Punjab

Fatehgarh Sahib

CC/40/2016

Varinder singh - Complainant(s)

Versus

National insu comp - Opp.Party(s)

Sh Navneen bhel

21 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                         Consumer Complaint No.40 of 2016

                                                                Date of institution:  08.04.2016                    

                                                                Date of decision   :  21.07.2017

Varinder Singh aged about 59 years son of Sh. Mohinder Singh, R/o C/o Oberoi Traders, Bassi Road, Sirhind, District Fatehgarh Sahib.

……..Complainant

Versus

National Insurance Company G.T.Road Sirhind District Fatehgarh Sahib, through its Branch Manager.

       …..Opposite party      

Complaint under Sections 11 to 14 of the Consumer Protection Act

Quorum

Sh. Ajit Pal Singh Rajput, President          

Sh. Inder Jit, Member

         

Present :   Sh. Naveen Behl, Adv.Cl. for the complainant.

                   Sh. Vinay Sood, Adv.Cl. for the Opposite party.

ORDER

By Inder Jit, Member

                Complainant, Varinder Singh aged about 59 years son of Sh. Mohinder Singh, R/o C/o Oberoi Traders, Bassi Road, Sirhind, District Fatehgarh Sahib, has filed this complaint against the Opposite party (hereinafter referred to as “the OP”) under Sections 11 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.             The complainant had purchased a Mediclaim Policy from OP in the year 2000 for a sum assured of Rs.1,50,000/- and with the passage of time he got it enhanced to Rs.4,00,000/-. The policy was issued on 23.12.2014 for the period from 23.12.2014 to 22.12.2015, vide policy No.404702/48/14/8500000109. The complainant paid Rs.50,781/- as premium. The policy covered a risk of Rs.4,00,000/- for the complainant and his wife and Rs.3,00,000/- each for his children and mother since the year 2012. The complainant is suffering from diabetes and some other ailments and is frequently prone to dialysis. The complainant is frequently getting his dialysis from the Fortis Hospital Ludhiana. The complainant has been issued cashless policy but no cashless facility has been provided to the complainant. The complainant is getting treatment from Fortis Hospital Ludhiana since 2013 but the disbursement has not been made by the OP as per the bills and a total deduction of Rs.3,36,391/- is made from the bills.  The complainant had applied for the information of payments made by the OP under Right to Information Act from 01.04.2013 onwards but the OP supplied the information only w.e.f. 01.01.2014 to 22.12.2015. An amount of Rs.3,36,391/- is still outstanding against the OP. The act and conduct of the OP for not settling the claim as per policy is uncalled for and is against the principles of natural justice. The OP had intentionally withheld the genuine claim of the complainant, which amounts to deficiency in service on its part. Hence, this complaint for giving directions to the OP to pay an amount of Rs.3,36,391/- along with interest and Rs.1,00,000/- on account of compensation and Rs.25,000/- as litigation expenses.

3.             The complaint is contested by the OP, who filed written reply. In reply to the complaint, OP raised certain preliminary objections, inter alia, that the present complaint is not maintainable; the complaint is misuse and abuse of the process of the law; the complaint is false, frivolous and vexatious to the knowledge of the complainant; the complainant has not come to the Court with clean hands and the complainant has no cause of action to file the present complaint. As regards the facts of the complaint, the OP stated that the payment of the treatment has been made to the complainant as per the terms and condition of the mediclam and not as per the bills submitted by the complainant. The deductions, which are necessary from the bills are made as per the terms and conditions of the policy.  The liability of the company is only upto Rs.2,00,000/-. It is further stated that most of the payments of the complainant has already been made, only some of the bills are pending, which are still due. There is no deficiency in service on its part.  After denying the other averments made in the complaint, the OP prayed for dismissal of the complaint.

4.             In order to prove his case the complainant tendered in evidence his affidavit Ex. C-1, attested copies of documents Ex. C-2 to Ex. C-5 and closed the evidence. In rebuttal the OP tendered in evidence affidavit of Sh. Lalit Mohan, Branch Manager Ex. OP-1, copies of terms and conditions of the policy Ex. OP-2 & OP-3 and closed the evidence.

5.             The Ld. counsel for the complainant submitted that the complainant had a policy which covered the risk of Rs.4,00,000/- for him and his wife and Rs.3,00,000/- for each of his children and mother since 2012. This fact has been admitted as correct by the OP vide para No.2 of amended written statement(on Merits) of OP. Ld. counsel further submitted that vide para 8 of the preliminary objections raised by OP in the amended written statement, OP states that the complainant was suffering from pre-existing disease and suppressed the same, and as such company cannot enhance the risk of complainant beyond Rs.2,00,000/-. This is contrary to the fact already admitted. Moreover, the OP has not placed on record any record pertaining to pre-existing disease of the complainant.  Therefore, OP be directed for making the residual payment of medical bills besides compensation/litigation charges as requested for in the complaint.

 6.             On the other hand, the Ld. counsel for the OP argued that the complainant was suffering from pre-existing disease and he concealed this fact,  and hence claim cannot be admitted beyond Rs.2,00,000/-. He also argued that the part claim has been paid to the complainant as per the terms and conditions of the policy. He prayed for dismissal of the complaint.

7.             After hearing the Ld. counsel for the parties and going through the pleadings, evidence produced and oral arguments, we find force in the submissions of Ld. counsel for the complainant.

8.             In view of the above discussion, we accept the present complaint and find that OP has committed deficiency in service by not making the payment to the complainant as per the policy agreed to vide para No.2 of the amended written statement(On Merits) of OP wherein OP has admitted that complainant had a policy which covered risk of Rs.4,00,000/- for the complainant and his wife and Rs.3,00,000/- each for his children and mother. Moreover, OP could not place on record any document/report of any doctor etc to prove any pre-existing disease, the complainant was suffering from. Hence, we direct the OP to review the claim of the complainant as per the policy covering the risk of Rs.4,00,000/- for complainant and his wife and also as per the terms and conditions of the policy to the entire satisfaction of the complainant and pay the residual amount, whatsoever comes out on a realistic basis, within 45 days from the date of receipt of this order. The complainant is also held entitled for compensation of Rs. 15,000/-(Fifteen Thousands) alongwith litigation costs to the tune of Rs.5,000/-(Five Thousands). All the payments will be paid by the OP within 45 days from the date of receipt of copy of this order, failing which OP shall pay 9% p.a. interest till its realization.

9.             The arguments on the complaint were heard on 14.07.2017 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated:-21.07.2017

(A.P.S.Rajput)       President

 

 

(Inder Jit)

Member