THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 433 of 2014
Date of Institution : 7.8.2014
Date of Decision : 28.08 2015
S. Lakhwinder Singh (Advocate) S/o S. Puran Singh R/o H.No. 52, New Model Town, PO R.S. Mills, Chheharta,Amritsar
...Complainant
Vs.
National Insurance Co.Ltd (401901) branch office Amritsar Rayon And Silk Mill, G.T. Road, Chheharta, Amritsar through its Sr. Branch Manager/Principal Officer
Park Mediclaim TPA Pvt.Ltd., Third Party Administrator Health Services, through its Incharge/Manager, 702, Vikrant Tower, Rajjendra Place, New Delhi 1100088
Mangat Ram (Agent) S/o Hans Raj, R/o Sunder Nagar, Near Maie Da Gurdwara, Post Office, Rayon & Silk Mill, G.T. Road, Chheharta, Amritsar
....Opp.parties
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh.Raman Randev,Advocate
For the opposite parties No.1 & 2 : Sh. S.S.Randhawa,Advocate
For opposite party No.3 : Ex-parte
-2-
Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member &
Sh.Anoop Sharma,Member
Order dictated by :-
Bhupinder Singh, President
1 Present complaint has been filed by Lakhwinder Singh under the provisions of the Consumer Protection Act alleging therein that he has obtained mediclaim policy bearing No. 401901/48/11/8500000255 covering himself, his wife , daughter and son with sum assured Rs. 1,50,000/- each for self and wife and Rs. 1,00,000/- each for son and daughter for the period from 29.11.2011 to 28.11.2012. According to the complainant he had been obtaining the same mediclaim policy from the opposite party since 2010 and he had never received any claim from the opposite party. During the policy period of 2011-2012 , wife of the complainant suffered pain in gall bladder due to stone in the gall bladder. She was admitted in Uppal Hospital on 31.10.2012 and was discharged on 2.11.2012. The complainant incurred a sum of Rs. 25000/- on the treatment of his wife towards hospital charges, operation charges, medicine charges and other ancillary expenses . The complainant submitted his claim with the opposite party by submitting all the relevant documents with the request to reimburse the amount of Rs. 25000/-. But the TPA of the opposite party i.e. opposite party No.2 vide its letter dated 11.2.2013 demanded additional documents , which were also supplied by the complainant vide letter dated 28.2.2013 and 16.3.2013. Thereafter complainant requested the opposite party many times to settle his claim and disburse the claim amount to him, but to no avail. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to pay claim amount of Rs. 25000/- alongwith interest @ 18% p.a. Compensation of Rs. 30000/- alongwith litigation expenses were also demanded.
2. On notice, opposite parties No.1 & 2 appeared and filed written version in which it was submitted that the present complaint is not legally maintainable as mediclaim policy does not cover the expenses incurred on treatment of surgery of Gall bladder and bile duct excluding malignancy and calculus disease for two years of inception of cover as per clause 4.3. The case of the complainant falls within the period of two years, as such the complainant is not entitled for any reimbursement. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-16.
4. Opposite parties No. 1 & 2 tendered into evidence affidavit of Sh. Ravi Kant Arora Ex.OP1 alongwith documents Ex.OP2 to Ex. OP20.
5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by the ld.counsel for the parties with the valuable assistance of the ld.counsel for the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that complainant obtained mediclaim policy bearing No. 401901/48/11/8500000255 covering himself, his wife , daughter and son with sum assured Rs. 1,50,000/- each for self and wife and Rs. 1,00,000/- each for son and daughter for the period from 29.11.2011 to 28.11.2012. The complainant had been obtaining the same mediclaim policy from the opposite party since 2010 and he had never received any claim from the opposite party. During the policy period of 2011-2012 Ex.OP2, wife of the complainant suffered pain in gall bladder due to stone in the gall bladder. She was admitted in Uppal Nursing Home, Amritsar on 31.10.2012 as per discharge card Ex.C-11 and was discharged on 2.11.2012. The complainant incurred a sum of Rs. 25000/- on the treatment of his wife towards hospital charges, operation charges, medicine charges and other ancillary expenses as per bills Ex.C-13 to Ex.C-15. The claim was lodged with the opposite party alongwith all the relevant documents. The TPA of the opposite party i.e. opposite party No.2 demanded additional documents/information from the complainant which was provided by the complainant vide letter dated 28.2.2013 and 16.3.2013 and also informed to the opposite party that he had already submitted all the requisite documents in original to the opposite party. But opposite party did not settle the claim of the complainant. The complainant also served legal notice dated 28.2.2013 Ex.C-7 and notice dated 16.3.2013 Ex.C-8 but all in vain . The TPA of the opposite party repudiated the claim of the complainant vide letter Ex.OP20 on the ground that as per terms and conditions of the policy the expenses incurred on treatment of surgery of gall bladder and bile duct excluding malignancy and Calculus disease for two years of inception of cover are not payable under the Exclusion clause 4.3 . Ld.counsel for the complainant submitted that opposite party only supplied cover note of the policy to the complainant. They never supplied even the policy documents to the complainant nor any terms and conditions of the policy. As such these terms and conditions of the policy are not binding upon the complainant. So the TPA has wrongly repudiated the claim of the complainant vide letter Ex.OP20 dated 18.3.2013 which was never conveyed to the complainant. All this amounts to deficiency of service on the part of the opposite party qua the complainant.
7. Whereas the case of opposite parties No.1 & 2 is that the complainant , his wife , son and daughter have obtained mediclaim policy from the opposite party since 2010. Wife of the complainant was hospitalized in Uppal Nursing Home where she undergone surgery of gall bladder. As per exclusion clause 4.3 of the terms and conditions of the policy, the treatment of diseases related to surgery of gall bladder and bile duct excluding malignancy and calculus etc. are not payable for two years of inception of the policy. As such the complainant is not entitled to the claim.
8. From the entire above discussion, we have come to the conclusion that the complainant got mediclaim policy from the opposite party covering himself, his wife , daughter and son, since 29.11.2010 and during the policy period from 29.11.2011 to 28.11.2012 Ex.OP2, wife of the complainant suffered severe pain in gall bladder. She was admitted in Uppal Nursing Home as per discharge card Ex.C-11 on 31.10.2012 and was discharged on 2.11.2012 and the complainant incurred a sum of Rs. 25000/- as per bills Ex.C-13 to Ex.C-15 on the treatment of his wife. The complainant lodged claim with the opposite party.. The TPA of the opposite party demanded certain documents from the complainant which were supplied by the complainant to the opposite party. However, TPA i.e. opposite party No.2 had written letter Ex.OP20 dated 18.3.2013 to opposite party No.1 that as per exclusion clause 4.3 of the terms and conditions of the policy the expenses incurred on treatment of surgery of gall bladder are not payable for two years of inception of cover. This letter was never supplied to the complainant . On the basis of this letter the opposite party No.1 did not settle the claim of the complainant nor sent any repudiation letter to the complainant. The complainant has categorically submitted in his complaint that he was only supplied with cover note of the policy. He was not furnished with even the original policy documents nor he was supplied with the terms and conditions of the policy.
9. It has been held by the Hon'ble National Commission in case Oriental Insurance Co. Ltd. Vs. Satpal Singh & Others 2014(2) CLT 305 that onus of proof that terms and conditions of the policy were supplied to the insured lies upon the Insurance company. But in the present case opposite party could not produce any document to prove that they furnished the terms and conditions of the policy including the exclusion clause, to the complainant. It has been held by the Hon'ble Supreme Court of India in case M/s. Modern Insulators Ltd Vs. Oriental Insurance Co.Ltd 1(2000) CPJ 1 (SC) that if the terms and conditions were not supplied to the complainant ,the exclusion clause is not binding upon the complainant. Opposite party could not prove the supply of terms and conditions of the policy, as such this exclusion clause 4.3 is not applicable to the complainant. As such we hold that complainant is entitled to reimbursement of Rs. 25000/- i.e. amount spent by him on the medical treatment of his wife.
10. Resultantly we partly allow the complaint with costs and the opposite party No.1 is directed to pay the amount spent by the complainant on the medical treatment of his wife i.e. Rs. 25000/- to the complainant within one month from the date of receipt of copy of orders ; failing which opposite party No.1 shall be liable to pay interest @ 9% p.a on Rs. 25000/- from the date of filing of the complaint till payment is made to the complainant. Opposite party No.1 is also directed to pay litigation expenses Rs. 2000/- to the complainant. 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.
28.08.2015 ( Bhupinder Singh )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
/R/ Member Member
