DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

                            Complaint Case No: CC/71/2022

                                                           Date of Institution: 03.03.2022

                            Date of Decision: 28.08.2024

Shimla Devi aged about 71 years widow of Darshan Kumar resident of H.No. B-X-229, Ahata Narain Singh Wala, Gillan Wali Gali, Ward No. 16, Barnala, District Barnala, Punjab.     

        ﾅComplainant

                                                   Versus

1. M/s Oriental Insurance Company Limited, K.C. Road, Near Gali No. 6, Barnala-148101, through its Branch Manager.   

2. M/s Raksha TPA Pvt. Ltd., 15/5, Mathura Road, Faridabad, Haryana, through its Branch Manager.   

                                                                                              ﾅOpposite Parties

Complaint Under Section 35 of the Consumer Protection Act, 2019.

Present: Sh. Jashan Modi Adv counsel for complainant.

              Sh. N.K. Garg Adv counsel for opposite party No. 1.

    Opposite party No. 2 exparte.  

Quorum.-

1. Sh. Ashish Kumar Grover: President

2. Smt. Urmila Kumari: Member 

3. Sh. Navdeep Kumar Garg: Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against M/s Oriental Insurance Company Limited, K.C. Road, Near Gali No. 6, Barnala-148101, through its Branch Manager & others (in short the opposite parties). 

2. The facts leading to the present complaint are that the husband of the complainant purchased one cashless PNB-Oriental Mediclaim Policy for both the complainant and her husband schedule IRDA/NL-HTL/OIC/P-H/V.1/454/13-14 from the opposite parties bearing policy No. 233200/48/2015/2832 for the period from 6.1.2015 to 5.6.2016 and paid premium upto date under policy No. 233500/48/2021/605 regularly. It is further alleged that at the time of issuance of the policy the doctors of the opposite parties checked both of the complainant and her husband. The complainant is legal heir as well as nominee in the said medical policy. It is alleged that the husband of the complainant was having bank account with the PNB-Barnala bearing account No. 0044000104189964 and the premium of the said policy was paid from this account. It is further alleged that on 2.1.2021 the last installment amounting to Rs. 14,820/- of the policy was paid. It is alleged that the terms and conditions did not supply by the opposite parties for the said policy. It is further alleged that on 19.01.2021 the husband of the complainant was admitted in Amar Hospital, Patiala and the doctors at the Hospital told that the patient has developed gangrene in the 3rd, 4th and 5th toes of left foot due to diabetic and suggested amputation and the doctors of the hospital amputated the said toes and again on 25.01.2001 the said patient was admitted in the said hospital and after treatment the doctors discharged the patient on the same day. It is further alleged that again on 28.1.2021 the husband of the complainant went to Chandigarh Heart Centre, Sangrur for treatment and the doctors at the said hospital gave treatment and medicine to the patient. It is further alleged that after the treatment the husband of the complainant was recovering slowly but suddenly died on 2.2.2021. Thereafter, the complainant filed claim form with the opposite parties for claiming of Rs. 35,780/- and submitted the original death certificate, admission and discharge card, receipts of medicines but the opposite parties repudiated the claim of the complainant under policy condition 5.2(V) of terms and conditions of the policy. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-

i. The opposite parties may be directed to a sum of Rs. 25,780/- alongwith interest @ 18% per annum from the date of death till realization.  

ii. To pay an amount of Rs. 3,00,000/- as compensation for causing mental agony and harassment to the complainant and Rs. 11,000/- as litigation expenses.

3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version by taking preliminary legal objections on the grounds that the complainant has no locus- standi or cause of action to file the present complaint at this stage and is pre mature one so the complaint is liable to be dismissed. This Commission has no jurisdiction to try, entertain and decide the present complaint. The complainant has dragged the opposite parties into unwanted litigation by filing a false and frivolous complaint. The complainant has concealed true facts from this Commission. It is further alleged that the professional medical experts of opposite party No. 2 (TPA) observed that there were insufficient documents for processing of the claim. The documents which were required for further processing of claim were informed by opposite party No. 2 to the Principal Insured vide letters dated 31.03.2021, 08.04.2021 & 15.04.2021, as the complainant did not provide the required documents, hence the claim was closed as per policy condition 5.2.(v).

4. On merits, it is admitted to the extent that the policy was purchased by the husband of the complainant with Policy No. 233200/48/2015/2832 for the period w.e.f. 06.01.2015 to 05.06.2016 as mentioned in the complaint which was got renewed till 05.01.2022 vide Policy No. 233599/48/2021/605. It is further submitted that the claim papers were duly scrutinized by the professional medical experts of Raksha Health Insurance TPA Pvt. Ltd. and vide their letters dated 31.03.2021, 08.04.2021 and 15.04.2021, it was advised to provide following documents for the processing and settlement of the claim:

1. Kindly provide the Hospital registration certificate/inpatient facility certificate.

2. Original Prescriptions Dated 13/01/2021, 18/01/2021, 19/01/2021, 28/01/2021, 31/01/2021 supporting investigation expenses.

3. Kindly Provide letter from treating doctor with Specific reason for prolonged stay in the hospital.

4. Kindly provide duly filled and signed Claim form Part B (To be filled by the Hospital) as per IRDA guidelines with Claimed amount. Form available on our website www.rakshatpa.com.

5. Kindly provide all original documents instead of photocopies which you have provided earlier.

6. Kindly provide clarification letter from Treating Doctor regarding the need for Two separate admissions from dated 19/01/2021 to 19/01/2021 and from 20/01/2021 to 28/01/2021 for the same ailment. As none of the documents have been provided by the complainant till date. Therefore, the claim has been closed as No Claim. All other allegations of the complaint are denied and prayed for the dismissal of complaint. 

5. The opposite party No. 2 was proceeded against exparte vide order dated 5.5.2022 due to non appearance. 

6. Ld. Counsel for complainant has suffered the statement that I do not want to file any rejoinder in the present case. 

7. The complainant tendered into evidence affidavit of Shimla Rani as Ex.C-1, copy of insurance policy as Ex.C-2 (containing 3 pages), copy of treatment plan as Ex.C-3 (containing 4 pages), copy of discharge summary as Ex.C-4 (containing 2 pages), copy of discharge summary as Ex.C-5, copy of death certificate as Ex.C-6, copy of claim form as Ex.C-7 (containing 14 pages), letter dated 04.08.2021 as Ex.C-8, copy of statement of account as Ex.C-9 (containing 2 pages) and closed the evidence. 

8. The opposite party No. 1 tendered into evidence copies of letters dated 31.03.21, 8.4.2021, 15,4,2021 regarding demanding of documents are Ex.OP1/1 to OP1/3 respectively, copy of recommendation for repudiation dated 10.05.2021 as Ex.OP1/4 (containing 2 pages), copies of prescription slips dated 19.01.2021 & 23.01.2021 are Ex.OP1/5 & OP1/6, copy of pre repudiation letter dated 04.08.2021 as Ex.OP1/7 and closed the evidence. 

9. We have heard the learned counsel for the parties and have gone through the record on the file. 

10. It is admitted case of the opposite party No. 1 that the policy was purchased by the husband of the complainant with Policy No. 233200/48/2015/2832 for the period w.e.f. 06.01.2015 to 05.06.2016 as mentioned in the complaint which was got renewed till 05.01.2022 vide Policy No. 233599/48/2021/605 (as per Ex.C-2).  

11. Ld. Counsel for the complainant argued that on 19.01.2021 the husband of the complainant was admitted in Amar Hospital, Patiala and the doctors at the Hospital told that the patient has developed gangrene in the 3rd, 4th and 5th toes of left foot due to diabetic and suggested amputation and the doctors of the hospital amputated the said toes and again on 25.01.2021 the said patient was admitted in the said hospital and after treatment the doctors discharged the patient on the same day (as per Ex.C-4). It is further argued that again on 28.1.2021 (as per Ex.C-5) the husband of the complainant went to Chandigarh Heart Centre, Sangrur for treatment and the doctors at the said hospital gave treatment and medicine to the patient. It is further argued that after the treatment the husband of the complainant was recovering slowly but suddenly died on 2.2.2021 (as per Ex.C-6). It is further argued that the complainant filed claim form (as per Ex.C-7 containing 14 pages) with the opposite parties for claiming of Rs. 35,780/- and submitted the original death certificate, admission and discharge card, receipts of medicines but the opposite parties repudiated the claim of the complainant under policy condition 5.2(V) of terms and conditions of the policy (as per Ex.C-8).

12. Ld. Counsel for the opposite party No. 1 argued that the complainant has no locus- standi or cause of action to file the present complaint at this stage and is pre mature one. It is further argued that the professional medical experts of opposite party No. 2 (TPA) observed that there were insufficient documents for processing of the claim and the documents which were required for further processing of claim were informed by opposite party No. 2 to the Principal Insured vide letters dated 31.03.2021, 08.04.2021 & 15.04.2021 (Ex.O.P1/1 to Ex.O.P1/3) but the complainant did not provide the required documents as mentioned in the above said letters, hence the claim was closed as No Claim as per policy condition 5.2.(v). On the other hand, Ld. Counsel for the complainant further argued that the opposite parties can easily take the entire documents (alongwith medical record) from the Court file as the complainant has tendered all the documents in her evidence. 

13. We have gone through copy of repudiation letter dated 4.8.2021 Ex.C-8 placed on record by the complainant vide which it is mentioned that "Having examined the case it was found by the medical professional of TPA that the patient is a case of A K/C/O OF DM, HTN,CVA PRESENTED WITH LEFT DIABETIC FOOT WITH GANGRENE, 3,4,5, TOES, PAIN SWELLING IN LEFT FOOT TOES, managed by amputation of left 3,4,5, toes amputation and debriment was done. Hence, claim is hereby recommended for repudiated under policy condition 5.2(v) of terms and conditions of Policy". Moreover, from the perusal of the file it shows that all the documents (alongwith medical record) are already on the Court file and we are of the view that if the opposite parties required the same to settle the claim of the complainant, then they could have procure the same from the Court file. Ld. Counsel for the complainant further argued that the terms and conditions of the policy were not supplied to the complainant alongwith policy. On the other hand, the opposite party No. 1 (insurance company) has failed to place on record even the copy of insurance policy and also failed to prove the fact that they have supplied the terms and conditions to the complainant alongwith policy. The opposite parties relied upon the policy condition No. 5.2(v), but despite ample opportunities opposite parties failed to produce the said terms and conditions in evidence. We have carefully gone through the insurance policy Ex.C-2 from which it established that the policy sent by the opposite party No. 1 (insurance company) is containing 3 pages and the terms and conditions of the policy are not the part of the said insurance policy. Therefore, the terms and conditions on which the opposite parties relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that "As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause." The Hon'ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that "Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses". Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims. 

14. Therefore, we are of the view that at this stage the insurance company cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties. 

15. However, the perusal of the copies of medical bills and pharmacy receipts i.e. Ex.C-7 (containing 14 pages) it is proved that an amount of Rs. 33,850/- has been spent on the treatment of husband of the complainant. But the complainant in the present complaint has claimed an amount of Rs. 35,780/-. So, we are of the view that the complainant being the legal heir and nominee of the deceased Darshan Kumar is entitled to Rs. 33,850/-.  

16. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 33,850/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

28th Day of August, 2024

 

       (Ashish Kumar Grover)

                                                     President

         

                      (Urmila Kumari)

                                                      Member

 

       (Navdeep Kumar Garg)

                                                       Member