Punjab

Faridkot

CC/18/97

Vipan Vig - Complainant(s)

Versus

Mrs Santosh Kumar - Opp.Party(s)

Vipen Wadhawan

04 Jun 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :                97 of 2018

Date of Institution:     12.06.2018

Date of Decision :        4.06.2019

 

Vipan Vig, son of  Vijay Kumar Vig,  r/o Dhodha Street Kotkapura, M/s Dhodha House, Railway Road, Kotkapura, District Faridkot.

...Complainant

Versus

1. Mrs Santosh Kumar, Agent Code AGN 1044901, Agent of United India Insurance Company Ltd, Opp. Giani Zail Singh Market, Near Jyoti Model School, Moga Road, Kotkapura District Faridkot.
2. United India Insurance Company Ltd, Opp. Giani Zail Singh Market, Near Jyoti Model School, Moga Road, Kotkapura Faridkot.
3. The Branch Manager, United India Insurance Company Ltd, Opp. Giani Zail Singh Market, Near Jyoti Model School, Moga Road, Kotkapura Faridkot.
4. Raksha Health Insurance c/o TPA Pvt Limited, c/o Escorts Corporate Centre, 15/5 Mathura Road, Faridabad, Haryana 121003.
5. The Manager, Raksha Health Insurance c/o TPA Pvt Limited, c/o Escorts Corporate Centre, 15/5 Mathura Road, Faridabad, Haryana 121003.

.....Opposite Parties

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Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Param Pal Kaur, Member.

 

Present: Sh Vipen Wadhawan, Ld Counsel for Complainant,

              Sh Ashok Monga, Ld Counsel for OP-2 and 3.

              Sh Amandeep Singh on behalf of  OP-4 and 5.

              OP-1 Exparte.

 

ORDER

(Ajit Aggarwal, President)

                                         Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of insurance claim worth Rs.1,12,378/- and for further directing OPs to pay Rs.1,00,000/- as compensation for deficiency in service, harassment, inconvenience, mental agony alongwith litigation expenses of Rs.22,000/-.

2                                     Briefly stated, the case of the complainant is that  on assurance of OP-1 agent of OPs complainant purchased a Family Medicare Policy bearing no. 20122022817 P 101541824 from OPs for sum assured of Rs.10 lakhs on 20.04.2017 and during the subsistence of said policy, daughter of complainant suffered from severe abdomen pain on 7.09.2017. Doctor diagnosed that she was suffering from Recurrent Acute Appendicitis. Complainant immediately reported the matter to OP-2 who told him to take treatment anywhere

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and assured that OPs would pass the claim. On advise of doctor, complainant got conducted operation of his daughter for Appendicitis from Doctor Nirmaljieet Singh of SPS Hospital, Ludhiana and spent Rs.1,67,054/-on her treatment. Thereafter, complainant completed all formalities and submitted requisite documents with OPs for claim of Rs.1,67,054/-, but OPs reimbursed the amount of Rs.54,678/-to complainant and withheld the remaining amount of Rs.1,12,378/- vide letter dt 18.11.2017 without disclosing any reason. Complainant made several requests to OPs to make payment of remaining amount but all in vain, which amounts to deficiency in service and trade mal practice on the part of OPs. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief of making payment of remaining claim amount. Hence, the complaint.

3                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 13.06.2018, complaint was admitted and notice was ordered to be issued to the OPs.

4                                    On receipt of the notice, the OP-2 to 5 filed reply wherein admitted that daughter of complainant suffered from Appendicitis and she has undergone surgery, but denied all the allegations of complainant that he spent an amount of Rs.1,67,054/-on treatment of his daughter and the record produced by complainant is false and not genuine. It is averred that complaint filed by complainant is not maintainable and it is filed with malafide intention to extract money

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from OPs. It is averred that complicated questions of law and facts are involved that require voluminous evidence, which is not possible in summary proceedings of this Forum. It is further averred that claim amount of Rs.54,676/-has already been paid to complainant as per terms and conditions of the Policy and nothing is due towards OPs. It is further averred that Rs.12,000/- as room charges, Rs.9000/-of doctor fee, Rs.52500/-as Surgeon’s fee; Rs.2720/-for lab charges; Rs.5231/- hospital services; Rs.4397/-from medication charges, Rs.2699/-towards consumable charges, Rs.1446/- for one day medicine payable out of package, Rs.1530/-towards admission fees and Rs.15,625/-have been deducted as OT Charges as being non payable as per hospital Gipsa PPN Package Rates. All this amount has been rightly deducted as per policy terms and conditions and claim amount of Rs.54,676/-has been paid to him within two months after due enquiry and due application of mind on merits and as per terms and conditions of the policy in question and complainant received this amount without any protest and now nothing is due towards them and they are not liable to pay the same. However, on merits, OP-2 to OP-5 have denied all the allegations of complainant being wrong and incorrect and reiterated the same pleadings as taken in preliminary objections. It is further averred that there is no deficiency in service on their part and prayed for dismissal of complaint against        them.

5                                              Registered cover containing notice and copy of complaint alongwith relevant documents was sent to OP-1, the

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same has not been received back undelivered and it is presumed to be served. Even after expiry of statutory period, no body appeared in the Forum either in person or through counsel, therefore, vide order dated 8.08.2018, OP-1 was proceeded against exparte.

6                                                        Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-4 and then, closed their evidence.

7                                                      In order to rebut the evidence of the complainant, Counsel for OP-2 and 3 tendered in evidence affidavit of R N Bansal as Ex OP-2,3/1 and documents Ex OP-2,3/2 to OP-2,3/4 and closed the evidence. Dinesh Kumar Assistant Manager appeared on behalf of OP-4 and 5 and tendered in evidence affidavit of Vinay Batra ExOP-4, 5/1 and closed the same on behalf of OP-5

8                                               We have heard the ld counsel for complainant as well as OP-2 to OP-5 and have carefully gone through evidence and documents placed on record by respective parties.

9                                              From the careful perusal of the record and after going through the evidence and documents, it is observed that the case of the complainant is that daughter of complainant was insured under the policy in question. He got conducted her operation for

 

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Recurrent Acute Appendicitis at SPS Hospital, Ludhiana from Doctor Nirmaljeet Singh and complainant spent Rs.1,67,054/-on her treatment. Complainant lodged claim with Ops, but Ops made payment of Rs.54,676/-only and withheld the reimbursement of remaining amount. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of remaining claim amount to complainant which amounts to deficiency in service. He has prayed for accepting the complaint. In reply, OP-2 to 5 have stressed mainly on the point that they have already paid the reasonable amount admissible as per rules and as per terms and conditions of policy and nothing is due towards them. Complainant is not entitled for further relief of claim amount as sought by him. Moreover, they have stressed on the point that they deducted Rs.12,000/- as room charges, Rs.9000/-of doctor fee, Rs.52500/-as Surgeon’s fee; Rs.2720/-for lab charges; Rs.5231/- hospital services; Rs.4397/-from medication charges, Rs.2699/-towards consumable charges, Rs.1446/- for one day medicine payable out of package, Rs.1530/-towards admission fees and Rs.15,625/-have been deducted as OT Charges as being non payable as per hospital Gipsa PPN Package Rates. This amount is rightly deducted as per policy terms and conditions and  Rs.54,676/-have been paid to him after due enquiry and due application of mind on merits and as per terms and conditions of the policy in question and now nothing is due towards them. It is reiterated that there is no deficiency in service on their part and prayed for dismissal of complaint.

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10                                                          From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that he was insured with them as per Family Medicare Policy. OP-2 to 5 argued that as per policy terms and conditions and reasonable rate for the treatment under policy in question, the complainant is entitled only for Rs.54,676/-as reimbursement for treatment at SPS Hospital, Ludhiana and he is not entitled for any other amount than this and this amount has already been paid to complainant and now, complainant is not entitled for anything else. OP-2 to 5 have made payment of Rs.54,676/-to complainant, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement that how they calculated this amount on their own. Admittedly, the complainant spent Rs.1,67,054/- for treatment of his daughter and paid this amount to hospital authorities, the Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the persons.

11                                                            Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them 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

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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 generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The 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 the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

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12                                                    From the above discussion and case law produced by the complainant, we are of considered opinion that OPs have wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy and reasonable rates out of entire amount, spent on treatment by complainant, which was covered under the Mediclaim insurance policy. From the documents produced by the complainant it is proved that he spent Rs.1,67,054/-for treatment of his daughter, which is also admitted by the OPs. The OPs have failed to prove that how they assessed Rs.54,676/-as reasonable rate. Hence, present complaint is hereby accepted and OPs are directed to pay Rs.1,12,378/-to complainant, which was wrongly deducted by them out of amount spent by complainant on treatment of his daughter alongwith interest at the rate of 9% per anum from the date of filing the present complaint till final realization. They are directed to pay Rs.5,000/-to complainant as consolidated compensation for harassment and mental agony suffered by him and as litigation expenses. Compliance of this order be made within prescribed period of 30 days of receipt of the copy of this order, failing which complainant shall be entitled to proceed under section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 4.06.2019

                                                                       

(Param Pal Kaur)              (Ajit Aggarwal)

                                        Member                          President