Punjab

Sangrur

CC/579/2017

Mukesh Khipla - Complainant(s)

Versus

IFFCO TOKIO General Insurance Company Limited - Opp.Party(s)

Sh. J.S.Sahni

19 Feb 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                           

                                                Complaint No.  579

                                                Instituted on:    01.11.2017

                                                Decided on:       19.02.2018

 

Mukesh Khipla son of Sh. Ashok Kumar, R/O H.No.233, Street No.3, Ward No.10, Peer Banna Banoi Road, Sunam, District Sangrur.

                                                        …Complainant

                                Versus

1.             IFFCO TOKIO General Insurance Co. Ltd. Iffco Tower-II, Plot No.3, Sector 29, Gurgaon (Haryana) 122 001 through its MD.

2.             IFFCO TOKIO General Insurance Co. Ltd. Branch Office 2^nd Floor, Hotel Hot Chop Building, Kaula Park, Sangrur 148001 through its Branch Manager.

                                                        ..Opposite parties.

For the complainant  :       Shri J.S.Sahni, Adv.

For Opp. Parties       :       Shri Darshan Gupta, Adv.

 

 

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

       

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Mukesh Khipla, 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 availed the services of the OPs by getting a medical insurance policy number 52739083, namely, Swashtya Kavach  for Rs.3,00,000/- for the period from 15.1.2017 to 14.1.2018 by paying the requisite premium of Rs.7970/-.  It is further averred that the complainant has been taking the insurance policy since the year 2014. It is further averred that as per the policy, the complainant and his family members could get free treatment from the network hospitals under cashless scheme upto Rs.3,00,000/-. The OP also sent health cards to the family members of the complainant.

 

2.             The case of the complainant is that in the month of May/June, 2017, the minor son of the complainant, namely, Keshav Khipla suffered some problem and was admitted in the Medanta Medicity Hospital Gurgaon due to the problem of (R23.0-Cyanosis (signs and symptoms – cyanosis) on 12.6.2017 and was proposed to the line of treatment 06BMOZZ/Omedical and surgical 6 lower veins B excision M Femoral Vein, Right 0 open Z No device Z No Qualifier (ITGI-350:NSP-General Surgery)  and as such the hospital authorities wrote to the Ops for cashless request for the patient, but the same was rejected by the OPs vide letter dated 13.6.2017. Further case of the complainant is that his son was treated in the hospital and he spent an amount of Rs.42,885/- on the treatment, but the same was not paid/reimbursed to the complainant despite submission of the bills to the Ops for reimbursement.   Further case of the complainant is that again on 27.6.2017, the complainant got admitted her son Keshav Khipla at same hospital at Gurgaon after arranging sufficient funds for the purpose of proposed line of treatment by the hospital, but again the OPs denied the cashless facility to the complainant, as such, he spent an amount of Rs.2,54,729/- on the treatment of his son from his own, but the amount was not reimbursed despite lodging the claim with the OPs and both the claims were repudiated vide letters dated 22.8.2017 and 25.8.2017.  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 the claim amount of Rs.2,97,614/- along with interest @ 24% per annum from the date of discharge of the hospital till realisation and further claimed compensation and litigation expenses.

 

3.             In reply filed by the OPs, legal objections are taken up on the grounds that the present complaint is totally misconceived, groundless and unsustainable in law, that the complaint is baseless and flagrant abuse of process of law, that the complainant has not come to the Forum with clean hands and that present complaint involves intricate questions of law and facts which require extensive evidence.  On merits, it is admitted that the complainant had obtained the policy in question for the period from 15.1.2017 to 14.1.2018 for Rs.3,00,000/-, which is subject to the terms and conditions of the policy. It has been denied that the OPs issued only policy and the terms and conditions were not issued to the complainant.  It is admitted that the complainant submitted medical documents of his son –Master Keshav Khipla for reimbursement of medical expenses to the tune of Rs.42,885/- for hospitalisation from 12.6.2017 to 14.6.2017 in Medanta Global Health Pvt. Limited, Gurugram and on perusal of the received documents by the OPs, it was noted that patient was admitted and as per the discharge summary of the patient, it was found that “A 6 years male child admitted in Medanta Hospital with diagnosis of Congenital cyanotic heart disease, Tetralogy of fallot since birth, non restrictive doubly committed VSD with aortic override and underwent BT shunt in 2011. He is known case of Left Renal Agenesis, right grade 5 with VUR. Now the patient was admitted for total correction of tetralogy of fallout. As per the discharge summary, the patient is having congenital cyanotic heart disease since birth.  All the ailment is present since birth in the said case, so it falls into the category of congenital diseases which is not admissible as per the policy clause number 9, as such, the claim was repudiated vide letter dated 22.8.2017 and similar is the position for another claim of Rs.2,54,729/-, which was also repudiated vide letter dated 25.8.2017.  The other allegations levelled in the complaint have been denied in toto.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-41 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OP has produced Ex.OP/1 affidavit along with Annexure A to C and closed evidence.

 

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

 

6.             It is an admitted fact between the parties that the complainant  along with his family members was  insured with the OPs under medi claim insurance policy for Rs.3,00,000/- by paying the requisite premium for the period from 15.1.2017 to 14.1.2018, as is evident from the copy of the insurance policy on record as Ex.C-3.  It is further an admitted fact that son of the complainant, namely, Keshav Khipla took treatment twice from Medanta Meditiy Hospital at Gurugaon and spent an amount of Rs.42,885/- and Rs.2,54,729/- on the treatment. To support this contention, the complainant has produced on record various documents as well as medical bills as Ex.C-12 to Ex.C-29.  On the other hand, the learned counsel for OPs has contended vehemently that no claim amount is payable to the complainant and the claim is said to has been rightly repudiated on the ground that the son of the complainant was suffering with heart problem since birth which is not covered under the insurance policy.  But, we are unable to go with this contention of the learned counsel for the OPs because the Ops have not produced any such documentary evidence, more so when the complainant is taking the medical insurance policy since the year 2014, whereas the disease of  Keshav Khipla was detected only in the year 2017.  Further the learned counsel for the complainant has contended vehemently that no terms and conditions were ever supplied to the complainant, as such, the terms and conditions are not binding upon the complainant as the same were never brought to the knowledge of the complainant since the year of taking the policy in question. To support this contention, the learned counsel for the complainant has cited Dr. J.R.Banik Ad versus Managing Director National Insurance Co. Ltd. 2017(2) CLT 376 (NC), wherein the Commission has held that when the insurance company has not supplied the terms and conditions, then the claim is payable.  Further same view has been taken by the Hon’ble Apex Court of India in  United India Insurance Co. Ltd. versus M.K.J. Corporation 1996(8) SCC 428 and in Modern Insulators versus Oriental Insurance Co. Ltd. 2000(2) SCC 734.  Further the Hon’ble Punjab State Commission in The Oriental Insurance Co. Ltd. versus Dr. Ram Kumar in FA No. 947 of 2016 decided on 18.9.2017 has also taken the same view as taken by the Hon’ble Supreme Court of India.

 

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

8.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the claim amount of Rs.2,97,614/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 01.11.2017 till realisation.  We further order the OPs to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and 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.

                        February 19, 2018.

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member