BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 312 of 2015

Date of Institution: 15.05.2015

Date of Decision: 13.07.2016  

1) Mrs.Radhika Soni widow of Vikas Soni, 2) Mrs.Radhika Soni widow of Vikas Soni being the natural guardian of minor daughter Harshita Soni, Legal heirs of the deceased Vikas Soni resident of House No. 2147, Bazar Sikri Bandan, Katra Dullo, Amritsar. Aged 40 years.

Complainants

Versus

National Insurance Company Limited, Kolkata through its Chairman/ Managing Director/ Principle Officer, service through its Branch Office at D-26, Court 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 Complainants: Sh.Deepinder Singh, Advocate

              For the Opposite Party: Sh. S.S.Randhawa, 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.       Smt.Radhika Soni and her minor daughter Harshita Soni, have brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that the complainants are the legal heir of deceased Vikas Soni, who had taken the Health Insurance Policy from Opposite Party for himself and the complainants vide policy No. 404400/48/14/8500000791 covering the risk period w.e.f. 26.11.2014 to 25.11.2015 for sum insured of Rs.5 lacs. The copy of the policy document is annexed. The complainants are the consumers as provided under the Act and  are competent to invoke the jurisdiction of this Forum. Deceased Vikas Soni unfortunately fell ill and was to be hospitalized at Medanta  Medicity, Gurgaon for the period 30.11.2014 till 2.12.2014 and the claim for his hospitalization and medical treatment was referred to Opposite Party who paid Rs.50,000/- as pre authorization and later the balance claim bill of Rs.1,54,548.55 paisa was filed with the Opposite Party which was repudiated by the Opposite Party through its repudiation letter dated 17.4.2015 on the frivolous ground that the limit is exhausted under these some clause 1-C. It is pertinent to mention over here that no policy condition is communicated to the complainants or the deceased by Opposite Party ever and now repudiating the claim on such ground which is never a part of an agreement between the parties and moreover, the deceased and complainants were covered for the amount of Rs.5 lacs as per the policy cover note issued by Opposite Party and is annexed with the complaint and the claim of Rs.1,54,548.55 paisa had been preferred only. Said repudiation of genuine claim of the complainants without ascertaining the correct facts by the Opposite Party is the arbitrary act of the Opposite Party. The aforesaid acts of the Opposite Party in repudiating the genuine claim of the complainants is an act of deficiency in services, unfair trade practices, mal practices and is not sustainable in the eyes of law and has caused lot of mental financial loss to the complainants and for which the Opposite Party is liable to pay the compensation of Rs.1 lac to the complainants. The cause of action has arisen to the complainants to file the present complaint when the Opposite Party repudiated the  genuine claim of the complainants vide their letter dated 17.4.2015. The complainants have sought the following reliefs vide instant complaint:-

a)       Opposite Party be directed to pay the amount of Rs.1,54,548.55 paisa alongwith interest @ 12% per annum from the date of payment till realization.

b)      Opposite Party be directed to pay the compensation of Rs.1 lac to the complainants.

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

d)      Any other relief to which the complainants are found entitled to under the law, equity and justice be also allowed.   

Hence, this complaint.

2.       Upon notice, Opposite Party appeared and contested the complaint by filing  written statement taking certain preliminary objections therein inter alia that the present complaint is not legally maintainable. As per the terms and conditions of the policy, the amount of Rs.50,000/- (50% of SI for any one illness) as eligible sum insured is Rs.1 lac, has already been paid vide authorisation letter dated 2.12.2014 and remaining amount is not payable to the complainants as per clause 1-C (maximum limit exhausted per illness upto 50% sum insured); that the complainant is estopped by their own act and conduct from filing the present complaint; that the complainants have not approached this Forum with clean hands and have suppressed the true and material facts from the notice of this Forum. Hence the complaint is liable to be dismissed. On merits, it is matter of record. However, it is admitted that Rs.50000/- has been paid. It is also admitted that the claim of the complainants regarding any other amount has been legally repudiated as per the terms and conditions of the policy. It is denied that the repudiation has been made on the frivolous grounds, rather it has been rightly done as per Clause 1-C which is binding on the complainants. It is denied that policy terms and conditions were not communicated to the complainants or the deceased by the Opposite Party. All the documents were communicated to the deceased at the time of issuance of the policy and he after going through the contents of same obtained the policy.  It is denied that the said terms and conditions are not part of the agreement. Rather all the terms and conditions are part of the agreement. It is denied that amount covered is Rs.5 lacs for the deceased, rather it was Parivar Mediclaim Policy and deceased is only covered for Rs.1 lac. It is denied that the alleged acts of repudiation is an act of deficiency in service, unfair trade practice, mal practices or is not sustainable in the eyes of law. Remaining facts narrated in the complaint have been specifically denied and a prayer for the dismissal of the complaint with costs has been made.         

3.       In his bid  to prove their case, the complainants tendered into evidence affidavit Ex.C1, copy of insurance cover Ex.C2, copy of repudiation letter Ex.C3, claim form Ex.C4, medical slips Ex.C5 to Ex.C7, authorisation letter Ex.C8, documents containing 24 pages Ex.C9   and closed his evidence.

4.       To rebut the evidence of the complainants, the Opposite Party tendered into evidence the affidavit of Sh.Suresh Kumar Sharma, Divisional Manger Ex.OP1, copy of letter dated 17.4.2015 Ex.OP2, copy of policy Ex.OP3, copy of hospital LAMA summary (16 pages) Ex.OP4, affidavit of S.K.Sharma, DM Ex.OP5, copy of process sheet Ex.OP6, copy of deduction detail Ex.OP7, copy of authorisation letter Ex.OP8, copy of cashless request Ex.OP9, copy of process sheet Ex.OP10, copy of deficiency letter Ex.OP11, copy of letter Ex.OP12, copy of repudiation letter Ex.Op13, copy of confirmation of rejection of claim Ex.Op14, copy of discharge summary Ex.OP15, copy of policy Ex.OP16, copy of guidelines Ex.OP17, cop of patient initial assessment record Ex.OP18, copy of e-mail Ex.OP19, copy of terms and conditions Ex.OP20, copies of insurance policies Ex.OP21 to Ex.OP23  and closed the evidence.

5.       We have heard the ld.counsel for the parties and have carefully gone through the evidence on record. We have also gone through the written submissions submitted on behalf of the complainants as well.

6.       On the basis of evidence on record, ld.counsel for Opposite Party has vehemently contended that there is no denying the facts that  deceased Vikas Soni was insured vide Pariwar Mediclaim Policy, copy whereof is Ex.C2  effective w.e.f. 26.11.2014 to 25.11.2015. It is also not denied that deceased Vikas Soni suffered from illness and was admitted in Medanta  Medicity, Gurgaon for treatment. It is also not denied that Rs.50,000/- were paid by Opposite Party as pre authorisation amount in accordance with terms and conditions of the policy in dispute. It is further stated that the remaining amount incurred on the treatment of Vikas Soni was declined by the Opposite Party as per Clause 1-C of the Insurance Policy as it was a Parivar Mediclaim Policy and the deceased was insured upto the amount of Rs.1 lac only and was entitled to receive Rs.50,000/- i.e. 50% of the insured amount regarding one illness. It is further contended that there is neither any deficiency of service nor unfair trade practice or mal practice on the part of the Opposite Party in repudiating the claim of the complainants. The complaint has got no force and the same is liable to be dismissed with costs.

7.       But however, from the appreciation of the evidence on record, it becomes evident that the claim of the complainants was repudiated vide letter dated 14.2.2015, copy whereof is Ex.OP13, wherein the claim was declined on the plea that as per the discharge summary Cirrhosis and Alcoholic Hepatitis Alcoholic Liver Disease with Cirrhosis. As per the terms and conditions of the policy, the expenses related to treatment of disease caused by Alcoholic Addiction are not payable. Hence the claim is inadmissible  under the clause 2.1.8. But however, in the written statement a different plea has been taken that the deceased was entitled to Rs.50,000/- i.e. 50% of the sum insured for one illness. As eligible sum insured of Rs.1 lac has already been paid vide authorisation letter dated 2.12.2014 and the remaining amount was not payable to the complainants as per clause 1-C (maximum limit exhausted per illness upto 50% sum insured). Not only this, a contrary plea has been taken in repudiating the claim. However, a perusal of the clause 1-C, more precisely one 1-C(a) would make whole picture clear which is reproduced as under:-

“Company’s liability would arise if the treatment of disease or injury contracted/ suffered is incepted during the policy period. Total expenses incurred for any one illness is limited to 50% of overall sum insured per family. Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured mentioned in the schedule.”   

The contention that it being  a Parivar Mediclaim Policy and sum insured was Rs.1 lac only, does not find favour from the fact that sum insured under the policy was Rs.5 lacs. As per clause 1-C (a), the beneficiary under the insurance cover was entitled to 50% of the sum insured for one illness. In such a situation, a sum payable would be Rs.2,50,000/-, whereas the claim of the complainants in the whole comes to Rs.  Rs.2,04,548.55 paisa, out of which an amount of Rs.50,000/- has already been paid by the Opposite Party and the remaining amount comes to Rs.1,54,548.55 paisa only, which is much short of sum insured of Rs.2,50,000/-. It appears that insurance companies show green pastures to the insured persons at the time of selling  the insurance policy and when it comes to payment of the insurance claim, they invent all sort 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.  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 seams 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.

8.       The alleged plea  that Vikas Soni was Alcoholic Addict, has not been taken in the written statement, but however, letter Ex.OP14 regarding confirmation of rejection of the claim states that Vikas Soni  was admitted in Dayanand Medical College & Hospital, Ludhiana for Alcohol Cirrhosis and Alcoholic Hepatitis on 16.10.2014 and was discharged on 29.11.2014. As per discharge summary the claimant is aknown case of  Alcoholic Liver Disease with Cirrhosis. As per  terms and conditions expenses related to treatment of disease caused by Alcoholic Addiction are not payable. Hence the claim is inadmissible under the clause 2.1.8. But however, the medical record Ex.OP4 produced on record by the Opposite Parties themselves clearly states that Vikas Soni was treated for NASH (Non Alcoholic Steato Hepatitis) which relates to non alcoholic disease.

9.       Keeping in view the facts aforesaid,it becomes evident that Opposite Party has repudiated the medi-claim of the complainants without any reasonable cause or excuse. The Opposite Party is deficient in service and are under legal obligation to repay the amount of  Rs.1,54,548.55 paisa to the complainants alongwith interest @ 9% per annum from the date of passing of the order until full and final recovery in equal shares. The costs of the litigation are assessed at Rs.2000/-. Since the complainant No.2 is minor, the amount falling to her share be kept in nationalized bank in the shape of FDR for a period until she attains the age of majority. Compliance of this order be made within 30 days from the date of receipt of copy of the order, failing which the complainant shall be at liberty to invoke the jurisdiction of this Forum to get the order executed.    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: 13.07.2016.                                                     (S.S.Panesar)                                                                                         President

                                          (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member

hrg