BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BHIWANI.
Complaint No.: 205 of 2015.
Date of Institution: 15.07.2015.
Date of Decision: 11.04.2019.
Raman Jain son of Shri Subhash Chand, resident of House No. 7, Bajrang Bali Colony, Rohtak Road, Bhiwani, Tehsil & District Bhiwani.
….Complainant.
Versus
1. Shri Dinesh Goyal, Shop No. 12, 1st Floor, City Mall, Hansi Gate, Bhiwani.
2. Vipul Med Crop TPA Ltd., SCO-98, 1st floor, Industrial Area, Phase-II, Chandigarh-160002.
3. Vipul Med Crop TPA Private Ltd., 515, Udyog Vihar, Phase-V, Gurgaon-122016.
4. National Insurance Company Limited, Clock Tower, Bhiwani, Tehsil and District Bhiwani through its Branch Manader.
…...Opposite Parties.
COMPLAINT UNDER SECTIONS 12 AND 13 OF
THE CONSUMER PROTECTION ACT, 1986.
Before: - Hon’ble Mr. Manjit Singh Naryal, President.
Hon’ble Mr. Parmod Kumar, Member.
Hon’ble Mrs. Saroj Bala Bohra, Member.
Present: Shri P. K. Punia, Advocate for the complainant.
Shri Avinash Sardana, Advocate for the OP No. 4.
OP No. 1 to 3 already exparte.
ORDER:-
PER MANJIT SINGH NARYAL, PRESIDENT
Brief facts of the case are that the complainant has purchased a family hospitalization benefit policy No.420303/48/11/8500000308 from OP No. 4 through OP No. 1 valid from 1.12.2011 to 31.11.2012 and in this policy the float sum insured was one lakh rupees by paying the requisite premium. It is further alleged that during the continuation of policy the father of the complainant suffered TYPHOID and PARATPHOID fever on 13.3.2012 and was got admitted in Medanta the Medicity Hospital, Gurgaon and intimation regarding ailment of complainant’s father was duly given to the OPs. It is further alleged that the father of the complainant remained admitted in the Hospital and spent a sum of Rs.35,810/- on his treatment. It is further alleged that the claim was lodged with the OPs after completing all the formalities, but the complainant was surprised when he received a voucher of Rs.21,772/- as reimbursement. It is further alleged that the OPs have deducted a sum of Rs.14,038/- and complainant enquired the matter and he was told that he did not submit HRCT Chest and X-ray bills with the OPs. It is further alleged that the complainant has submitted HRCT Chest and X-ray report with bills on 6.6.2012, but the OPs did not accept the claim of Rs. 3500/- against chest report and X-ray report bills. It is further alleged that the complainant has further submitted the indoor bill of Rs.818/- and the OPs accepted the claim of complainant of Rs.22,590/-. It is further alleged that the complainant has submitted all the documents as per requirements of the OPs and clarification was sent alongwith report (HRCT Chest) through courier vide POD No.313967698 on 5.9.2012 and also sent many e-mails to the OPs regarding payment of remaining amount, but to no effect. It is further alleged that the complainant has got served legal notices upon the OPs on 11.10.2013 and 9.12.2014 through his counsel, but to no effect. Hence, it amounts to deficiency in service on the part of OPs and hence, this complaint.
2. On notice, no appeared on behalf of the OP No. 2 & 3 and they were proceeded as exparte vide order dated 10.9.2015. OP No. 1 appeared in person on 10.9.2015, but lateron the OP No. 1 did not appear and he was also proceeded as exparte vide order dated 17.11.2016.
3. On appearance, the OP No. 4 filed the written statement alleging therein that the complainant has submitted claim of Rs.35,810/- and later an indoor bill of Rs.818/-, out of which he has paid Rs.22,590/-. It is further alleged that it would thus be seen that a sum of Rs.14,038/- has been deducted/disallowed out of the amount claimed. It is further alleged that as per the report of OP No. 2 and 3 Vipul Med Corp TPA Ltd., who settled the claim of the complainant and the deductions have made on account of room charges etc. It is further alleged that it would be seen that the amount of Rs.22,590/- has rightly been release/paid and there is no deficiency in service on the part of the answering OP and complaint of the complainant is liable to be dismissed with costs.
4. Ld. counsel for the complainant has placed on record documents Annexure-C1 to Annexure C14 and closed the evidence.
5. On the other hand, ld. counsel for the OP No. 4 has placed on record duly sworn affidavit as Ex.RW1/A and documents Annexure R1 to R6 in support of its case and closed the evidence.
6. We have heard ld. counsel for both the parties at length.
7. Ld. Counsel for the complainant reiterated the contents of the complaint. Ld. Counsel for the complainant has further contended that OPs have wrongly & illegally assessed less claim of the complainant. Ld. counsel for the complainant has placed his reliance upon National Insurance Company Limited Vs Ravidutt Sharma and another PLR (2011-4), 154.
8. On the other hand, ld. Counsel for OP No.4 reiterated contents of the written statement. Ld. Counsel for the OP No.4 has further contended that the claim of the complainant was rightly assessed. Hence, there is no deficiency in service on the part of OPs and the complaint of the complainant is liable to be dismissed.
9. Now question of law arises as to whether the insurance company was justified in assessing the mediclaim of the complainant on lesser side. The sought answer is “No”. The mediclaim of the complainant was assessed less and the remaining amount was deducted on account of room charges etc. This plea of the OPs cannot be taken into count, because the policy has been taken by the complainant for the reimbursement of the amount to be incurred on the treatment of any member of his family. It was bounden duty of the company to reimburse the mediclaim amount and satisfy insured. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to the insured under the garb of baseless grounds.
10. It is very unethical and wrong procedure always adopted in the insurance cases by the insurance companies just to grab the money from the poor peoples and harass them and their legal heirs when they were in need of the money. It is also moral & social duty of the insurance companies before accepting the hard earned money from the buyers, with open eyes, as they are on giving hand and they cannot escape from their liability and they cannot harass the poor people with unnecessary excuses merely at the time of facing difficulties by assured or their legal heirs. Generally it is seen that when a common man search on internet about insurance/mediclaim policies, then he receives many unwanted telephone calls from different insurance companies and these company try to induce the poor people through their agents without disclosing the entire terms & conditions and at that time the only purpose of their agents is to extort money from assured and to get the commission on that amount and they complete all the formalities by themselves including filling the proposal form and also obtained the signature of assured on some blank forms and for this they always adopt the unethical, unsocial and un-genuine criteria to get insure the buyers and when the assured need for claim and apply for the same, then agents of the insurance companies some- times unethically bargains for settling the claim or repudiate the claim. So after considering all above mentioned important issues, we come to the conclusion that these insurance companies should have held liable for the errors & negligence committed on their part and for the purpose to protect the interest of genuine buyers of the insurance policies. The Insurance Companies and their agents are also duty bound before issuing the policy with open eyes to protect the interest of the consumers and these companies are also duty bound to get aware the consumer with all hidden terms & conditions or to get investigate the assured with their entire satisfaction before issuing the insurance/mediclaim policies. In present case, there are also so many discrepancies and the OPs have failed to prove on record that the claim of the complainant was rightly assessed by leading some cogent and convincing evidence. Thus, there is clear cut deficiency in service and unfair trade practice on the part of the OPs. Hon’ble Punjab & Haryana High Court, Chandigarh titled as National Insurance Company Limited Versus Ravidutt Sharma and another PLR (2011-4) 154 held as under:-
The insurance companies, in my view, are not acting fairly in all such matters after charging huge premium intention is always to repudiate the claim on one ground or the other. The conditions of the insurance agreements are so minutely printed that per-son gets hardly any time to go through such conditions to make it legally binding in any appropriate manner.
11. As regards quantum, complainant has claimed Rs. 35,810/- along with interest @ 24% pa. The complainant has placed copy of discharge voucher Annexure C3, which shows that the insurance company has settle the claim of the complainant to the tune of Rs.21,772/-, out of total amount of Rs.35,810/-, whereas the OP No. 4 has stated that they have settle the claim to the tune of Rs.22,590/-, but placed nothing on record to prove this fact. The complainant has made representation vide Annexure C4 to the OP No. 4 for paying further claim of Rs.3500/- alongwith the copy of report, but the OP No. 4 did not pay the same. Therefore, in such circumstances, in our view, it would be appropriate, if complainant is awarded a lump sum amount of Rs. 25,000/- on account of mediclaim of the complainant. The OP No. 4 has claimed that the claim of the complainant was settled, but failed to prove on record that the payment of the claim was made to the complainant. The complainant has also placed on record Annexure C9, vide which he has supplied the detail of bank account. So, the OP No. 4 has harassed the complainant without any genuine reason & not disburses the claim amount to complainant with malafide intention, which shows unfair trade practice on the part of the OP No. 4.
12. Moreover, the Insurance Companies deliberately with malafide intention does not settle the claim of its consumers in time and harassed them without any reason. So in our view the complainant is also entitled for compensation on account of mental and physical harassment & punitive damages for deficiency in service & mal trade practice on the part of the Insurance Company. Therefore, in view of the facts and circumstances mentioned above, complaint of the complainant is partly allowed and the OPs are directed:-
i) To pay the lump sum amount of Rs.25,000/- (Twenty five thousand only) on account of mediclaim along with interest @ 9% p.a. from the date of filing of the complaint till its realization.
ii) To pay Rs.10,000/- (Ten thousand only) as compensation on account of mental agony, physical harassment & hardship, due to deficiency in service & mal trade practice on the part of OPs and punitive damages.
iii) To pay Rs.5000/- (Five thousand only) as counsel fee as well as the litigation charges.
The compliance of the order shall be made within 30 days from the date of the order. Certified copies of the order be sent to parties free of costs. File be consigned to the record room, after due compliance.
Announced in open Forum.
Dated: - 11.04.2019.
(Saroj Bala Bohra) (Parmod Kumar) (Manjit Singh Naryal)
Member. Member. President,
District Consumer Disputes
Redressal Forum, Bhiwani.
