Punjab

Sangrur

CC/625/2014

Gurpreet Singh - Complainant(s)

Versus

Manoj Kumar Sharma - Opp.Party(s)

Shri S.S. Ratol

18 May 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    625

                                                Instituted on:      19.11.2014

                                                Decided on:       18.05.2015

 

Gurpreet Singh aged 30 years son of Davinder Singh son of Sucha Singh, VPO Chathe Sekhwan, Tehsil and Distt. Sangrur.

                                                        …Complainant

                                Versus

1.     Manoj Kumar Sharma son of Shri Jia Lal Sharma (Agent Birla Sun Life) H.No.157, Ward No.6, Nabha, District Patiala.

2.     Manager, Birla Sun Life Insurance, Opposite DC House, Gaushala Road, Sangrur.

3.     Birla Sun Life Insurance Company Ltd. through its D.M. One India Bulls Centre, Tower 1, 15 and 16^th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400 013.

                                                        ..Opposite parties

 

For the complainant    :       Shri S.S.Ratol, Adv.

For OPs                    :       Shri Amit Goyal, Adv.

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

Order by : K.C.Sharma, Member.

 

1.             Shri Gurpreet Singh, 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 obtained the services of the Ops by purchasing a health insurance policy number 005142994 for the period from 12.10.2011 to 12.10.2021 after completing all the formalities and the payment was paid at Village Chathe Sekhwan to OP number 1. It is further averred that the sum insured under the policy was Rs.10.00 Lacs. 

 

2.             The case of the complainant is that during the subsistence of the insurance policy, the complainant fell down from the stairs in his house and due to the accident, the right thigh of the complainant was fractured and complainant was immediately taken to DMC Hospital Ludhiana and he remained admitted there from 9.7.2012 to 16.7.2012.  It is further alleged that the operation for plating and bone grafting was conducted of right thigh of the complainant and spent an amount of Rs.1,24,615/- on medicine etc.  Thereafter the complainant immediately informed the OPs through its agent and submitted all the original bills etc. The OP allotted claim number 1531861.  It is further stated that despite submission of all the documents to the Ops, the Ops did not settle the claim.  As such, complainant filed complaint number 22 dated 8.1.2014 before this Forum which was disposed of by this Forum on 6.8.2014.  The documents were again submitted to the OPs through their counsel, but the Ops only issued a cheque for Rs.28,000/- which was accepted by the complainant under protest.  It is further stated that the Ops have not paid the full claim and has not assigned any reason for the payment of less claim amount. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay an amount of Rs.1,46,615/- along with interest @ 18% per annum from the date of accident i.e. 9.7.2012 till realisation and further claimed compensation and litigation expenses.

 

3.             In reply filed by the OPs, preliminary objections are taken up that the policy in question is a ULIP policy, as such this Forum has no jurisdiction to decide the complaint, that the complaint is not maintainable that the complaint is liable to be dismissed on the ground that the complainant has already accepted a cheque for Rs.28,000/- without any protest.  On merits, it is that the complainant opted for BSLI Saral Health Plan of the OPs with a total annual premium of Rs.11,937/- against the sum assured of Rs.10.00 Lacs.  The other allegations of the complainant have been denied. It is stated further that the complainant submitted documents only after order dated 6.8.2014 in the previous complaint number 22/8.1.14  and after that the OPs processed the claim and paid Rs.28,000/- vide cheque number 001222 dated 12.9.2014. It is stated further that the amount of Rs.28000/- has been paid as the complainant remained admitted for 7 days.  It is stated that the amount of Rs.28000/- has been paid according to the policy terms and conditions. The complainant has even failed to plead in his complaint that what deficiency in service has been committed by the OPs or what kind of unfair trade practice has been adopted by the OPs.  The complainant is not entitled to claim an amount of Rs.1,46,615/- on account of other expenses. However, any deficiency in service on the part of the OPs has been denied.

 

4.             The learned counsel for the complainant has produced Ex.C-1 copy of letter, Ex.C-2 copy of discharge summary, Ex.C-3 copy of patient card, Ex.C-4 copy of claim form, Ex.C-5 copy of schedule of expenses, Ex.C-6 copy of medical certificate, Ex.C-7 copy of letter, Ex.C-8 copy of statement of Gurpreet Singh, Ex.C-9 copy of letter, Ex.C-10 to Ex.C-58 copies of bills, Ex.C-59 to Ex.C-60 copy of courier receipts, Ex.C-61 affidavit of the complainant and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OP-1 affidavit, Ex.OP-2 copy of authority letter, Ex.OP-3 copy of proposal/application form, Ex.OP-4 copy of terms and conditions, Ex.OP-6 copy of cheque and closed evidence.

 

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

 

6.             After hearing the arguments of the learned counsel for the parties and on perusal of the documents placed on record, we find that the complainant had earlier filed a complaint on 8.1.2014 and as per the order of this Forum, the documents were again submitted by the complainant with the OPs for the payment of claim amount, but the OPs have paid only a sum of Rs.28,000/- to the complainant, whereas the amount of the claim was Rs.1,74,615/- and the present complaint is with regard to the balance claim amount of Rs.1,46,615/- as an amount of Rs.28,000/- has already been paid to the complainant by the Ops.

 

7.             We have very carefully gone through the version of the OPs. The learned counsel for OPs number 2 and 3 has argued vehemently that since the claim of Rs.28,000/- has already been received by the complainant, as per terms and conditions of the policy,  which are on record as Ex.OP-4, as such, the complaint of the complainant should be dismissed.  On the perusal of the document Ex.OP-4, we find that under the head ‘policy benefit provisions’ the claim is restricted to Rs.4000/- per day for a maximum period of ten days in a year.  As the complainant had remained admitted in the hospital for seven days, so the Ops had paid a sum of Rs.28,000/- accordingly, but then this clause is limited with regard to the expenses incurred during the hospitalisation and not for the over all expenses, like medicines and other misc expenses incurred by the beneficiary, which are covered under the ‘health insurance benefit’ of the same document, Ex.OP-4.  This clause says that “your policy details show that the sum assured applicable to your policy during the health insurance benefit term, the maximum amount that can be claimed under the Health Insurance Benefit is 20% of sum assured as per policy year in case of Hospitalization and 100% over the health insurance benefit term in case of both Hospitalization and Critical Illness combined’.  So, in our opinion, the claim of the complainant is covered under the clause  ‘Health Insurance Benefit’.  In our opinion, it has been clearly mentioned “the maximum amount that can be claimed under the Health Insurance Benefit is 20% of the Sum Assured per policy year in case of hospitalisation”.  In this case, the sum assured under the policy was Rs.10.00 Lacs, as such, the amount of claim could be to the extent of Rs.2,00,000/- and had there been any critical illness like cancer, heart attack, major organ transplant and stroke then the amount eligible is upto 100% of the sum assured i.e. Rs.10,00,000/-.  So, in the light of above guidelines contained in the document Ex.OP-4 of the OPs, we are unable to rely upon on the version of the OPs that the complainant was only eligible for a sum of Rs.28,000/- because had it been so, then there should not have been the clause of 20% and 100% of the sum assured in the terms and conditions vide which the policy is governed.

 

8.             Further we have gone through the evidence of the complainant and find that all the bills submitted by him have been counter signed by the doctor concerned, which is a confirmation to the effect that the said treatment and medicines were required to be given to the complainant.

 

9.             The OPs have also taken the plea that the policy has been obtained by the complainant with an intention to earn more, but on the perusal of the document, we do not find any mention that whether the risk profile was aggressive, moderate or conservative, only the policy in which the amount has been invested in the share market may be considered that the policy holder had obtained the policy with the motive to earn profit, but in the absence of any expression wording as is in this case, we do not consider that the complainant had obtained the policy with a motive to earn profit.  More over, the question before us is only with regard to the payment of the amount spent on the treatment and not with regard to the maturity value of the policy amount.  The Ops have not been able to produce any evidence to show that the complainant had received the payment of Rs.28,000/- and had signed any satisfaction letter in token of receiving the said amount.  In support of this version, the learned counsel for the complainant has also cited judgment of Hon’ble Supreme Court of India  pronounced in Punjab university versus Unit Trust of India and others in Civil Appeal No.400 of 2007 with Civil Appeal Nos.503 of 2008 and 4664 of 2009, decided on 9.7.2014.

 

10.            So, keeping in view the facts mentioned above, we find that the Ops are deficient in service and as such, we allow the complaint and direct OPs number 2 and 3 to pay to the complainant a sum of Rs.1,46,615/- on account of the claim amount along with interest @ 9% per annum from the date of filing of the present complaint i.e 19.11.2014 till realisation.  Ops number 2 and 3 are further directed to pay to the complainant an amount of Rs.10,000/- on account of compensation for mental tension, agony and harassment and litigation expenses.

11.            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.

                May 18, 2015.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member

 

 

                                                                (Sarita Garg)

                                                                    Member