Haryana

Karnal

CC/441/2021

Sushil Kumar - Complainant(s)

Versus

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

Balwan Singh

17 Jul 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 441 of 2021

                                                        Date of instt.03.09.2021

                                                        Date of Decision:17.07.2023

 

Sushil Kumar son of Shri Atma Ram, resident of house no.698, Sector-6, Urban Estate, near Tagore School, Karnal. Age 63 years. Mobile no.9416039540.

                                               …….Complainant.

                                              Versus

 

1. Cholamandlam MS General Insurance Co. Ltd., 2^nd floor, Dare House, 2, N.S.C. Bose Road, Chennai-600001 through its Manager.
2. Punjab National Bank, Area office Sector-12, Karnal, through its Area Manager.

                                                                      …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

 

Before   Sh. Jaswant Singh……President.

              Sh. Vineet Kaushik……Member 

      Dr. Rekha Chaudhary……Member

          

 Argued by: Shri Balwan Singh, counsel for the complainant.

                    Shri Mohit Goyal, counsel for the OP no.1.

                    Shri Somesh Garg, counsel for the OP no.2.

 

                    (Jaswant Singh President)

ORDER:                     

          

                 The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant obtained a health insurance cover viz Fam,ily Floater/Arogya through Punjab National Bank (OP no.2) from OP no.1, vide master policy no.2876/00051267/000006/000/00, POI 26.02.2020 to 25.02.2021, for a sum insured of Rs.3,00,000/- by paying a premium of Rs.7866/-. Persons covered under the policy are Mr. Sushil Kumar-self and Mrs. Raj Rani wife of Shri Sushil Kumar with health card numbers A5762907A, A5762907B respectively. On 08.02.2021 at 1.27 p.m. Mrs. Raj Rani was admitted in the Fortis Hospital, Mohali for installing stent 2.75x38mm deployed in ostium LAD (for proximal edge dissection, stent 3.5x12mm deployed in prximal-mid LAD with final result successful PTCA +stent to Lad. The total expenses to the tune of Rs.2,04,870/- have been incurred. The claim was lodged with the OP no.1 for reimbursement of the said amount but the same has been denied on the pretext that it cannot be entertained being beyond coverage of policy. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

 2.            On notice, OP no.1 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 after getting the information about the claim of the complainant, OP started to process the claim and they wrote letter dated 30.1.2021 to the hospital of complainant i.e. Sanjeev Bansal Cygnus Hospital, Karnal to submit the following documents:

1. Treating Doctor Certificate confirming the exact duration of the present ailment of complainant. (DM, HPN).
2. First consultation paper.
3. All past consultation papers relating to case of complainant (DM, HPN)
4. All past treatment records related to complainant regarding present ailment.

Till date neither there is any reply nor any contact with the OP to the hospital of complainant. It is further pleaded that OP is ready to process the claim of the complainant, but complainant and its hospital has not provided the necessary documents. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

3.             OP no.2 filed its separate written version raising preliminary objections with regard to maintainability; jurisdiction and concealment of true and material facts. On merits, it is pleaded that complainant has not mentioned his account details from which the premium of the policy has been paid by OP no.2 to OP no.1 and that from perusal of complaint also, it reveals that the role of the OP bank is only that OP has paid the premium to OP no.1 from the account of complainant on the instruction of the complainant. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of medical bills and reports dated 08.02.2021 and 09.02.2021 Ex.C1, copy of health certificate ExC2, copy of Group Health Insurance Policy Ex.C3, copy of health insurance card Ex.C4, copy of Pan card of Raj Rani Ex.C5, copy of aadhar card of Raj Rani Ex.C6 and closed the evidence on 26.08.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Sujeet Kuamr Sahu Ex.OPW1/A, copy letter dated 30.01.2021 Ex.OP1 and closed the evidence on 11.05.2023 by suffering separate statement.

6.             Learned counsel for the OP no.2 has tendered into evidence affidavit of Subhash Chand, Chief Manager Ex.OP2/A and closed the evidence on 09.01.2023 by suffering separate statement.

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

8.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant  obtained a health insurance policy from the OP no.1 through OP no.2 covering himself and his wife for sum insured of Rs.3,00,000/-. On 08.02.2021 wife of complainant was admitted in the Fortis Hospital, Mohali for installing stent and spent to the tune of Rs.2,04,870/- on the treatment. Complainant lodged the claim with the OP no.1 for reimbursement of the said amount but the same has been denied by the OP on the false and frivolous ground and lastly prayed for allowing the complaint.

9.             Per contra, learned counsel for the OP no.1, while reiterating the contents of written version, has vehemently argued that after getting the information about the claim of the complainant, OP started to process the claim and wrote letter dated 30.1.2021 to the hospital of complainant i.e. Sanjeev Bansal Cygnus Hospital, Karnal to submit the documents but till date neither there is any reply nor any contact with the OP to the hospital of complainant thus the claim of the complainant has rightly been denied by the OP and prayed for dismissal of the complaint.

10.           Learned counsel for the OP no.2, while reiterating the contents of written version, has vehemently argued that the role of the OP bank is only to pay the premium to OP no.1 from the account of complainant on the instruction of the complainant and prayed for dismissal of the complaint qua OP no.2

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

12.           Admittedly, complainant purchased the policy in question from the OP no.1 through OP no.2. It is also admitted that the wife of complainant has taken treatment from Fortis Hospital, Mohali during the substance of the insurance policy.

13.           The claim of the complainant has been denied by the OP no.1 on the ground, which is reproduced as under:-

1. Treating Doctor Certificate confirming the exact duration of the present ailment of complainant. (DM, HPN).
2. First consultation paper.
3. All past consultation papers relating to case of complainant (DM, HPN)
4. All past treatment records related to complainant regarding present ailment.

14.           Admittedly, the insured has taken the treatment from Fortis Hospital, Mohali but OP no.1 has sought the record pertaining to Sanjeev Bansal Cygnus Hospital, Karnal. It is not a case of the insured that she had taken the treatment from Sanjeev Bansal Cygnus Hospital, Karnal. Thus, the question for submitting the alleged record does not arise at all. Moreover, the most of the documents sought by the OP no.1 are irrelevant and there is no legal hitch to decide the claim without the submission of the pending documents, when the complainant had already submitted the required documents for settlement of the claim. Hence, the demand of abovementioned documents is unnecessary and irrelevant and just to harass the insured and for denial of the claim of the complainant. Furthermore, it is neither the case of the complainant nor the OP that complainant has taken treatment from the Sanjive Bansal Cygnus, Hospital, Karnal.  Hence, in view of the above, we found no substance in the contention of the OP no.1.

15.             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”.

16.           Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, we are of the considered view that act of the OP no.1 while denying the claim of the complainant amounts to deficiency in services, which is otherwise proved genuine one.

17.           The complainant claimed Rs.2,04,870/- and in this regard she has placed on file medical record and medical bill Ex.C1. The said medical bill has not been rebutted by the OP no.1. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP no.1 to pay Rs. 2,04,870/- (Rs.two lakhs four thousand eight hundred seventy only) to the complainant alongwith interest @ 9% per annum from the date of closing of the claim till its realization. We further direct the OP no.1 to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The complaint qua OP no.2 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:17.07.2023                   

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

                (Vineet Kaushik)        (Dr. Rekha Chaudhary)      

                      Member                        Member