Before the District Consumer Disputes Redressal Commission, Room No. 208 2nd Floor, District Administrative Complex, Tarn Taran
Consumer Complaint No : 107 of 2019
Date of Institution : 22.11.2019
Date of Decision : 11.04.2023
Amarjit Kaur wife of Balkar Singh resident of village Kot Dharam Chand Khurd, Tehsil and District Tarn Taran.
…..Complainant
Versus
- M.D. India Health Insurance TPA Pvt. Ltd. Mohali Towers 1st Floor, Plot No. F-539, Phase 8-B, Industrial Area, Airport Road Mohali, 160071 through its MD
- United India Insurance Company Ltd. 24 Whites Road, Cheenai 600014, through its M.D.
…Opposite Parties
Complaint Under Section 12 & 13 of the Consumer Protection Act
Quorum: Sh. Charanjit Singh, President
Ms. Nidhi Verma Member
Sh. Varinder Pal Singh Saini, Member
For Complainant Sh. H.S. Sandhu Advocate
For Opposite Parties Sh. Sandeep Khanna Advocate
PER:
Charanjit Singh, President
1 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 13 against the opposite parties on the allegations that the complainant is a farmer and she is a member of Farmer Co operative Society, Kot Dharam Chand Kalan Tehsil and District Tarn Taran and this society got the complainant insured with the opposite parties under health scheme of the Government of Punjab. The complainant paid premium for availing this policy to the opposite parties through the secretary of the cooperative society and the secretary sent the list of insured members to the opposite parties and got them insured under this scheme. The complainant felt severe pain in her lower back & she visited many local doctors regarding it and all those doctors referred her for Ludhiana and as such she was immediately taken to Global Heart and Super Specialty Hospital, Ludhiana where she was admitted by the hospital authorities on 11.12.2018 and several investigative tests were conducted upon her and the doctors diagnosed the complainant and referred for a implant surgery by way of which some gadgets were to be affixed in the back bone of the complainant. The complainant was operated upon by the hospital authorities on 12.12.2018 and some gedgets as mentioned above were installed into her body and the expenses of purchasing these and also the expenses of surgery and medicines amounting to Rs.01 Lac was spent by her from her own pocket and she was discharged from the hospital on 17.12.2018. After some recovery, the complainant immediately approached the opposite parties and submitted her reimbursement claim as she is insured with the opposite parties under the above mentioned health scheme, by supplying them all the necessary documents as required by them and the opposite parties issued a claim No.366601 to the complainant and also gave one telephone number which being 01722236540 and told the complainant that she can call any time on this number and can get information regarding the status of the claim case by giving the above mentioned claim number, so the complainant called several times on this number and all occasions the opposite parties told her that her claim case is still in process and same will be released to her in a few days time. The husband of the complainant also visited personally at the above mentioned address of the opposite parties for getting the reimbursement claim released from them but the same was the answer as stated above by the opposite parties on these visits. The complainant prayed that the following reliefs may kindly be granted to the opposite parties.
- The opposite parties may kindly be directed to release the reimbursement claim amount of Rs. 1,00,000/- to the complainant.
- The opposite parties may kindly be directed to pay compensation of Rs. 50,000/- alongwith litigation expenses of Rs. 50,000/- to the complainant.
Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, Self attested copy of Health Card Ex. C-2, Self attested copy of discharge summary Ex. C-3, Self attested copy of bills of treatment, medicines etc. Ex. C-4.
2 Notice of this complaint was sent to the opposite parties and opposite parties appeared through counsel and filed written version by taking the preliminary objections that the present complaint has become infructuous as the claim in question has been settled and duly paid by the opposite parties. The complainant has already received payment of Rs. 43,883/- vide UTR No. 19054902738 on 31.10.2019, on account of hospitalization as full and final payment pertaining to the treatment in question. The complainant is not entitled to the relief claimed for. The treatment / procedure in question costs around Rs. 40,000/- as per agreed package rates in the best Hospitals of Ludhiana, with similar infrastructure and located in same geographical area. Under reasonable and customary clause of the policy in question, Rs. 43,883/- was allowed by the competent authority of the opposite parties against the claimed amount of Rs. 88,794/-. Accordingly, on the basis of the said partial approval the sanctioned amount of Rs. 43,883/- as paid by the opposite parties and the complainant has already received the same. The complainant neither made any representation nor approached the opposite parties for her alleged grievance after receiving the payment. The complainant has got no cause of action arisen to her to file the present complaint against the opposite parties. The complainant has not approached this commission with clean hands and has tried to conceal the material facts. The complainant is guilty of misleading the opposite party by furnishing false and incorrect information pertaining to the claim in question. The complainant has settled the present claim with his own free will and consent and had duly received the settled payment of Rs. 43,883/- in that regard. If the complainant was not satisfied with the claim as settled by the opposite parties, the complainant could have either refused to receive the settled amount or should have receive the payment under protest. Neither the above said options were exercised by the complainant which makes it clearly evident that the payment was voluntarily accepted by the complainant. As such, the complainant is not entitled to get the relief claimed for. The claim file of the complainant has been disposed of as Fully Settled by the competent authority of the OPs, no consumer dispute survives. The complainant is not entitled to the relief claimed for. On account of claim being satisfied by the opposite parties, there is no question of any delay or deficiency on the part of the opposite parties. The relief of damages and costs in the present complaint is not payable. There is no such provision to grant any such relief either under the Consumer Protection Act nor there is any agreed clause in the contract of Insurance to pay any such claim. The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record affidavit Ex. OPs 1,2/1, Photocopy of email Ex. OPs 1,2/2, Photocopy of authority of payment Ex. OPs 1,2/3.
3 We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record placed on the file.
4 In the present case insurance is not disputed. It is also not disputed that the complainant has taken the treatment because after admitting the insurance policy and after admitting the treatment, the opposite party has made payment of Rs. 43,883/- to the complainant which has been received by the complainant from the opposite parties. According to complainant, she spent Rs. 1,00,000/- on her treatment and she is entitled to Rs. 1,00,000/-. But on the other hands, the case of the opposite parties is that complainant has already received payment of Rs. 43,883/- vide UTR No. 19054902738 on 31.10.2019, on account of hospitalization as full and final payment pertaining to the treatment in question. The treatment / procedure in question costs around Rs. 40,000/- as per agreed package rates in the best Hospitals of Ludhiana, with similar infrastructure and located in same geographical area. Under reasonable and customary clause of the policy in question, Rs. 43,883/- was allowed by the competent authority of the opposite parties against the claimed amount of Rs. 88,794/-. Accordingly, on the basis of the said partial approval the sanctioned amount of Rs. 43,883/- was paid by the opposite parties and the complainant has already received the same. In this complaint, the controversy is with regard to the amount which was settled by the opposite party i.e. to the tune of Rs. 43,883/-. The opposite party has stated in their written version that as per terms and conditions of their policy said amount was reimbursed to the complainant. However it is not on the record that whether, this amount was sent to the complainant in his account or it was given to the complainant in cash.
5 From the bare perusal of record placed on the file by the opposite parties there is no terms and conditions have been placed on record by the opposite party which shows that how an amount of Rs. 43,883/- has been assessed by the opposite parties. The opposite parties have failed to prove on record that the complainant is only entitled for the sum of Rs. 43,883/-. Further, the opposite party has stated in their written version that the treatment / procedure in question costs around Rs. 40,000/- as per agreed package rates in the best Hospitals of Ludhiana with similar infrastructure and located in same geographical area and as such, under reasonable and customary clause of the policy in question an amount of Rs. 43,883/- was allowed. But the opposite party has not placed on record a single document which proves the contention of the opposite party.
6 The as per the opposite party an amount of Rs. 43,883/- has been paid to the complainant and the complainant is not satisfied with the amount which he has received, as such she has filed the present complaint before this commission. On the other hands, opposite parties have failed to prove that the amount which has been assessed by the opposite parties is as per the terms and conditions of the policy. As a matter of act, there is no terms and conditions placed on record by the opposite parties and in this situation, the complainant cannot be deprived from his lawful claim for amount of Rs. 1,00,000/-
7 As the opposite parties have failed to prove on record that on the basis of which terms and conditions, the complainant is not entitled to the remaining remount of treatment, it amounts to deficiency in service and unfair trade practice on the part of the opposite parties. As such, the complainant is entitled to the relief which he has claimed in the present complaint. 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 In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Parties are directed to make the remaining payment of Rs. 56117/- (Rs. 100000-43883=56117). The complainant has been harassed by the opposite parties unnecessarily for a long time. The complainant is also entitled to 5,000/- ( Rs. Five Thousand only) as compensation on account of harassment and mental agony and Rs. 5,000/- (Rs. Five Thousand only) as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.
Announced in Open Commission.
11.04.2023
(Charanjit Singh)
President
(Nidhi Verma) (V.P.S. Saini)
Member Member
