Order by:
Sh.Amrinder Singh Sidhu, President
- The complainant has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (as amended upto date) on the allegations that he purchased the policy bearing No.133723854 on 28.03.2015 from Opposite Party No.2 through Opposite Party No.3. Further alleges that he had a medical problem and hence, the complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana from 02.08.2018 to 08.08.2018 and thereafter from 16.08.2018 to 23.08.2018 where he spent Rs.81,448.80 paisa and Rs.1,25,892/- on account of medical charges to Dayanand Medical College & Hospital, Ludhiana. In this regard, the complainant also informed the Opposite Parties and after discharge, the complainant lodged claim for the reimbursement of his claim with the Opposite Parties and also completed all the formalities, but the Opposite Parties are lingering on the matter on one pretext to another and hence, there is deficiency in service on the part of the Opposite Parties. Due to the aforesaid acts and conduct and deficiency in service on the part of the Opposite Party, the Complainant has suffered mental tension, harassment. Vide instant complaint, the complainant has sought the following reliefs.
- The Opposite Parties may be directed to make the claim amount of Rs.2,07,340/- alongwith interest @ 12% per annum from the date of claim till its realization and also to pay Rs.50,000/- as compensation for causing him mental tension and harassment besides Rs.25,000/- as costs of litigation or any other relief to which this District Consumer Commission may deem fit be also granted.
2. Upon notice, Opposite Party No.2 appeared through counsel and contested the complaint by filing written reply taking certain preliminary objections therein inter alia that the complaint is not maintainable and is liable to be dismissed as there is no deficiency in service rendered by the Opposite Party. The present complaint is pre mature and the claim is still pending for settlement on account of non submission of requirements by the complainant. The complainant lodged a claim on 02.08.2019 with the Opposite Parties concerning his aforesaid treatment. The complainant has submitted the form for claiming hospital cash benefit/ major surgical benefit by signing the same on 02.08.2019. Since this is a health insurance place and not a medi claim policy and only fixed benefits are available as per the policy conditions irrespective of the quantum of expenses incurred by the policy holder on his treatment in order to verify and to rule out the application of exclusion clauses like any pre existing conditions etc. the claim was registered and the same was forwarded to TPA M/s.Genins India Insurance TPA Limited Noida on 05.08.2019 for its settlement according to terms and conditions of the policy. Said TPA demanded some information regarding exact past history of Hypertension, COPD (Chronic Obstructive Pulmonary Disease0f, Old Mesenteric Ischemic 9operated) certified by the treating doctor supported by the first consultation doctor, Etiology of Malena and treatment record of operated Mesenteric ischemic Disease, for the settlement of health insurance claim and in this regard, the answering Opposite Party wrote registered letter dated 14.08.2019 followed by a registered reminder dated 27.09.2019 requesting the complainant to provide the above mentioned information, but the complainant has failed to comply with the requirements as raised by the TPA. As such, the claim requirements are continuously being demanded from the complainant, but he has failed to comply with the requirements as raised by the TPA. As such, the claim requirements are continuously being demanded from the complainant and are still awaited which have not been submitted by him till date and instead the complainant has rushed to file this complaint without any cause of action and the claim of the complainant can not be decided in the absence of the requirements as called from him and as being demanded by the TPA and thus, the complaint is not maintainable. On merits, Opposite Party No.2 took almost same and similar pleas as taken up by them in the preliminary objections and hence, there is no deficiency in service on the part of Opposite Party No.2. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with special costs has been made.
3. On notice, none has come present on behalf of Opposite Party No.1 and Opposite Party No.3 and hence, Opposite Parties No.1 and 3 are proceeded against exparte.
4. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents Ex. C2 to Ex.C24 and closed the evidence.
5. On the other hand, to rebut the evidence of the complainant, Opposite Party No.2 has tendered into evidence the affidavit of Sh.Ramesh Kumar, Manager Ex.OP2/A alongwith copies of documents Ex.OP2/B to Ex.OP2/I and closed the evidence on behalf of Opposite Party No.2.
6. We have heard the ld. counsel for the parties, perused the written submissions of the complainant and have carefully gone through the evidence on record.
7. Ld.counsel for the complainant has reiterated the averments as narrated in the complaint and contended that the complainant purchased the policy bearing No.133723854 on 28.03.2015 from Opposite Party No.2 through Opposite Party No.3. Further contended that he had a medical problem and hence, the complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana from 02.08.2018 to 08.08.2018 and thereafter from 16.08.2018 to 23.08.2018 where he spent Rs.81,448.80 paisa and Rs.1,25,892/- on account of medical charges to Dayanand Medical College & Hospital, Ludhiana. In this regard, the complainant also informed the Opposite Parties and after discharge, the complainant lodged claim for the reimbursement of his claim with the Opposite Parties and also completed all the formalities, but the Opposite Parties are lingering on the matter on one pretext to another and hence, there is deficiency in service on the part of the Opposite Parties.
8. On the other hand, ld.counsel for Opposite Party No.2-LIC has repelled the aforesaid contention of the ld.counsel for the Complainant on the ground that the present complaint is pre mature and the claim is still pending for settlement on account of non submission of requirements by the complainant. The complainant lodged a claim on 02.08.2019 with the Opposite Parties concerning his aforesaid treatment. The complainant has submitted the form for claiming hospital cash benefit/ major surgical benefit by signing the same on 02.08.2019. Since this is a health insurance place and not a medi claim policy and only fixed benefits are available as per the policy conditions irrespective of the quantum of expenses incurred by the policy holder on his treatment in order to verify and to rule out the application of exclusion clauses like any pre existing conditions etc. the claim was registered and the same was forwarded to TPA M/s.Genins India Insurance TPA Limited Noida on 05.08.2019 for its settlement according to terms and conditions of the policy. Said TPA demanded some information regarding exact past history of Hypertension, COPD (Chronic Obstructive Pulmonary Disease), Old Mesenteric Ischemic 9operated) certified by the treating doctor supported by the first consultation doctor, Etiology of Malena and treatment record of operated Mesenteric ischemic Disease, for the settlement of health insurance claim and in this regard, the answering Opposite Party wrote registered letter dated 14.08.2019 followed by a registered reminder dated 27.09.2019 requesting the complainant to provide the above mentioned information, but the complainant has failed to comply with the requirements as raised by the TPA. As such, the claim requirements are continuously being demanded from the complainant, but he has failed to comply with the requirements as raised by the TPA. As such, the claim requirements are continuously being demanded from the complainant and are still awaited which have not been submitted by him till date and instead the complainant has rushed to file this complaint without any cause of action and the claim of the complainant can not be decided in the absence of the requirements as called from him and as being demanded by the TPA and thus, the complaint is not maintainable.
9. The only plea raised by the Opposite Party No.2-LIC for not settling the claim of the complainant is that the complainant has not produced the exact past history with treatment record of present Hypertension, COPD since when, certified by the Treating doctor, supported by the first consultation prescription slip as well as Etiology of malena and due to this reason, the claim could not be processed. But on the other hand, the complainant has specifically rebutted this contention of the ld.counsel for Opposite Party No.2-LIC on the ground that whatever record was within the custody of the complainant has already been submitted to Opposite Parties at the time of lodging the claim for the reimbursement of his treatment expenses. Not only this, the complainant while filing the instant complaint on 08.07.2020, has filed the relevant record i.e. Discharge Summary dated 23.08.2018 Ex.C16 in which the treating doctor has mentioned the diagnosis in detail to the following effect:-
“Coad (60 Pack year) with right pulmonary thromboembolic with necrotizing pneumonia (pseudomans) with haemoptysis old mensenteric Ischaemic (operated) with common iliac vein thrombosis with GI bleed (ileal ulcer/ Gastric nodularity/ external haemorrhoids)”
No only this, the complainant has also placed on record the Discharge Summary Ex.C17 in which also, the detail of the hospital course has been mentioned. Further copy of Discharge Summary Ex.C18 (three pages), Discharge Summary Ex.C19 (4 pages) and in these discharge summaries, the treating doctor has specifically mentioned all the details as required by the TPA of the Opposite Parties. It is pertinent to mention over here that the copies of these documents have duly been supplied to all the Opposite Parties by this District Consumer Commission at the time of serving the notice of complaint at its initial stage i.e. on 02.03.2021 which has duly been received by Branch Manger of LIC of India, Moga under his signatures on 01.03.2021 and during this period, the Opposite Parties could process the claim of the complainant, but despite of lapse of sufficient time i.e. about one year from the date of required documents/ information, the Opposite Party No.2-LIC kept mum for the reasons best known to their concerning officials and due to non settlement of the claim, the complainant is suffering badly and he has already spent hefty amount on his treatment.
10. Further, as per the averment of the Opposite Party No.2-LIC, they relied upon the instructions/ report of TPA M/s.Genins India Insurance TPA Limited Noida dated 05.08.2019 for the settlement of the claim of the complainant, with which the Complainant has no concern at all. In this regard, recently, Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.1105 of 2014 decided on 25-04-2017 in case titled as Sukhdev Singh Nagpal Vs. New Karian Pehalwal Cooperative Agriculture service Society & Others has held that TPAs have no authority to reject the claim- such power lies, exclusively with the Insurance Companies (Para No.25 to 27).
11. In such a situation the repudiation made by the Opposite Parties-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All 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 clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
12. In view of the above discussion, we hold that all the Opposite Parties have wrongly and illegally not settled the claim of the complainant.
13. Now come to the quantum of compensation. As per the claim of the complainant, he spent the amount of Rs.81,448.80 paisa and Rs.1,25,892/- on account of medical charges to Dayanand Medical College & Hospital, Ludhiana (Ex.C9 to Ex.C15), total amounting to Rs.2,07,340/- and hence we allow the complaint upto that extent.
14. In view of the aforesaid facts and circumstances of the case, we allow the complaint of the Complainant and direct Opposite Parties No.1 and 2 jointly or severally to reimburse the medical bills of the complainant amounting to Rs.2,07,340/- (Rupees two lakh seven thousands three hundred forty only) alongwith interest @ 8% per annum from the date of filing the complaint i.e. 08.07.2020 till its realization. The Opposite Parties No.1 and 2 are also directed to pay compensation to the complainant jointly or severally for causing him mental tension and harassment to the tune of Rs.10,000/- (Ten thousands only). The compliance of this order be made by Opposite Parties No.1 and 2 within 45 days from the date of receipt of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Commission. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.
15. Reason for delay in deciding the complaint.
This complaint could not be decided within the prescribed period because the State Government has not appointed any of the Whole Time Members in this Commission for about 3 years i.e. w.e.f. 15.09.2018 till 27.08.2021 as well as due to pandemic of COVID-19.
Announced in Open Commission.
Dated:08.03.2022.
