BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 602 of 2015

Date of Institution: 29.09.2015

Date of Decision: 06.06.2016

Mr.Harpreet Singh son of Mr.Bhola Singh, resident of 27-27A, Classic Plaza, Majitha Road, Amritsar, age 68 years.

Complainant

Versus

National Insurance Company Limited, through its Chairman/ Managing Director/ Principle Officer, service through its Branch Office at D.O III, Queens Road, Amritsar, through its Branch Manager.

Opposite Party

Complaint under section 12 & 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh.Deepinder Singh, Advocate

              For the Opposite Party: Sh.Sandeep Khanna, Advocate

Coram

Sh.S.S.Panesar, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member     

Order dictated by:

Sh.S.S. Panesar, President.

1.       Sh.Harpreet Singh has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that  the complainant has obtained health insurance from the Opposite Party for himself and his wife, vide cover note No.401404768764 covering risk period from 16.2.2015 to 15.2.2016, copy of cover note is annexed. The complainant is ‘consumer’ as provided under the Act and is competent to invoke the jurisdiction of this Forum. The wife of the complainant unfortunately fell ill and was to be hospitalized at Abrol Medical Centre, Gurdaspur  for the treatment of both knees and she had to undergo total knee replacement procedure, from 11.6.2015 till 6.7.2015. The hospitalization and treatment cost came to Rs.4,27,388/- and the claim bills were filed with Opposite Party. The Opposite Party had insured the complainant and his wife on cashless basis, for the medical treatment upto Rs.3.50 lacs, but the complainant had to pay the hospitalization & treatment charges out of his pocket.  The Opposite Party verbally informed the complainant that his claim was only passed  for Rs.62,000/- out of his entitlement of Rs.3.50 lacs. The complainant made strong protest to the Opposite Party and informed them not to deposit the said amount in his account and pay him the complete claim of Rs.3.50 lacs as per the entitlement. The Opposite Party vide their letter dated 7.9.2015 reiterated that the complainant is entitled for Rs.62,000/- as per his policy entitlement of year 2009-2010, whereas the claim arose when the complainant has entitlement of Rs.3.50 lacs in the year 2015-2016 and the premium has been paid on such amount to the Opposite Party. Said non settlement of genuine claim of the complainant without ascertaining the correct facts by the Opposite Party is the arbitrary act  of the Opposite Party. It is pertinent to mention over here that no policy terms and conditions were ever conveyed to the complainant by the Opposite Party. The aforesaid acts of the Opposite Party in not settling the genuine claim of the complainant is an act of deficiency in service, unfair trade practice, mal practice and is not sustainable in the eyes of law and has caused lot of mental tension, agony and harassment to the complainant besides financial loss to the complainant and for which the Opposite Party is liable to pay compensation of Rs.50,000/- to the complainant. The complainant has sought following reliefs vide instant complaint.

a)       Opposite Party be directed to pay the claim of Rs.3.50 lacs less Rs.62,500/- already paid alongwith interest @ 12% per annum thereon from the date of payment till realization.

b)      Opposite Party be directed to pay compensation of Rs.50,000/- to the complainant.

c)       Opposite Party be directed to pay the adequate cost of the present litigation.                   

Hence, this complaint.

2.       Upon notice, Opposite Party appeared and contested the complaint by filing  written reply taking preliminary objections therein inter alia that  in the present case, the sum assured of the wife of the complainant was Rs.50,000/- for the policy period 2010-2011, Rs.50,000/- for policy period 2011-2012, Rs.1,00,000/- for the policy period 2012-13 and Rs.3,00,000/- for the policy period 2013-2014.  It is worthwhile to mention here that as per the basic conditions of the policy- for increasing SI (Sum assured) more  than 2/3 slab the waiting periods as in exclusions 4.1/ 4.2/ 4.3 of the policy shall apply on the enhanced Sum Assured as if it is a new policy. The benefit shall accrue for PED or waiting period diseases once the policy with enhanced Sum Assured completes the waiting period noted in the policy for these diseases. Therefore, in the light of the aforesaid provision of the policy in question, the policy of the year 2013-2014 has to be considered as a new policy pertaining the sum assured of Rs.3 lacs and accordingly, the waiting period of 4 years qua the new policy with enhanced sum assured of Rs.3 lacs ends in the year 2016-2017 and the benefit on the said policy, pertaining to the disease in question, shall accrue to the wife of the complainant in the year 2017-2018.  However, the treatment in question was taken by the wife of the complainant in policy period 2015-2016. Accordingly, the present claim was settled by M/s.Dedicated Health Service –TPA at a genuine amount of Rs.62,000/- (i.e. Rs.50,000/- as sum assured and Rs.12,000/- as cumulative bonus) after considering the status of the insurance policy of the complainant for the last four years since the complainant was having a sum assured of Rs.50,000/- at that time. Therefore, the Opposite Party intimated the same vide letter dated 7.9.2015 which was addressed to the complainant clearly stating that the claim of Rs.62,000/- only was payable. The Opposite Party had settled the present claim at Rs.62,000/-  and were ready to pay the same to the complainant. But however, the complainant himself refused to receive the settled claim amount and hence, the complainant is not entitled to the relief claimed for. As per the terms and conditions  of the policy in question, the claim documents have to be submitted with the insurance company within 7 days of discharge from the hospital, but the complainant has failed to submit the said requisite documents with the Opposite Party within the stipulated period. As such, the complainant has violated the basic terms and conditions of the policy and is not entitled to the relief claimed for. As per the terms and conditions of the policy in question, the claim has to be reported within 48 years of admission in the hospital but before discharge from the hospital. It is worthwhile to mention here that the alleged hospitalisation of the complainant was neither in a situation of emergency nor in connection to any serious ailment, as such the complainant should have intimated the Opposite Party within the stipulated period as mentioned above, about the alleged hospitalization; that the complainant has not approached this Forum with clean hands and has concealed the material facts; that the parties to the complaint are strictly governed by the terms and conditions of the policy in question as it has been held by Hon’ble Supreme Court in various judgements, that the present complaint is not legally maintainable as the complainant is not authorised to file the present complaint as the present claim pertains to Upinder Kaur. On merits, facts narrated in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.

3.       In his bid  to prove the case, complainant made in the witness box as his own witness and filed duly sworn affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copy of insurance cover note Ex.C2, repudiation letter Ex.C3, letter dated 10.7.2015 Ex.C4, hospital bills Ex.C5 to Ex.C8, discharge card Ex.C9 and closed his evidence.

4.       To rebut the evidence of the complainant, the  Opposite Party tendered into evidence the affidavit of Sh.Suresh Sharma, Divisional Manager Ex.OP1, copies of previous insurance cover notes Ex.OP2 to Ex.OP6,  copy of cover note dated 13.2.2015 Ex.OP7, copy of intimation letter Ex.OP8, copy of list of clauses Ex.OP9, copy of opinion of TPA Ex.OP10, copy of deduction detail Ex.OP11, copy of terms and conditions Ex.OP12 and closed the evidence.

5.       We have heard ld.counsel for both the parties and have carefully gone through the evidence on record.

6.       From the appreciation of the facts and circumstances of the case it becomes evident that the complainant and his wife were insured with the Opposite Party  vide cover note No.401404768764 covering risk period from 16.2.2015 to 15.2.2016. Copy of insurance cover accounts for Ex.OP7. It is further case of the complainant that the complainant and his wife were getting insurance cover from the Opposite Party  from the period w.e.f. 2010 till date regularly. It is further case of the complainant that wife of the complainant suffered knee problem and she got herself admitted in Abrol Medical Centre, Gurdaspur for the treatment of her knees and she underwent the total knee replacement procedure w.e.f. 11.6.2015  to 6.7.2015. The total expenditure for hospitalization  and treatment cost came to be Rs.4,27,388/-. However, the Opposite Party, when applied for claim, only passed claim for Rs.62,000/- on the plea that waiting period of 4 years was required from the inception of the insurance cover for getting total benefits under the insurance cover. Since the present policy covers risk period from 16.2.2015 to 15.2.2016, the entitlement of the wife of the complainant for reimbursement of assured amount shall accrue to her in the year 2017-2018 only, as per clauses 4.1/ 4.2/ 4.3 of the policy. But however, it is the case of the complainant that since the complainant and his wife have been getting insurance covers from the Opposite Party  from the year 2010 regularly and the knee replacement treatment of the wife of the complainant was undergone w.e.f. 11.6.2015 to 6.7.2015 at Abrol Medical Centre, Gurdaspur, she is entitled to the total assured amount of Rs.3 lacs + cumulative bonus.

7.       From the appreciation of the facts as well as  documentary evidence produced by both the parties in support of their case, an ambiguity arises as to whether the wife of the complainant namely Upinder Kaur is entitled to sum assured vide current insurance policy, copy whereof is Ex.OP7 or she is entitled to Rs.62,000/- as is the case of the Opposite Party. It is settled principle of law that when there is ambiguity in the terms of the policy, the interpretation has to be made in favour of the insured. Reliance in this connection can be had on LIC of India Petitioner  Vs. Ram Singh Tanwar Respondent, 1(2007) CPJ 48 (NC) wherein it has been laid down that “In our view, this would be the reasonable interpretation and in conformity with the principle that if the terms of the policy are vague it should be interpreted for the benefit of the assured as it would serve the purpose and object of getting insurance coverage.” It has been further laid down that in any case where there is any ambiguity or term is capable of two interpretations, interest of justice would be served if interpretation one beneficial to the policy holder is accepted.   Since the complainant and his wife have been regularly obtaining the health insurance cover w.e.f. 2010 till date, which is obvious for the complainant and his wife to claim for sum assured in case of reimbursement of medical expenses incurred by the wife of the complainant because since 2010, a period  of 4 years  has already elapsed and wife of the complainant was competent to claim the sum assured vide latest insurance policy for the year 2015-2016, wherein the insured sum was to the tune of Rs.3 lacs + cumulative bonus. There is no dispute inter se parties regarding the expenses incurred by the wife of the complainant on the treatment. They have also produced on record the requisite bills issued by Abrol Medical Centre, Gurdaspur which accounts for Ex.C5 to Ex.C8. In our considered opinion, Smt.Upinder Kaur wife of the complainant is entitled to receive the sum assured i.e. Rs.3 lacs + cumulative bonus as reimbursement of the medical expenditure from the Opposite Party and the fact that only Rs.62,000/- against the insurance claim has been paid by the Opposite Party, shows that Opposite Party is deficient in service. When the complainant and his wife were under the health insurance ever since the year 2010 till date, the wife of the complainant need not wait for uptil the year 2017-18 to seek the claim under the current insurance policy.  The current insurance policy can not be treated to be a new policy as per clause 4.1, 4.2 and 4.3 as wrongly relied upon by the Opposite Party.  

8.       Consequently, the complaint filed by the complainant for grant of Rs.3 lacs + cumulative bonus minus Rs.62,000/- as already paid, succeeds. Opposite Party is given one month’s time to make the payment to the complainant, failing which the awarded amount shall carry interest @ 9% per annum from the date of filing the complaint until full and final payment. The complainant is also awarded costs to the tune of Rs.5,000/-  on account of litigation expenses.  Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum

Dated: 06.06.2016.                                                         (S.S.Panesar)                                                                                                    President

                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member

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