Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 145
Instituted on : 26.03.2015.
Decided on : 22.04.2016.
Surya Kant s/o Sh.Shardanand R/o H.No.163/12 Kuchhal Niwas, Silani Gate, Jhajjar.
………..Complainant.
Vs.
- National Insurance Company Ltd. Regd. Office 3 Middleton Street, Post Box No.9229 Kolkata-700071.
- National Insurance Company Limited Policy Issuing Office Narain Shopping complex, Civil Road, Rohtak through its Branch Manager.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.JOGINDER KUMAR JAKHAR, PRESIDENT.
MS. KOMAL KHANNA, MEMBER.
SH. VED PAL, MEMBER.
Present: Sh.Parveen Goyat Advocate for the complainant.
Sh.O.P.Punia, Advocate for the opposite parties.
ORDER
SH. JOGINDER KUMAR JAKHAR, PRESIDENT :
1. The present complaint has been filed by the complainant with the averments that he had taken the Parivar Mediclaim Policy No.421600/14/850000163 dated 17.06.2014 through opposite party no.2 and paid Rs.4022/- for the period from 17.06.2014 to 16.06.2015. It is averred that on 28.02.2015 the complainant Mr. Surya Kant suffered with some heart disease and accordingly he was admitted in Braham Shakti Sanjivani Hospital Bahadurgarh being nearest paneled heart care hospital and remained admitted there w.e.f. 28.02.2015 to 02.03.2015 and had incurred a sum of Rs.251577/- on his treatment. It is averred that on 28.02.2015 complainant intimated the opposite parties and the hospital about the health policy and on 3.3.2015 the hospital got received an authorization letter from Vipul Medcorp TPA Pvt. Ltd. with the guarantee of payment of Rs.100000/- with a special note approved as per policy terms and conditions and further enhancement possible limit exhausted. It is averred that complainant personally met with the TPA on 04.03.2015 telephonically to Vipul Medcorp about remaining insured amount i.e. Rs.100000/- being TPA of the opposite parties, but after not getting satisfactory response, complainant personally visited the TPA on 08.03.2015 with all the documents but despite submitting all the required documents, opposite parties failed to make the payment accruing in favour of the complainant. It is averred that the act of opposite parties of repudiating the lawful claim is illegal and amounts to deficiency in service. As such it is prayed that the opposite parties may kindly be directed to pay the remaining mediclaim amount of Rs.100000/- alongwith interest, compensation and litigation expenses.
2. On notice, opposite parties appeared and filed their written statement submitting therein that the complainant got the Parivar Mediclaim for family. The risk of 3 family members i.e. Surya Kant complainant Smt. Payal-wife, Sh.Soham-son. As per terms and conditions of the policy is (a) 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 sum insured per family. It is averred that the complainant has received 50% of sum insured as per terms and conditions of the policy so the complainant is not entitled for Rs.251577/-. It is averred that the amount for which the complainant is entitled has already been paid. Hence the complainant is not entitled for any amount and dismissal of complaint has been sought.
3. Both the parties led evidence in support of their case.
4. Ld. Counsel for the complainant in his evidence tendered affidavit Ex.CW1/A and documents Ex.C1 to Ex.C4 and has closed his evidence. On the other hand, Ld. counsel for the opposite party tendered affidavit Ex.R1, documents Ex.R2 to Ex.R7 and has closed his evidence.
5. We have heard ld. counsel for the parties and have gone through material aspects of the case very carefully.
6. In the present case it is not disputed that as per policy Ex.C1, the complainant and his family members were insured with the opposite parties for the sum insured Rs.200000/-. It is also not disputed that as per bill Ex.C4, the complainant had spent an amount of Rs.251577/- on his treatment taken from Brahm Shakti Sanjivani Hospital. The TPA Vipul Medicorp Pvt. Ltd. vide its letter Ex.C3 written to the hospital, had authorized only Rs.100000/- and for the amount exceeding Rs.100000/- further authorization was required. The contention of ld. counsel for the complainant is that as per policy the Sum Insured was Rs.200000/- whereas the opposite party has only paid the amount of Rs.100000/-. Hence the complainant is entitled for the remaining amount from the opposite party. On the other hand contention of ld. counsel for the opposite party is that as per terms and conditions of the policy placed on record as Ex.R7, “Total expenses incurred for any one illness is limited to 50% of 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 Scheme”.
7. After going through the file and hearing the parties it is observed that as per schedule of policy Ex.C1, the complainant was entitled for the sum Insured of Rs.200000/- but the opposite parties have only paid the amount of Rs.100000/- to the complainant on the ground that as per terms and conditions of the policy, complainant was only entitled for 50% amount. To prove its contention opposite party has placed on file document/policy Ex.R7 but it is not proved on file that the alleged policy was supplied to the complainant. Hence its terms and conditions cannot be relied upon. In this regard we have placed reliance upon 2015(1)CLT591 titled as Star Health and Allied Vs. Asha & Others, whereby it is held that: “Insurance policy-Exclusion clause-Not explained to insured when cover not was issued-Insurance company cannot derive any benefit from exclusion clause”, as per IV(2015)CPJ 376(NC) titled as United India Insurance Co. Ltd. Vs. Dinaz Vervatwala & Anr., Hon’ble National Commission, New Delhi has held that “No evidence that OPs ever supplied terms and conditions of group personal accident policy-Unfair trade practice proved-Repudiation not justified”. 2013(1)CLT 589 titled as New India Asurance Co. Ltd. Vs. Pabbati Sridevi & Others whereby Hon’ble National Commission has held that: “Terms and conditions therein, not communicated to the insured-Whether can be used by Insurance Company-No-Held that the terms and conditions were never issued to the insured-Policy is in the nature of standard, printed documents. There is nothing to show that its contents were part of the policy document issued to the insured-Terms and conditions in insurance policy cannot be rely upon by insurance company”, as per 2009(3)CLT 184 titled ICICI Lombard General Insurance Co. Ltd. Vs. Gurmeet and another, Hon’ble Punjab State Commission, Chandigarh has held that: “No evidence to prove if the document was either signed by the complainant-insured or if it was an enclosure of the insurance policy or if it was duly communicated to respondent no.1-The insurance Company cannot avail the benefits of these terms and conditions contained in the document” and as per 2008(3)CLT 377 titled Dharmendra Goel Vs. Oriental Insurance Co. Ltd., Hon’ble Supreme Court of India has held that: “If a particular claim to compensation is possible on the material on record, it should not be denied on hyper technical pleas that claim was limited by complainant to a lower amount”. In view of the aforesaid law which are fully applicable on the facts and circumstances of the case it is observed that the repudiation of remaining claim by the opposite parties is illegal and unjustified and the complainant is entitled for the remaining claim amount of Rs.100000/-.
8. In view of the facts and circumstances of the case, it is directed that opposite parties shall pay the amount of Rs.100000/-(Rupees one lac only) along with interest @ 9% p.a. from the date of filing the present complaint i.e. 26.03.2015 till its actual realization and shall also pay a sum of Rs.3500/-(Rupees three thousand five hundred only) as litigation expenses to the complainant within one month from the date of decision failing which the opposite parties shall be liable to pay interest @ 12% p.a. on the awarded amount from the date of decision. Complaint is allowed accordingly.
9. Copy of this order be supplied to both the parties free of costs.
10. File be consigned to the record room after due compliance.
Announced in open court:
22.04.2016.
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Joginder Kumar Jakhar, President
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Komal Khanna, Member.
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Ved Pal, Member
