BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.77 of 2018

Date of Instt. 26.02.2018

Date of Decision:07.07.2022

Mohinder Singh son of Sh. Gurbachan Singh, resident of Village Boparai, Goraya, Tehsil Philluar, District Jalandhar.

..........Complainant

Versus

M/s United India Insurance Company Limited, G. T. Road, Near Bus Stand, Goraya, Jalandhar through its Branch Manager.

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)   

Present:       Sh. D. K. Gupta, Adv. Counsel for the Complainant.

                   Sh. R. S. Arora, Adv. Counsel for OP.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant got health insurance policy from OP company firstly in the year 2002 and he has been paying insurance premium regularly to the OP company since then and he has never made any claim under said insurance policies. The complainant lastly got health insurance policy from OP Company bearing No.2013-042816P116619514 with validity uptill 16.03.2018. At the time of insurance, it was told by representative of the company that all medical expenses for treatment upto Rs.2,00,000/- shall be paid/reimbursed by the company and believing the same, complainant use to renew the insurance policy. In the month of March, complainant suffered eye problem/Cataract in both eyes and he consulted Thind Eye Hospital, Jalandhar and the doctor concerned suggested complainant to undergo eye operation. In the month of March, 2017 the complainant underwent Eye operation at Thind Eye Hospital, Jalandhar for one eye, for which he remained admitted in the hospital and paid sum of Rs.1,15,000/- vide bill No.JAL/16-17/24/9078 dated 17.03.2017 for medical treatment and lens fee. Similarly on 19.04.2017, the complainant underwent Eye operation for the other eye at Thind Eye Hospital, Jalandhar and paid sum of Rs.64,500/- vide bill No.JAL/17-18/92/587 dated 19.04.2017 for medical treatment and lens fee. As such, total amount of Rs.1,79,500/- was spent for medical treatment. The complainant submitted all the bills with the concerned authorities for getting insurance claim as the amount was well within the insured limit of Rs.2,00,000/-. The complainant also served a legal notice dated 28.07.2017, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse or make payment of Rs.1,79,500/- towards medical expenses incurred by the complainant alongwith interest @ 18% per annum from the date of respective payments till the date of realization and further OPs be directed to pay Rs.50,000/- towards legal expenses, mental agony and tension suffered by the complainant for deficient services on the part of the OP.

2.                Notice of the complaint was given to the OP, who filed reply and contested the complaint by taking preliminary objections that the complaint does not lie. The complainant ought to have received the offered amounts from the side of the OP by sending the details of his bank account and for the balance, if any, had claimed the amount, but having not done so, the complaint is liable to be dismissed with heavy costs. There is no deficiency on the part of the OP. The insurance company covers the cost of cataract surgery with lens implant. The additional charges above Rs.22,500/- were liable to be borne by the complainant. There is no stopping by the insurance company of the complainant going in for any amount of additional costs of implantation of soft, faster, better or toric lenses out of his pocket so as to rule out wearing eyeglasses at all times after the surgery. It is further averred that the complainant is barred by his act and conduct to bring the present complaint. The complainant, as insured of the OP, is acting in bad faith in insurance against the OP.  The OP is vexed and harassed and unnecessarily brought into litigation by the complainant. On merits, the factum with regard to taking insurance policy by the complainant is admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA and documents Ex.C-1 to Ex.C-9 and closed the evidence.

4.                In order to rebut the evidence of the complainant, the counsel for the OP tendered into evidence affidavit Ex.OA alongwith some documents Ex.O-1 and Ex.O-2 and closed the evidence.

5.                We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.

6.                The factum of the complainant having got health insurance policy from OP Company bearing No.2013-042816P116619514 with the validity up till 16.03.2018 has been admitted. The complainant has proved on record the details of the bills for eye operation at Thind Eye Hospital allegedly operated on 17.03.2017. The bill has been proved as Ex.C-8. He has also proved on record the bill from the Thind Eye Hospital for operation Ex.C-9.

7.                The contention of the OP is that the complainant has denied the supply of the insurance policy and terms and conditions, but this allegation of the complainant cannot be considered as if he was not supplied with the copy of insurance policy, then from where he got the number of the insurance policy. The counsel for the OP has further submitted that the complainant is the insured with the OP for the last 16 years i.e. from 2002 till since then he has never brought to the notice of the OPs that the terms and conditions have not been supplied to him and he is not aware of the terms and conditions. The complainant has not produced on record the original insurance policy. He has relied upon a judgment titled as “National Insurance Co. Vs. Pati Bell J. V. Company, cited in 2015 (2) CLT 527 (NC), wherein it is held that “On this sole ground of non-production by the complainant the insurance policy, the complaint of the complainant is incompetent and liable to be dismissed”. He has further submitted that against the claim of Rs.1,79,500/- of the complainant, the complainant been offered by the registered communication by post Rs.22,500/- with detailed justification, but the complainant has not agreed with that and after dis-satisfaction, the remedy available with the complainant is to file civil suit only. Thus, the complainant is not entitled to any amount. Request has been made to dismiss the complaint.

8.                Perusal of Ex.C-8 and Ex.C-9 shows that the complainant has proved two bills to show that he was operated upon and spent Rs.1,15,000/- and Rs.64,500/- respectively. The complainant has not proved on record any document to show as to when he was admitted in the hospital and when he was discharged from the hospital. He has also not produced on record any document to show as to when the operation of his eye conducted. Perusal of Ex.C-8 and Ex.C-9 nowhere shows the date of admission, date of operation and date of discharge of the complainant. These are the bills issued on 30.10.2018 i.e. after the 6/7 months of the alleged operation. The complainant has not produced on record even the policy, but in this complaint has alleged that the OP has assured to reimburse all the medical expenses for treatment upto Rs.2,00,000/-, but there is no document on the record to prove this fact. The proposition of law is not disputed that it is the complainant who is to place on record the complete copy of the insurance policy and to prove the same as per law, but as discussed above he has not produced on record any document. The discharge summary and the insurance policy was produced on record by the OPs for admission and denial of the document, but the complainant has simply stated that the discharge summary and copy of the policy were not supplied to the complainant, but this contention cannot be considered and is not tenable as the discharge summary is to be given by the hospital, from where he got himself operated and not by the OPs. It is admitted fact that he has been purchasing the insurance policy since 2002, but till 2018 he has never raised objection that he did not get the insurance policy. The OPs themselves have admitted, vide Ex.C-6 and Ex.C-7 that the patient was admitted in Thind Eye Hospital, Jalandhar as a case of cataract right eye and the claim-54551718005478 has been approved for Rs.23,545/- and the amount approved for surgery is Rs.22,500/-. This fact is corroborated and supported by Ex.O-1, which is the agreement between the insurance company and the Raksha TPA and Thind Eye Hospital, whereby the package of Rs.22,500/- has been mentioned for the cataract eye. Though, the complainant has not produced on record any document to show his admission in the hospital and discharge from the hospital. He has not proved on record the date when the amount as alleged by the complainant vide Ex.C-8 and Ex.C-9 was spent by the complainant, but since this fact has been admitted by the OP that the amount of Rs.22,500/- have been approved against the claim of Rs.1,79,500/- accordingly, the complainant is entitled to this amount.

9.                In the light of above detailed discussion, the complaint of the complainant is partly allowed and OP is directed to pay an amount of Rs.22,500/- as was approved by the OP since he himself has not accepted the amount approved by the OPs and has not proved on record his case, hence not entitled to any compensation. However, he is entitled to Rs.3000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

10.              Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr.Harveen Bhardwaj     

07.07.2022         Member                          Member           President