Before the District Consumer Disputes Redressal Forum, Room No. 208 2^nd Floor, District Administrative Complex, Tarn Taran

Consumer Complaint No  :   12 of 2018

Date of Institution           :  12.02.2018

Date of Decision               : 20.01.2020

TarjitKaur (now deceased) widow of Kulbir Singh son of Jagjit Singh resident of Ward No. 13, Nikki Mandi Patti, Tehsil Patti, District Tarn Taran through her legal representatives 1A. Prabhdeep Singh son of Kulbir Singh, 1B.NavjjitKaur daughter of Kulbir Singh both residents of Ward No. 13 Nikki Mandi Patti, Tehsil Patti, District Tarn Taran.

                                                ...Complainants

Versus

1. Life Insurance Corporation of India JeevanArogya Health Insurance Divisional office, District Shopping Complex, 4-5 Ranjit Avenue, , near M.K. Hotel Amritsar through Divisional Manager,
2. Life Insurance Corporation of India JeevanArogya Health Insurance Branch Office at Building Sarhali Road, Tarn Taran  through Senior Branch Manager,
3. Life Insurance Corporation of India JeevanArogya Health Insurance branch Office Patti through branch Manager,
4. Harish Sood agent of Life Insurance Company JeevanArogya, resident of Nikki Mandi Patti, Tehsil Patti, District Tarn Taran.
5. Life Insurance Corporation of India JeevanArogya Health Insurance office of the Ombudsman (insurance) SCO No. 101-103, Batra Building, 2^nd Floor, Sec-17-D, Chadnigarh through Manager/ Director/ Head.

…Opposite Parties.

Complaint Under Section 12 and 13 of the Consumer Protection Act, 1986.

Quorum:               Sh. Charanjit Singh, President

Smt. JaswinderKaur, Member

For Complainant                               Sh.Jagmeet Singh BhullarAdvocate

For Opposite Parties No. 1 to 3                  Sh. B.S. ChawlaAdvocate

For Opposite Party No. 4                           Ex-parte

For Opposite Party No. 5                           Withdrawn vide order dated 3.4.2018.

ORDERS:

Charanjit Singh, President;

1        The complainant TarjitKaurhas filed the present complaint under Section 12 and 13 of the Consumer Protection Act against the opposite parties on the allegations thatthe opposite party Life Insurance Company are doing the business of Insurance and opposite party No.2 is its agent. The opposite party No.4 Sh.HarishSood is agent of Life Insurance Corporation JeevanArogya Branch Office at Patti, Tehsil Patti, District Tarn Taran. The complainant has taken health Insurance plan from the opposite party No.1 on 15.06.2016 for a sum of Rs.1,00,000/- vide policy No.474-37120 at their branch office i.e. opposite party No. 2 and 3 on the basis of half yearly installment and the complainant has paid her first premium of Rs.2,250/- at the same time at the branch office and the first coverage plan commencing period was started from 16.6.2016 onwards. The premium of insurance is being paid by the complainant to opposite party regularly up-till today. None of the copy of the terms and conditions was supplied by the insurance company as well as its agents to the insured at the time of issuance of insurance policy. On 12.05.2017 at 2:00 P.M, the complainant was going to Ludhiana for her Health Checkup and the condition of the complainant was very serious on the way and complainant was got admitted at DayaNand Medical College and Hospital for treatment and concerned doctor has advised the complainant for admission in Hospital for medical treatment and after admission of the complainant the concerned doctor has conducted the requisite following test of diagnoses and after diagnose test it revealed  that the complainant was suffering from hypersensitivity pneumonitis. As the complainant has taken treatment of above said hospital and spent Rs.25,297/- on her treatment. The complainant has also spent Rs.50,000/- on  transportation etc.. The original documents of bills have already been submitted by complainant to the opposite party No.2. The complainant remained admittedin the above said hospital from 12.05.2017 to 14.05.2017.  On 14.05.2017 after treatment the complainant discharged from above said Hospital and complainant has come to back in her house.  The complainant alongwith her son namely Prabhdeep Singh approached to the opposite party No.2 at their branch office and also provided them the copies of treatment of complainant, medical bills and the complainant lodged  her claim to the opposite party No.2 and the said claim alongwith record was forwarded to their Divisional Office i.e. opposite  party No.1 for settling the claim of the complainant. After that the complainant has approached to the opposite parties No.2 to 4 so many times, but every times, they lingered on the matter from one pretext or another and Opposite Party No.1 has accepted the claim and the opposite party No.1 has given only Rs.1,000/- instead of Rs.25,297/- as claim amount in the bank account, but have not paid the full claim amount to the complainant and have not given any written reply as well as full claims to the complainant. The complainant is entitled to the claim of Rs.25,297/-. The complainant has paid his full premium of above said policy to the opposite party No.1 , but the opposite party No. 1 has intentionally prolonged/ in-ordinarily delayed, refused, disbursement of insurance claim, putting in mental agony, depression, harassing and teasing. The opposite parties No.2 to 4 have been asked several times by the complainant to pay the claim and compensation of Rs.50,000/- to the complainant for unnecessary harassment, mental pain and agony, but the opposite party is putting off the matter under one pretext of the other and has finally refused to accept the genuine request of the complainant since a day back from filing the present complaint. The complainant has prayed that the opposite parties may be directed to pay damages and compensation to the tune of Rs. 50,000/- alongwith litigation expenses and Rs. 25,297/- i.e. remaining treatment amount may also be awarded in favour of the complainant. 

2        After formal admission of the complaint, notice was issued to Opposite Parties and opposite parties No. 1 to 3 appeared through counsel and filed written version contesting the complaint by taking preliminary objections that the present complaint is not maintainable. The complainant has not come to the Forum with clean hands, as such she is not entitled to the relief claimed in the present complaint. On merits, it was admitted by the opposite parties No. 1 to 3 that the complainant had taken a health insurance plan from the opposite party No.1 on 15.06.2016 bearing Policy No. 474037120.  It is also admitted by the opposite parties No. 1 to 3 that the complainant was admitted in the DMC Hospital, Ludhiana from 12.05.2017 to 14.05.2017 and got treatment of Hypersensitivity Pneumonitis. The complainant had only submitted the total bills of Rs.20,487/- for the period 12.05.2017 to 14.05.2017 for her claim to the opposite parties.  It is also admitted by the opposite parties No. 1 to 3 that medical bills and copies of the treatment were submitted by the complainant to the replying opposite parties .The claim of the complainant has been admitted by the replying opposite party and paid a sum of Rs.1,000/- as per policy conditions to the complainant through NEFT on 3.12.2017. The real facts are that the above said policy bearing No.474037120 is a fixed policy and not a reimbursement policy. The benefits payable under the policy are linked with the chosen Initial Daily Benefit (IDB) per day i.e. Rs.1,000/2,000/3,000 or 4,000/-. In the policy in hand the complainant TarjitKaur has chosen Initial Daily Benefit of Rs.1,000/- per day. The policy holder TarjitKaur has submitted a claim in respect of her admission in DMC Hospital, Ludhiana from 12.05.2017 (12:20 hrs) to 14.05.2017 (15:56hrs) i.e. hrs + 3:26 hrs for Non Surgical treatment of Chronic Hypersensitivity Pneumonitis & Hypertension as per Discharge Summary of the hospital.There are mainly four mainly types of benefits in respect of hospitalization claim under the policy. The claim is settled under either of the four benefits. The first benefits HCB ( Hospital Cash Benefit ) pertains to non-surgical treatment whereas the other three benefits (MSB/OSB/DCPB) pertain to surgical treatment and the detail is as under:-

1. Non Surgical Treatment: Only Hospital Cash benefit is paid. Under this benefit, ADB  (Applicable Daily Benefit) is paid for the no. of day’s hospitalization excluding first 24 hrs i.e. claim amount = ADB X (No. of days-1), called HCB (Hospital Cash Benefit).
2. Surgical Treatment: Depending upon the types of surgery undergone, the insured is paid either of:-

1. Lumpsum  MSB (Major Surgical Benefit) equal to a fixed Percentage of MSB Sum Assured for listed 140 surgeries plus HCB Calculated as sub para (1) above, irrespective of expenses incurred.
2. Lumpsum DCPB (Day Care Procedure Benefit) equal to 5 times ADB, irrespective of expenses incurred, for listed another 140 surgeries.
3. Lumpsum OSB (Other Surgical Benefits) for unlisted surgeries equal to (No. of days Hospitalization x Double ADB) + (N-1) days x ADB).

Under the present complaint, the life insured has taken a nonsurgical treatment and in this case only HCB (Hospital Cash Benefit) as mentioned above in sub para 1 of this para is payable i.e. ADB X (No. of days -1) days = Rs.1000/- x (2-1)= 1000 x 1=Rs.1000/- . The part of the day where hospitalization is in excess of 4 hrs is treated as 1 day. In the present claim, the complainant is hospitalized for a period of 48 hrs + 3:26 hrs . Thus no benefit for 3:26 hrs can be given since 3:26 hrs is less than 4 hrs. Thus in this case the insurer is only entitled to a sum of Rs.1000/- which is already paid through NEFT. The complainant has spent Rs.20,487/- on her treatment from 12.05.2017 to 14.05.2017. But since the policy is a fixed benefit policy and not a reimbursement plan, the claim has been paid for the fixed benefit as per policy conditions, which amounts to Rs.1,000/- as stated above and the same has already been paid to the complainant. Had the claimant chosen higher IDB (Initial Daily Benefit) and had the Hospitalization been for higher Number of days, the claim amount would amount would have been higher. The complainant has paid her premiums. The opposite party has denied the other contents of the complaint and prayed for dismissal of the complaint.

3        The opposite party No. 4 appeared in person and filed written version on the same lines as filed by the opposite parties No. 1 to 3 and prayed for dismissal of the complaint.

4        The complaint has been withdrawn by the complainant against the opposite party No. 5 on 3.4.2018.

5        In order to prove the case of the complainant. ld. counsel for the complainant tendered in evidence affidavit or complainant Ex. C-1 alognwith documents Ex. C-2 to Ex. C-17, another affidavit of Prabhdeep Singh Ex. C-18. On the other hands, the opposite parties No.1  to 3 tendered in evidence affidavit of Ajaypal Singh Dhillon Assistant Administrative officer LIC Ex. OPs 1 to 3/1 alongwith documents Ex. OPOs 1 to 3/2 to Ex. OPs 1 to 3/14 and closed the evidence. The opposite party No. 4also tendered in evidence his affidavit Ex. OP 4/1 and closed the evidence.

6        Previously opposite party No. 4 appeared in this case and filed written version and also led evidence but later on he died not appear in this case and was proceeded against ex-parte vide order dated 2.9.2019 of this Forum.

7        In the present case it is admitted by the opposite parties No. 1 to 3 that the complainant had taken a health insurance plan from the opposite party No.1 on 15.06.2016 bearing Policy No. 474037120.  It is also admitted by the opposite parties No. 1 to 3 that the complainant was admitted in the DMC Hospital, Ludhiana from 12.05.2017 to 14.05.2017 and got treatment of Hypersensitivity Pneumonitis and it is submitted by the opposite parties No. 1 to 3 that the complainant had only submitted the total bills of Rs.20,487/- for the period 12.05.2017 to 14.05.2017 for her claim to the opposite parties.  It is also admitted by the opposite parties No. 1 to 3 that medical bills and copies of the treatment were submitted by the complainant to the opposite parties. The opposite parties have after admitting the insurance has paid Rs. 1,000/- to the complainant through NEFT on 3.12.2017.         Ld. counsel for the opposite parties No. 1 to 3 alleged that in the present case the life insured has taken a nonsurgical treatment and in this case only HCB (Hospital Cash Benefit) as mentioned above in sub para 1 of Para No. 8 of the written version is payable i.e. ADB X (No. of days -1) days = Rs.1000/- x (2-1)= 1000 x 1=Rs.1000/- . The part of the day where hospitalization is in excess of 4 hrs is treated as 1 day. In the present claim, the complainant is hospitalized for a period of 48 hrs + 3:26 hrs . Thus no benefit for 3:26 hrs can be given since 3:26 hrs is less than 4 hrs. Thus in this case the insurer is only entitled to a sum of Rs.1000/- which is already paid through NEFT. The complainant has spent Rs.20,487/- on her treatment from 12.05.2017 to 14.05.2017. But since the policy is a fixed benefit policy and not a reimbursement plan, the claim has been paid for the fixed benefit as per policy conditions, which amounts to Rs.1,000/- as stated above and the same has already been paid to the complainant. On the other hands, Ld. counsel for the complainant has contended that the opposite parties have not explained the terms and conditions of the policy in question to the complainant and same are not supplied or explained to her at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, It is usual with the insurance company to show all types of green pastures 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 DharmendraGoel 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.UshaYadav& 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.

8        The opposite party has failed to prove that the terms and conditions were ever supplied to the complainant. The opposite parties No. 1 to 3 have place d on record one document Ex. OPs  1 to 3/2 in which it has been mentioned that ‘This welcome kit’ contains your policy Bond, Conditions & Privileges under  your Jeevan Arogya Policy….’ But the opposite parties No. 1 to 3 have miserably failed to prove that all these documents were supplied to the complainant. The terms and conditions which are not communicated to the complainant  are not binding upon the complainant.  

9        The complainant has prayed Rs. 25,297 as treatment amount but the opposite parties have admitted in the written version that the complainant has deposited the bills of Rs. 20,487/- . But from the perusal of bills Ex. C-3 to Ex. C-15 it reveals that the complainant has made payment of Rs.23,961/- for treatment. As such, the complainant is entitled to Rs. 23,961/- only. The opposite parties No. 1 to 3 have already made the payment of Rs. 1,000/- to the complainant. As such, the complainant is entitled to Rs. 22,961/- only (Rs.23961-1000=22961).

10      During the pendency of the present complaint, the complainant Tarjit Kaur has died and after her death, Prabhdeep Singh being son and Navjit Kaur being daughter of Tarjit Kaur are her L.Rs and have been brought on record in place of complainant.

11      In view of the above discussion, the present complaint is allowed and the opposite parties No. 1 to 3 are directed to make the payment of Rs.22,961/-  (Rs. Twenty Two Thousand Nine Hundred and sixty one only) to the complainants in equal shares as follows:-

          (i)                Prabhdeep Singh            50%

          (ii)               Navjit Kaur                    50%

Complainant is also entitled to Rs.4,000/-(Rs. Four Thousand only) as compensation on account of harassment and mental agony and Rs. 3,000/-  (Rs Three Thousand only) from the opposite parties No. 1 to 3. Opposite Parties No. 1 to 3 are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainantsare entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.