Chandigarh

DF-II

CC/133/2022

Mrs. Daman Vohra - Complainant(s)

Versus

M/s United India Insurance Co. Ltd. - Opp.Party(s)

Paras Chugh

18 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	133 of 2022
Date  of  Institution	:	10.02.2022
Date   of   Decision	:	18.07.2024

 

 

 

 

Mrs.Daman Vohra, aged 74 years, w/o Late Sh.P.N.Vohra, R/o #114, Sector 45-A, Chandigarh

... Complainant

Versus

1]  M/s United India Insurance Co. Ltd., Office No.21, 2^nd Floor, Commercial Complex, SCO No.106, Sector 16, Faridabad, Haryana 121002

 

2]  Health Insurance TPA of India Ltd., 2^nd Floor, Majestic Omania Building, A-110, Sector 4, Noida, Uttar Pradesh 201301

 

3]  Mr.Chitvan Sethi, Insurance Advisor, United India Insurance Company Limited, H.No.1105, Sector 8, Faridabad 121006

    ….. Opposite Parties

 

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                    MR.B.M.SHARMA,                 MEMBER

                               

Argued by  :    Sh.Paras Chugh, Counsel for the complainant

Sh.Rajesh Gaur, Adv. (Through V.C.) & Sh.Suresh Gaur, Counsel for OP No.1.

 

OP No.2 exparte.

Ms.Manisha Chandla, Adv. proxy for Sh.Neeraj Sansaniwal, Counsel for OP No.3.

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

 

         The complainant has filed the present complaint pleading that she took the Health Insurance Policy Ann.C-1 from the OP No.1 valid from 11.6.2019 to 12.6.2020.  It is stated that during the policy coverage period, the complainant was taken to Kare Partners Heart Centre, Sector 19-D, Chandigarh on 16.9.2019 due to health issue where she had undergone treatment for HTN, RT Lobe as diagnosed by the Hospital and remained hospitalized till 21.9.2019.  However, after admission, the complainant came to know that the said hospital has no tie-up with TPA-OP No.2 for cashless treatment facility.  It is stated that even after discharge, the complainant also visited PGI, Chandigarh as an Outpatient (Ann.C-2 colly.).  After discharge, the complainant lodged claim with OPs No.1 & 2 for reimbursement of medical expenses incurred on her treatment during the policy period.  It is stated that the OPs No.1 & 2 raised certain queries in respect of her claim and she replied all queries as well as supplied all requisite documents to the OP NO.2 in support of her medical claim.  It is submitted that the OP No.1 & 2 kept on raising one after another issues and all were replied by the complainant supported by requisite documents.  However, the OP Insurance Company did not pay the claim and closed it.  The complainant sent legal notice to the OPs but despite of all the OPs did not pay the medical claim of the complainant. Hence, this complaint has been filed alleging the said repudiation of claim as illegal and deficiency in service with a prayer to direct the OPs to reimburse the medical expenses incurred on her treatment along with interest and to pay compensation as well as litigation cost. 

 

2]       After notice of the complaint, the OP No.1 Insurance Company has put in appearance and filed written version.  The OP No.1 while admitting the factual matrix of the case about the insurance policy stated that the hospital where the complainant alleged to have taken treatment during policy period was not the Network Hospital of the Op Insurance company and falls under Non-Network Hospital, so cashless facility was not provided.  It is submitted that the answering OP time & again asked for proper proof and validation of the complainant’s health and her medical expenses at the alleged Hospital but the complainant was unable to provide the same.  It is pleaded that the complainant was given numerous opportunities to provide the original required documents as well as provide proof of payments against the bills of her treatment but she failed to do so and as such the claim was rejected due to act & conduct of the complainant. Lastly denying all other allegations, the OP No.1 has prayed to dismiss the complaint with cost.

 

3]       The OP No.2 did not turn up despite service of notice, hence it was proceeded against exparte vide order dated 07.12.2022.

 

4]       The OP No.3 has filed written version stating that the health insurance policy in question has been sold through answering OP being agent of the insurance company.  It is stated that as an insurance agent, the answering OP is not legally bound to provide services which arise on the event of payment of insurance claim to the insured and it is the duty of the complainant to contact the TPA and provide information & documents in the event of a claim.   It is submitted that the answering OP in order to maintain good professional relationship, went above and beyond his duty, relayed all relevant information and documents to OP No.2 even if he was not bound.  It is also submitted that answering OP never gave any personal assurance to the complainant that he would make sure the claim is settled as the settlement of the claim was not in his power.  It is stated that the claim was again put under review when he delivered the documents to OP No.2 after lockdown. It is pleaded that the answering OP has nothing to do in the decision about allowing or rejecting any claim lodged with the Insurance Company by the insured.  Denying all other allegations, it is prayed that the complaint qua OP No.3 be dismissed with heavy cost.

 

5]       Parties led evidence in support of their contentions.

 

6]       We have heard the ld.Counsel for the contesting parties and perused the entire documents on record including written arguments.

 

7]       From the documents on record as well as the pleadings of the parties, it is revealed that OP Insurance Company has admittedly rejected the medi-claim of the complainant/insured on the ground that she failed to provide the documents required to process the claim, whereas the stand of the complainant is that she had already supplied all requisite documents to the OP Company but still the company failed to reimburse the claim and illegally rejected it.

 

8]       It is observed that the OP Insurance Company has not disputed that the complainant/insured got medical treatment during the policy period.  It is also observed that once the complainant had supplied the documents so received from the Hospital to the OP Company, then the OP Company cannot compel the complainant to provide the documents which are not in her possession.  Moreso, if the OP Insurance Company has any doubt regarding the documents or the claim of the complainant, the same could have been easily verified by it by appointing investigator but the OP Company instead rejected the genuine claim of the complainant, which is unjustified and amounts to deficiency in service.   

9]       In such a situation, the repudiation made by the OPs-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 sorts 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. 

10]      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 seems 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.

11]      Taking into consideration the above discussion & findings, it can be safely concluded that OP Insurance Company has committed deficiency in service by wrongly and illegally rejecting the genuine claim of the complainant. Therefore, the present complaint deserves to be partly allowed and the same is accordingly allowed against OP No.1.  The OP No.1 (Insurance Company) is directed to reimburse an amount of Rs.88,517/- (Ann.C-2 Pg.32 to 44) along with interest @9% per annum from the date of discharged from the hospital i.e. 21.9.2019 till its actual payment to the complainant.

         This order be complied with by the OP No.1 within 60 days from the date of receipt of its certified copy.

12]      The complaint qua OPs No.2 & 3 stands dismissed.

 

13]      Pending application(s) if any, stands disposed of accordingly.

        The Office is directed to send certified copy of this order to the parties, free of cost, as per rules & law under The Consumer Protection Rules & Act accordingly. After compliance file be consigned to record room.

Announced

18.07.2024                                                           Sd/-

                                                           (AMRINDER SINGH SIDHU)

PRESIDENT

 

 

Sd/-

(B.M.SHARMA)

MEMBER