DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                
                        Complaint No.    636
                        Instituted on:    26.10.2016
                        Decided on:    08.03.2017

Gopal Chand aged about 40 years son of Shri Suraj Bhan R/o Bhagwan Dass Arora Colony, Sunam, District Sangrur.
                            …Complainant
                Versus
1.ICICI Prudential Life Insurance Company Limited, ICICI Prulife Towers, 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai 400 025 through its MD/GM.
2.ICICI Prudential Life Insurance Company Limited, Building No.6, 2nd and 3rd Floor, Chhoti Baradari, Patiala 147001 through its Manager.
                            ..Opposite parties

For the complainant    :    Shri Ramit Pathak, Advocate.
For OPs            :    Shri Sushil Kumar, Advocate.

Quorum:    Sukhpal Singh Gill, President
        Sarita Garg, Member
        
Order by : Sukhpal Singh Gill, President.

1.     Shri Gopal Chand, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant took an insurance policy i.e. ICICI Prulife Health Saver from Ops in the month of July, 2009, of which he has been paying the premium regularly to the tune of Rs.15,000/- on yearly basis under which a sum of Rs.5,00,000/- was covered. The wife of the complainant Smt. Ritu Goyal was also covered under the policy.  It is further averred that at the time of taking the policy, the Ops told that it is a cashless policy and all the bills would be paid by the OPs company to the said hospital directly.  

2.        Further case of the complainant is that on 2.4.2015, the complainant got checked her wife Ritu Goyal at Fortis Hospital Mohali for knee problem and the complainant paid Rs.500/- as consultation charges at that time and the doctors advised to take medicine and also suggested for again check up after six months then again on 7.10.2015 and x-rays were also got conducted by paying the requisite charges.   After checking the x-rays, the doctors advised for operation, therefore, on the advice of the doctors on 18.01.2016, wife of the complainant was hospitalised for her treatment and she took treatment there and was operated and discharged on 21.1.2016. Further it is stated that the complainant took her wife to Mohali in a private ambulance by paying Rs.11000/- i.e. Rs.5500/- per visit for to and fro.  Further case of the complainant is that the total bill issued by Fortis Hospital Mohali was Rs.2,03,670/- including medicine, operation charges and other expenses, out of which the OPs paid Rs.1,60,449/-, whereas the company was liable to pay whole of the bill and as such the complainant paid Rs.43,221/- from his own pocket under the proper receipt.  It is further stated that at the time of discharge, the complainant also paid an amount of Rs.2762/- for purchase of medicines and further paid fee on different dates. As such, the complainant spent an amount of Rs.60,143/- at his own. The complainant requested the Ops so many times for the payment of Rs.60,143/-, but all in vain.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.60,143/- along with interest @ 18% per annum from the due date till realisation and further claimed compensation and litigation expenses.

3.        In reply filed by the OPs, preliminary objections are taken up on the grounds that this Forum has no jurisdiction to hear and try the present complaint, that on the basis of the proposal form the subject policy was issued and that the complainant’s wife i.e. Ritu Goyal for whose treatment the claim was submitted to the company was herself the agent/advisor under the said policy, that the present complaint is not maintainable as per the terms and conditions of the policy. It is further stated that the company was in receipt of pre hospitalisation authorisation request of Ms. Ritu Goyal on January 6, 2016. The nature of illness was right planter fasciitis. The request was accepted at  the time of discharge on January 21, 2016 in according with the terms and conditions of the policy and the authorised amount was clearly quoted in acceptance letter i.e. Rs.1,60,449/- and that the jurisdiction of this Forum is also disputed.  On merits, it is admitted that the complainant had taken the policy in question along with his wife Ritu Goyal. It is further admitted that the Ops were in receipt of pre hospitalisation authorisation and an amount of Rs.1,60,449/- was accepted and co-pay of 20% has been deducted from the claimed amount as per clause 1.5 and 3 A(3) of the policy. The other allegations levelled in the complaint have been denied.  Lastly, the Ops have prayed for dismissal of the complaint with special costs.

4.         The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 copy of first premium receipt, Ex.C-3 copy of detail bill, Ex.C-4 copy of discharge summary, Ex.C-5 copy of bill, Ex.C-6 to Ex. C-18 copies of bills and receipts, Ex.C-19 copy of legal notices as well as receipts and closed evidence.  On the other hand, the learned counsel for the Ops has produced Ex.OP-1 affidavit along with Ex.R-1 to Ex.R-7 and closed evidence.

5.        We have carefully perused the complaint, written version of the opposite parties, evidence of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

6.        The version of the complainant is that he had obtained the policy, namely, ICICI Prulife Health Saver from the Ops by paying the requisite premium of Rs.15,000/- per annum since the year 2009 and it is further not in dispute that her wife Ritu Goyal was also covered under the policy.  It is also admitted that during the subsistence of the insurance policy the wife of the complainant Smt. Ritu Goyal was hospitalised in Fortis Hospital, Mohali where she took treatment for the period from 18.1.2016 to 21.1.2016 and the said hospital charged an amount of Rs.203670/-, but the grievance of the complainant is that the Ops paid only an amount of Rs.160449/- out of the total bill and an amount of Rs.43221/- was paid by the complainant himself from his own pocket.  Now, the grievance of the complainant is that the Ops have wrongly deducted an amount of Rs.43,221/- from the total bill issued by the Fortis Hospital, Mohali and has further claimed a total amount of Rs.60143/- including the amount spent on the ambulance as well as other expenses.  On the other hand, the stand of the Ops is that the amount of Rs.1,60,449/- has rightly been paid and an amount of Rs.43,221/- has been deducted being 20% of the total amount  in view of clause 1.5 and 3 A(e) of the terms and conditions of the policy, but we are unable to go with such a contention of the learned counsel for the Ops that the amount of Rs.43,221/- has righty been deducted, as the Fortis Hospital is in the list of network hospitals, whereas 20% can only be deducted if the insured person avails hospitalisation or undergoes day care procedure at an out of network hospital as mentioned in clause 3.A(e) of the terms and conditions of the policy. We have also perused the copy of bill Ex.C-5, wherein it is clearly mentioned that the total bill is for Rs.2,03,670/-.  Further the complainant has relied upon the receipts issued by Ram Singh son of Noor Singh Ex.C-17 and Ex.C-18 showing the ambulance charges for to and fro to the tune of Rs.5500/- each, but we are again unable to go with such a contention of the learned counsel for the complainant.  As such, we are of the considered opinion that the ends of justice would be met if the Ops are directed to pay to the complainant an amount of Rs.43,221/- only as deducted by the OPs.

7.        Further it is the specific version of the complainant that the terms and conditions were never supplied by the OPs. In such like situation, reliance can be made on the citation of the Hon’ble Supreme Court of India delivered in Civil Appeal No.6895 of 1997 in the case of Modern Insulators Limited versus Oriental insurance Company Limited. The Hon’ble Supreme Court has held that “as the above terms and conditions of the standard policy wherein exclusion clause was included were neither a part of the contract of insurance nor disclosed to the appellant, respondent cannot claim the benefit of the said exclusion clause.” In the light of the above citation, we find that the OPs have failed to tender any reliable and cogent evidence in support of his version that the terms and conditions were supplied as no document has been placed on record to show that the terms and conditions were ever made known to the complainant.

8.        So, from the above discussion, we find that the OPs are not only deficient in service, but also had indulged in unfair trade practice and as such, we allow the complaint and direct the OPs to pay to the complainant a sum of Rs.43,221/-  along with interest @ 9% per annum from the date of filing of the present complaint i.e. 26.10.2016 till realisation. We further order the OPs to pay to the complainant a sum of Rs.10,000/- being the amount of compensation for mental tension and agony and a sum of Rs.5000/- on account of litigation expenses.

9.        This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.
        Pronounced.
        March 8, 2017.
                            (Sukhpal Singh Gill)
                               President

 
                            
                                (Sarita Garg)
                                    Member