Punjab

StateCommission

FA/12/1565

Satinder Singh - Complainant(s)

Versus

M/s NIC Ltd. - Opp.Party(s)

Suvir Sehgal

26 Feb 2015

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER  DISPUTES  REDRESSAL  COMMISSION,  PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.

                                     

                             First Appeal No.1565 of 2012

 

                                                          Date of Institution: 22.11.2012  

                                                          Date of Decision : 26.02.2015

 

Satinder Singh, son of Sh.Narinder Singh, resident of 11, S.F.A-Block, Ranjit Avenue, Amritsar.

 

                                                                                                                                …..Appellant/complainant

         

                                      Versus

 

M/s National Insurance Company Limited, having its branch office at Court Road, Amritsar , through its Branch Manager/Principal Office.

 

 

                                                                                                                                               ….Respondent/Opposite party

         

First Appeal against order dated 11.09.2012 passed by the District Consumer Disputes Redressal Forum, Amritsar.

Quorum:-

 

          Shri J. S. Klar, Presiding Judicial Member.

          Shri Vinod Kumar Gupta, Member.  

Present:-

 

          For the appellant              :         Sh.Suvir Sehgal, Advocate

          For the respondent :         Sh.B.S Tanque, Advocate

 

          . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

                            

J. S. KLAR, PRESIDING JUDICIAL MEMBER:-

                                     

           The appellant (the complainant in the complaint) has directed this appeal against the respondent of this appeal (the opposite party in the complaint), dismissing the complaint of the complainant by virtue of the order dated 11.09.2012 of District Forum Amritsar, which  has been challenged in this appeal by the complainant now appellant.

2.      The complainant Satinder Singh  has filed this complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OP on the allegation that he obtained medi-claim policy,  vide cove note no.G40 400910734433, bearing policy                                       no. 401900/48/10/8500000592 for a period of one year from 24.08.2010 to 23.08.2011, covering his own risk as well as of his wife  namely Surinder Kaur and his daughter Jasmeet Kaur against insured amount of Rs. 4 lacs plus Rs.11 lacs in respect of the complainant, Rs.3 lac plus Rs.85,000/- in respect of his wife and Rs.1 lac plus Rs.20,000/- in respect of his daughter against the requisite premium of Rs.20464/-. The complainant hired the services of the OP for the consideration and thus, became its consumer.  That complainant developed hypertension and was got  admitted in Vidya Sagar Institute for Mental Health, Neuro and Allied sciences, Institutional Area Nehru Nagar New Delhi and the  complainant was treated there and was discharged on 18.04.2011. The complainant incurred the expenses of Rs.514316/- on his treatment in the above hospital for the above ailment. The complainant  lodged insurance claim with the OP in this regard. The complainant received a cheque of Rs.3,30,600/- bearing no.880245 dated 7.05.2011, drawn on HDFC Bank Delhi from the OP but the OP failed to assign any reason for withholding the remaining claim amount. The complainant has incurred total amount of Rs. 5,14,316/- on his above treatment and prayed that the OP be directed to pay the amount of Rs.1,79400/-, wrongly withheld by the OP, along with interest @18% from the date of lodging the insurance claim till payment, besides Rs.50,000/- as compensation to the complainant along with cost of litigation, besides and further cost of litigation as well.

3.      Upon notice, OP filed written reply and admitted the fact that complainant was insured with the OP. That complainant never entered into any correspondence with the OP and TPA. That amount paid by the TPA is not acceptable to him. That the cheque of Rs.330600/- has already been sent to complainant regarding his insurance claim, which has been received by the complainant, vide covering letter dated 07.05.2011. That complainant has not given reference of the said letter deliberately, which is in the possession of the complainant. That in case of any medi-claim policy obtained by any person from the insurance company, he is issued a mediclaim card by the third party administrator, who is duly appointed under the Insurance Regulatory & Development Authority. That Park Mediclaim TPA Pvt.Ltd is working as TPA in this case and complainant made correspondence with the TPA and the above cheque was issued to him accordingly. That remaining amount of Rs.177796/- is not payable to complainant as per terms and conditions of the policy and hence OP prayed for dismissal of the complaint.

4.      The complainant tendered in evidence affidavit of the complainant Ex.C-1, copy of insurance cover notes Ex.C-2 to Ex.C-12, copy of cheque dated 7.5.2011 Ex.C-13, copy of repudiation letter Ex.C-14. As against it, OP tendered affidavit of Mr.R.L Mehta, Divisional Manager Ex.R-1, affidavit of Dr.A.K.Batra, Medical Director of Park Mediclaim TPA Ex.R-2, detailed note issued by Park Mediclaim TPA to OP confirming the payment payable by the company as well as the deduction made as per policy Ex.R-3, copy of letter dated 7.5.11 written by TPA to the complainant informing the deductions made under the policy as well amount payable by the Company Ex.R-4, certified copy of the insurance policy along with terms and conditions as well as concerned clause with respect to the deductions made under different heads Ex.R-5. On conclusion of the evidence and arguments, District Forum, Amritsar dismissed the complaint of the complainant by virtue of impugned order dated 11.09.2012. Dissatisfied with the order of the District Forum Amritsar, the complainant now appellant has preferred this appeal against the same. 

5.      We have heard learned counsel for the parties and also examined the record of the case.  

6.      The facts involved in this case are in dispute. It is an undisputed fact that complainant was insured with the OP against premium. Dispute centres around on this point as to whether the OP has deducted the amount of Rs.1,79,400/- out of the total expenses of Rs.5,14,316/-, as per terms and conditions of the policy or not. The insurance policy is  a contract of insurance between the parties and they are strictly bound by this contract of insurance and they cannot back out of the same. Now, we have to read the contract of the insurance between the parties in this case. The terms and conditions of insurance policy is Ex.C-14 on the record. Affidavit of complainant Ex.C-1 has been examined by us. We have also examined other policy documents Ex.C-2 to Ex.C-13 on the record. On the other hand, OP stoutly pleaded it in the written version that only amount of Rs. 3,30,600/- was payable to complainant as per policy terms and conditions, whereas the amount of Rs1,79,400/- was not admissible to complainant under the exclusion clause thereof. Affidavit of A.K.Batra, Medical Director, Park Mediclaim TPA Pvt. Ltd is Ex.R-2 on the record. The insurance policies Ex.R-3 to Ex.R-5 are on the record. Ex.R-3 is contract of insurance between the parties, it is laid down in this contract of insurance that Rs.3000/- amount in excess of Available Room Rent Limit 1% of total S.I per day + Rs.1000/- Admission charge +Rs.605/- Misc charge + Rs.50/- Registration charge + Rs.1000/- Expenses incurred before 30 days date of admission + Rs.200/- Goun charge + Rs.25/- Pillow cover + Rs.40/- Drawn sheet + Rs.177796/- OT, Investigation, Medicine & Consumable ETC Limit 50% of SI Limit Exhausted.  It has recorded no claim is admissible as per terms and conditions of the policy. We, thus, find that the amount of Rs.1,77,796/- was not admissible to the complainant as per the contract of insurance, entered into between the parties. We cannot travel beyond the terms and conditions of the contract of insurance between the parties. Even as per the terms and conditions of the policy document, it is also so recorded in Condition No.1 of the mediclaim insurance policy. We, thus, find that as per condition no.1.0 of the contract of insurance, this amount which has been withheld by the OP is not admissible to the complainant under the Contract of Insurance.

7.      The second submission of the counsel for the appellant is that insurance policy was not conveyed to the complainant and it is not binding upon him.  The appellant referred to law laid down in United India Insurance Company  Vs.   Subhash Chandra reported in III(2010) CPJ 5 (NC) and case titled as Subhash Malhotra  Vs. United India Insurance Company Ltd reported in III(2014) CPJ 123 (NC),wherein it was held that,  that principle of insurance is fundamental and  utmost good faith is required from the parties, forbiding the contracting parties from non-disclosure of material facts. Now on the point as to whether contract of insurance was conveyed to complainant by sending the policy documents to him or not. We find that as per case of the complainant alone, he has been taking mediclaim insurance policies even prior to contract of insurance of this case. The complainant has pleaded that he has been obtaining  mediclaim policy from the Ops since 2003-2004. It is not believable that complainant was not conveyed the terms and conditions of the policy by the OP, when he is the old purchaser of the policy. The complainant is old purchaser of the mediclaim policy from the OP and we are unable to agree with the above submission of the counsel for the complainant now appellant that the policy documents were not conveyed to him. The counsel for the appellant referred to law laid down in Modern Insulators Ltd.. Vs…. Oriental Insurance Company reported in (2000)2 Supreme Court Cases 734 to the effect that if the terms and conditions of the policy containing exclusion clause were not disclosed to insured, then insurer could not claim benefit of the exclusion clause therein. The above cited authority is distinguishable from the factual situation of the case herein. The complainant has been purchasing mediclaim policies already from OP since 2003-2004. There is categorical stand of the OP, as pleaded in the written version, that the complainant has been fully aware about the terms and conditions of the policy. Had the complainant purchased mediclaim policy for the first time, then somehow, we have been impressed with the same. The contention of the complainant now appellant is not acceptable to us on this point that he was not conveyed the terms and conditions of the policy, hence they are not binding upon him. The District Forum has elaborately dealt with this matter and reached the conclusion that complaint of the complainant is without any substance. We affirm the order of the District Forum under appeal in this case.

8.      In the light of our above discussion, we hereby dismiss the appeal of the appellant by upholding the order of the District Forum Amritsar dated 11.09.2012, resulting into the dismissal of the complaint of the complainant.

9.       Arguments in this appeal were heard on 20.02.2015 and the order was reserved. Now the order be communicated to the parties.

10.    The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                          (J. S. KLAR)

                                                             PRESIDING JUDICIAL MEMBER

                       

                                                                   (VINOD KUMAR GUPTA)

                                                                          MEMBER

 

February, 26  2015.                                                                 

(ravi)