BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BHIWANI.
Complaint No.: 8 of 2018.
Date of Institution: 10.01.2018.
Date of Decision: 14.06.2019.
Anju Kumari daughter of Shri Ramphal, resident of M. C. Colony, near Hanuman Mandir, New Bharat Nagar, Bhiwani, Tehsil & District Bhiwani.
….Complainant.
Versus
1. L. I. C. of India, Govt. of India, through its Branch Manager, Bhiwani, Tehsil & District Bhiwani.
2. L. I. C. of India, Govt. of India, S. C. O. No. 3, 4, 5, Sector-1, Rohtak through its Branch Manager.
…...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: Complainant in person.
Shri Mukesh Jangra, Advocate for the OPs.
ORDER:-
PER MANJIT SINGH NARYAL, PRESIDENT
Brief facts of the case are that the complainant has purchased a Medical Policy No. 179991529 dated 7.9.2015 of Rs.1,00,000/- valid for the period from the 7.9.2015 to 6.9.2016 and paid premium. It is alleged that the complainant fell ill due to Emteric Fever and for her treatment she admitted in Sharma Hospital from 12.8.2016 to 22.8.2016 and she was discharged on 22.8.2016. It is further alleged that after admission she informed about her treatment to the OP No. 1 on the same day by hand and by post. It is further alleged that the complainant lodged claim complete in all respect with application form of mediclaim, medicine bills and all other relevant documents under the said policy with the OPs on 14.9.2016 with the request to pay an amount of Rs.32,462/- (Rs.13,840/- Hospital Charges + Rs.18,622/- Medicine charges) and complete all the formalities, but the OPs did not pay the claim amount. It is further alleged that the complainant has sent reminders dated 2.1.2017, 4.2.2017 and 3.3.2017 to the OPs, but to no effect. Hence, it amounts to deficiency in service on the part of OPs. Hence, this complaint.
2. On notice, OPs appeared and filed contested written statement. It is alleged that the complainant is the holder of insurance policy No. 179991529 Jeewan Arogya Policy under table 904 issued by the Bhiwani office. It is further alleged that the complainant submitted hospitalization claim under the policy seeking claim of Rs.13,840/- and on receipt of medical claim, the matter was processed and after scrutinizing the claim paper with regard to the eligibility of the claim in terms of policy terms and conditions and after investigating into the details of hospitalization, nature of ailment for which treatment has been undergone etc., basing on the various records and documents submitted by complainant, came to the conclusion that the complainant is not eligible for the claim as it does not fall under the purview of the policy terms & conditions and does not satisfy the same and the claim of the complainant was repudiated and the same was conveyed vide letter LIC/TPA dated 12.4.2017. It is further alleged that complainant was not found eligible for the claim, as she was diagnosed enteric fever, hepatitis with jaundice which does not fall under the purview of the policy terms and conditions. Therefore, there is no deficiency in service on the part of the OPs and prayed for dismissal of complaint with costs.
3. The complainant to prove her case placed on record her duly sworn affidavit Ex. CW1/A and the documents Annexure C1 to C31 and closed the evidence.
4. Ld. Counsel for the OPs has placed on record the documents Annexure R1 to R6 in evidence.
5. We have heard ld. counsel for both the parties at length and gone through the case file very carefully.
6. The only plea taken by the OPs is that the complainant is not eligible for the claim as it does not fall under the purview of the policy terms & conditions and does not satisfy the same. This pea of the OPs is not tenable at all, because they have no where mentioned that as to which terms & conditions of the policy violated by the complainant. Ld. counsel for the OPs has placed on record documents Annexure R1 to R6 in support of its case. From the perusal of Annexure R4 letter dated 15.3.2017, it has been mentioned that “Investigation for this 2015-16 was made by Shri B. B. Madaan, Branch Manager of Bhiwani SSO on 17.10.2016 in which he stated “Anju Kumari is receptionist in same Hospital, but in the P. form she mentioned her nature of duty as Tuition. It seems that surgery made in that Hospital is due to this reason”. But from the perusal of written statement of the OPs there is no mention about this fact and now the OPs cannot be allowed to take the plea beyond their pleadings, thus, this plea of the OPs is not tenable at all. Moreover, in our view taking treatment in the same Hospital in which the complainant was working has no effect on her claim, rather it would helpful for the complainant in her treatment. There is no clause in the policy in question in this regard. Moreover, the complainant has successfully proved her case by placing on record documents Annexure C1 to C32. Thus, it is clearly proved that the OPs have wrongly repudiated the genuine claim of the complainant on the flimsy grounds.
7. Now question of law arises as to whether the insurance company was justified in repudiating the claim of the complainant. The sought answer is “No”. The claim of the complainant was repudiated on the allegations that the complainant has violated the terms & conditions of the policy. This plea of the OPs cannot be taken into count, because the OPs have nowhere stated that which terms & conditions have been violated by the complainant. 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 insured by raising unnecessary objections. So, it cannot be said that she had violated any terms & conditions of the policy. Moreover, it was the duty of OPs to prove on record that as to which terms & conditions have been violated by the insured, but they have failed to do so. So, violation of terms & conditions of the policy, if any, was not of such an important significance. So, it is clear that the OPs have failed to prove on record that the insured had violated any terms & conditions of the policy.
8. Moreover, the Insurance Companies adopt very unethical and wrong procedure just grab the money from the poor peoples and harass them when they are in need of the money. It is also moral & social duty of the insurance companies to conduct proper enquiry of buyers of the insurance policies before they accept the hard earned money on account of premium from policy buyers, as lateron they were on giving hand and they cannot escape from their liability and also cannot harass the poor people on unnecessary excuses especially at the time of giving the claim to the insured. Generally it is routine practice that as and when a common person searches on internet about insurance/mediclaim policies, then he receives many unwanted telephone calls from the different insurance companies and these companies 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 public and to get the commission on that amount and they complete all the formalities by themselves including filling of proposal form and they also obtained the signature of assured on some blank forms and for this they always adopt the unethical, unsocial and un-genuine procedure to issue the insurance policy. As 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. So after considering all above mentioned important issues, we come to the conclusion that the insurance companies should have held liable for their errors & negligence committed on their part and to protect the interest of genuine buyers of the insurance policies. The Insurance Companies and their agents are also duty bound to disclose all hidden terms & conditions of the insurance policy to protect the interest of consumers and these companies are also duty bound to get investigate the assured with their entire satisfaction before issuing the insurance/mediclaim policies. In our view, generally only 2-3 persons approached the insurance company for claiming the insurance claim, out of every 10 persons, but the insurance companies use to raise baseless objections to harass them for getting their insurance claims. It cannot be said that insured has violated the terms & conditions of the policy, because everything was within the approachable hand of the OPs and they must investigate all the facts pertaining to the insured before repudiation of the claim to provide proper justice to the needy claimants. 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”
Thus the claim of the complainant has been wrongly repudiated by the OPs on the ground that she has violated the terms & conditions of the policy, but OPs have failed to explain as to which terms & conditions of the policy have been violated.
9. From the above facts, it is clearly proved on record that OPs have failed to provide satisfactory services to the complainant i.e. settling the genuine claim of the complainant, for which they have charged the premium and they are bound to settle the genuine claims of their consumers. So, OPs have defeated the very purpose for which the complainant has taken the mediclaim policy. But the OPs have repudiated the claim of complainant only on the ground of violation of certain terms & conditions of the policy, whereas they have failed to produce any cogent & convincing evidence on record to prove the fact of violation of terms & conditions of the policy. Thus, there is gross negligence and deficiency in service on the part of OPs and they cannot be allowed to run away from their responsibility.
10. 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 Rs.32,462/- (Thirty two thousand four hundred sixty two only) together with interest @ 12% per annum from the date of repudiation of claim i.e. 12.4.2017 till its realization.
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iii. To pay Rs.15,000/- (Fifteen thousand only) as punitive damages for mal trade practice.
iv. To pay Rs.7000/- (Seven thousand only) as 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: - 14.06.2019.
(Saroj Bala Bohra) (Parmod Kumar) (Manjit Singh Naryal)
Member. Member. President,
District Consumer Disputes
Redressal Forum, Bhiwani.
