Punjab

Faridkot

CC/19/248

Amardeep Singh Sandhu - Complainant(s)

Versus

M/s Religare Health Insurance co. another - Opp.Party(s)

Atul Gupta

26 Feb 2020

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      248 of 2019

Date of Institution:   07.10.2019

Date of Decision :    26.02.2020

 

Amardeep Singh Sandhu aged about 52 years, son of Jaswant Singh son of Dhian Singh r/o Street No. 44, Adarsh Nagar, Faridkot Tehsil and District Faridkot.

...Complainant

Versus

1. M/s Religare Health Insurance Company Limited, through its Managing Director having registered office at D-3, P3B, District Centre, Nehru Place, New Delhi-110017.
2. Hardev Singh son of Arjun Singh resident of Near Saint Marry School, Faridkot, Tehsil and District Faridkot.

.....OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President.

               Smt. Param Pal Kaur, Member.

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Present: Sh  Atul Gupta, Ld Counsel for complainant,

             Sh Varun Gupta, Ld Counsel for OP-1,

               OP-2 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 them to make payment of insurance claim of 6,537.60 Canadian Dollars on account of funeral and cremation of expenses of  Amarjit Kaur insured and for further directing OPs to pay Rs.1,00,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.25,000.

2                               Briefly stated, the case of the complainant is that at the instance of OP-2, mother of complainant purchased Health Insurance Policy of OP-1 and paid amount through bank. Policy bearing No.11368148 was issued to her, but Ops never supplied any policy related documents to her. It is submitted that mother of complainant went to Canada and she died there after hospitalization

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and after her death, complainant being entitled to her entire estate applied for all monitory benefits to OPs, which were paid by them. it is further submitted that complainant spent 6573.60 Canadian Dollars on cremation of her mother and Cremanitorian duly supplied the bill for  cremation or funeral charges. Complainant requested OPs to make payment of funeral charges also, but OPs did not clear his bill. Even legal notice got served to OPs through e-mail by counsel for complainant also bore no fruit, rather Ops gave false reply to said notice. It is submitted that funeral expenses are part of health product and personal accident is an important segment of the policy and it comes as an additional benefit. Complainant visited the OPs and made several requests to clear his over due insurance claim on account of funeral expenses incurred by him but OPs paid no heed to clear his genuine insurance claim. All this amounts to deficiency in service and caused harassment and mental agony to complainant. He has prayed for accepting the present complaint alongwith compensation and litigation expenses besides main relief. Hence, the present complaint.

 

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3                                 Ld counsel for complainant was heard with regard to admission of the complaint and vide order dated 14.10.2019, complaint was admitted and notice was ordered to be issued to the opposite party.

4                            On receipt of the notice, OP-1 filed written statement taking preliminary objections that complaint is not maintainable as complainant has attempted to mislead the Forum. It is averred that complaint involves complicated questions of law and facts requiring lengthy evidence, which is not permissible in the summary proceedings of Consumer Act. He has not come to the Forum with clean hands and no cause of action arises in favour of answering OP. He has filed false and frivolous complaint on wrong facts and he is stopped by his own act and conduct to file the present complaint. On merits, it is admitted that Amarjit Kaur/mother of complainant was insured under Travel Insurance Policy for sum insured of USD 50000 subject to terms and conditions of the Policy. It is also admitted that death of Amarjit Kaur occurred during the subsistence of said policy.  It is averred that complainant approached answering OP on 20.06.2018

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for seeking claim for Repatriation of Mortal Remains of the insured, who died on 21.06.2017 and on perusal of same, it came to light that insured died due to Hypertensive Cardiovascular Disease and not due to any accident and as per terms and conditions of the policy in question benefit of repatriation of mortal remains is covered only when insured person died solely and directly due to accident, but in present case, insured Amarjit Kaur mother of complainant died a natural death. It is asserted that as per policy in question Company would indemnify repatriation of mortal remains up to the amount specified against this benefit in Policy Certificate and costs of repatriation of mortal remains of the insured person back to the place of residence or up to an equivalent amount for a local burial or cremation at the place where death has occurred, only if the insured person died solely and directly due to an accident during the period of insurance. It is further averred that as per terms and conditions of present policy, claim of complainant does not fall within criteria as granted by answering OP and he is not entitled for relief sought by him as death of insured did

 

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not occur in any accident. All the other allegations are denied being wrong and incorrect and prayed for dismissal of complaint with costs.

5                                  Notice issued to OP-2 received back with report ‘Refusal’ that shows that OP-2 was not interested in contesting the claim of complainant and therefore, vide order dated 27.11.2019, OP-2 was proceeded against exparte.

6                                Parties were given proper opportunities to prove their respective case. Complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-12 and then, closed the evidence.

7                               In order to rebut the evidence of the complainant, ld Counsel for OP-1 tendered in evidence affidavit of Kashif Nazki Ex OP-1/1, document Ex OP-1/2, and then, closed the same on behalf of OP-1.

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

 

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9                            From the careful perusal of record and in the light of evidence and documents placed on record, it is observed that case of the complainant is that his deceased mother purchased insurance policy from OPs and during the subsistence of said policy, his mother died in Canada and all her last rites were performed by complainant in Canada. Grievance of the complainant is that OPs paid all the monitory benefits to complainant but did not clear the bill worth 6573.60 Canadian Dollars that he spent on cremation of her mother and even despite several requests and issuance of legal notice, OPs paid no heed to clear his claim for 6573.60 dollars, which amounts to deficiency in service. On the contrary, plea taken by OPs in  not making payment of funeral charges is that as per terms and conditions of the policy in question benefit of repatriation of mortal remains is covered only when insured person dies solely and directly due to accident, but in present case, insured Amarjit Kaur mother of complainant died due to disease of hypertensive cardiovascular and did not die in any accident and thus,  claim of complainant does not fall within criteria as granted by 

 

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OP and he is not entitled for any relief as death of insured did not occur in any accident. There is no deficiency in service on the part of OP.

10                          Ld Counsel for complainant submitted before the Forum that at the time of purchase of said policy, no terms and conditions were ever supplied by Ops and it at that time it was not specified by them that funeral charges are payable only in case of death occurring in accident and are not permissible in case of natural death. 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 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

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(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

 

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unreasonable clause in a contract where parties are not equal in bargaining power.

11                         From the above discussion and case law produced by the complainant, we are of considered opinion that on the basis of false terms and conditions of the policy, which were never supplied or explained, OP-1 has wrongly and illegally not paid the amount of 6573.60 Canadian Dollars spent by complainant on funeral of her mother Amarjit Kaur who was insured with them and was covered under the Insurance Policy in question and this act of OP-1 in not reimbursing the funeral charges to complainant amounts to deficiency in service. Therefore, complaint in hand is hereby allowed against OP-1 with directions to OP-1 to pay amount of funeral charges in Indian Currency in rupees equal to 6573.60 Canadian Dollars to complainant alongwith interest at the rate of 9 % per anum from 7.10.2019 i.e the date of filing the present complaint till final realization. OP-1 is further directed to pay Rs.5,000/- to complainant as consolidated compensation for harassment and mental agony suffered by him as

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well as for litigation expenses incurred by him on present complaint. Compliance of this order be made within one month of receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Complaint against OP-2 stands hereby dismissed. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 26.02.2020

                                       (Param Pal Kaur)              (Ajit Aggarwal)

                                         Member                        President