant in toto. Hence, complainant is entitled to get 75% only of the admissible claim on non-standard basis.

21.           As per version of complainant, he has spent Rs.50,000/- on his treatment but as per copy of bills details Ex.C4 and copy of claim form Ex.OP1, he has spent Rs.40,910/- on his treatment . The said bills have not denied by the OPs. Hence the complainant is entitled for the said amount alongwith interest, compensation and litigation expenses etc.

20.           In view of the above discussion, we partly allow the present complaint and direct the OPs no.1 and 2 to pay Rs.30,682/- ( Rs.thirty thousand six hundred eighty two only) to the complainant alongwith interest @ 9% per annum from the date repudiation of claim till its realization. We further direct the OPs no.1 and 2 to pay Rs.10,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 45 days from the receipt of copy of this order. Complaint qua OPS no.3 and 4 stands dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 01.03.2023                                                                    

                                                                      President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

                (Vineet Kaushik)                (Dr. Rekha Chaudhary)

                        Member                             Member