Order by:
Sh.Amrinder Singh Sidhu, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that he purchased a Medi Claim Health Insurance Policy vide No.31007671201900 valid for the period w.e.f. 20.08.2019 to 19.08.2022 against paid up premium of Rs.5498/- for a sum assured of Rs.5 lakhs and said policy was again renewed for the period w.e.f. 20.08.2020 to 19.08.2021 and paid Rs.7615/- and the sum assured was enhanced to Rs.10 lakhs. Further alleges that during the policy period, the complainant fell ill and was suffering from Covid-19 and he was got admitted in Harbans Nursing Home and Maternity Hospital, Kot Ise Khan where he remained admitted from 17.06.2021 to 30.06.2021 and spent Rs.1,99,831/- on account of medical expenses. After discharge from the hospital, the complainant lodged the claim with the Opposite Parties for the reimbursement of his medical expenses, but the Opposite Parties repudiated the claim of the complainant vide letter dated 17.09.2021 with the reason “Misrepresentation as per received medical document and hospital records scrutiny done by us it was found that Discrepancy and Misrepresentation observe so claim is repudiated as per clause 10.21 As 24 hours of hospital not completed so claim is rejected as per clause 10.38. Note: patient taking treatment as day care basis.” But it is totally wrong because the complainant remained admitted in the hospital from 17.06.2021 to 30.06.2021 for about 15 days. Hence, the repudiation of the claim has been made by the Opposite Party on the false and frivolous grounds. In this way, said conduct of the Opposite Party clearly amounts to deficiency in service and as such, the Complainant is left with no other alternative but to file the present complaint. Vide instant complaint, the complainant has sought the following reliefs.
a) Opposite Party may be directed to reimburse the amount of Rs.1,99,831/- alongwith interest and also to pay Rs.1 lakhs as compensation on account of mental tension, physical harassment and Rs.50,000/- as costs of litigation.
2. Opposite Party appeared through counsel, but failed to file the written version within the stipulated period as required under the Consumer Protection Act, 2019. In this regard, Hon’ble Supreme Court of India in complaint titled as New India Assurance Company Limited Vs. Hilli Multipurpose Cold Storage decided on 4th March, 2020 hold that the District Forum (now Commission) has no power to extend the time for filing the response to the complaint beyond the period of 15 days in addition to 30 days as envisaged under section 13 of the Consumer Protection Act, 1986 (now under section 38(2) of the Consumer Protection Act, 2019 and the commencing point of limitation of 30 days under section 13 of the Act would be from the date of receipt of notice accompanied with the complaint by the Opposite Party. In view of this, this District Consumer Commission do not possess any power to give further time period after completion of 15 days in addition to 30 days as envisaged under section 13 of the Consumer Protection Act, 1986 (now under section 38(2) of the Consumer Protection Act, 2019 and hence, the right of filing the written statement of the Opposite Party stands closed by order.
3. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7 and closed his evidence.
4. On the other hand, to rebut the evidence of the complainant, Opposite Party tendered into evidence the affidavit of Sh.Rajan Sachdeva, Senior Branch Manager Ex.OPW1/1 alongwith copies of documents Ex.R1 to Ex.R5 and closed the evidence on behalf of the Opposite Party.
5. We have heard the ld.counsel for the parties and gone through the documents placed on record.
6. During the course of arguments, ld.counsel for the Complainant as well as ld.counsel for the Opposite Party have mainly reiterated the facts as narrated in the complaint as well as in the evidence produced by the Opposite Party. The main case of the complainant is that during the policy period, due to Corona disease he remained admitted in Harbans Nursing Home and Maternity Hospital, Kot Ise Khan where he remained admitted from 17.06.2021 to 30.06.2021 for about 15 days and spent Rs.1,99,831/- on account of medical expenses. After discharge from the hospital, the complainant lodged the claim with the Opposite Parties for the reimbursement of his medical expenses, but the Opposite Parties repudiated the claim of the complainant vide letter dated 17.09.2021 with the reason “Misrepresentation as per received medical document and hospital records scrutiny done by us it was found that Discrepancy and Misrepresentation observe so claim is repudiated as per clause 10.21 As 24 hours of hospital not completed so claim is rejected as per clause 10.38. Note: patient taking treatment as day care basis.” But it is totally wrong because the complainant remained admitted in the hospital from 17.06.2021 to 30.06.2021 for about 15 days. Hence, the repudiation of the claim has been made by the Opposite Party on the false and frivolous grounds. On the other hand, though the Opposite Party has failed to file the written version within the stipulated period in accordance with the law, but in affidavit of Sh.Rajan Sachdeva, Senior Branch Manager Ex.OPW1/1 has duly admitted that the complainant purchased the policy in question and the complainant submitted the documents for hospitalization from 17.06.2021 to 30.06.2021 on daycare basis and further during investigation of the claim it was revealed that the complainant had also filed a claim with Bajaj Allianz General Insurance and hence, there is no deficiency in service on the part of the Opposite Party. But we do not agree with the aforesaid contention of the ld.counsel for the Opposite Party. Firstly, the Opposite Party has failed to adduce any such document or evidence that the complainant ever took the reimbursement of his medical claim in question from any other insurance company like that Bajaj Allianz General Insurance. On the other hand, the complainant has produced on record the Indoor Record of Harbans Nursing Home & Maernity Hospital, Kot Ise Khan Ex.C2 in which it is clearly mentioned the Date of Admission as 17.06.2021 and Date of Discharge as 30.06.2021 as Indoor no. 746 in which the complainant remained admitted due to Covid-19 (Chest Congestion) and the patient (complainant) duly remained admitted in Room No. ICU and this Indoor Record has duly been signed by the attending doctor and this medical record has nowhere denied by the Opposite Party by filing any cogent and convincing evidence and how the Opposite Party can say that the complainant (patient) remained patient as daycare basis.
7. In such a situation the repudiation made by the Opposite Party-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters 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 Dharmendra Goel 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.Usha Yadav & 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 view of the above discussion, we hold that the Opposite Party-Insurance Company have wrongly and illegally rejected the claim of the complainant.
9. Now come to the quantum of compensation. The complainant has claimed the amount of Rs.1,99,831/- on account of hospitalization charges on his treatment under the policy. It is the case of the complainant that he remained admitted in Harbans Nursing Home, Kot Ise Khan for the period w.e.f. 17.06.2021 to 30.06.2021 (14 days) for treatment. On the other hand, Opposite Party has placed on record the Treatment Chart of the complainant, and as per the said Treatment Chart, the complainant is entitled to Rs.8000/- per day (including cost of PPE Rs.1200/-) in Non-NABH accredited Hospitals and the rates for private hospitals beds would be all inclusive as a package, however, in his complaint the complainant has claimed Rs.1,99,831/- on account of hospitalization charges on his treatment under the policy. In view of the aforesaid facts and documents produced on the record, since the complainant remained admitted in the hospital from 17.06.2021 to 30.06.2021 (14 days) and hence we hold that the complainant is entitled to the reimbursement of Rs.1,12,000/- (i.e. Rs.8000/- x 14 days) only.
10. In view of the aforesaid facts and circumstances of the case, we partly allow the complaint of the Complainant and direct Opposite Party-Insurance Company to pay Rs.1,12,000/- (Rupees One Lakh Twelve Thousands Only) to the complainant alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 21.02.2022 till its actual realization. The compliance of this order be made by the Opposite Party within 60 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Consumer Commission. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Commission.
