Sh.S.S. Panesar, President

1.       Sh.Gulshan Rai dua has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that he purchased one insurance policy to the tune of Rs.1,50,000/-  and aforesaid insurance policy is still continuing one and complainant has been making payment of premium of aforesaid insurance policy continuously well in advance. As such, the complainant is a consumer of Opposite Party since 14.5.2010 and is competent to invoke the jurisdiction of this Forum. The complainant has raised the limit of this insurance policy No.404402/48/14/850000373 bearing insurance policy of 2014 i.e. insurance policy No. 404402/48/15/8500000288 to the tune of Rs.4 lacs from previous limit of Rs.1,50,000/- and this insurance policy is valid and started from midnight of 14.5.2015 to 13.5.2016. The complainant has paid net premium of Rs.15049/- to Opposite Party by means of cheque. It is pertinent to mention over here that the complainant has not committed any default in making payment since 14.5.2010. As such, the complainant is entitled to claim Rs.4 lacs for health related problems and hospitalization.  The complainant suffered heart attack on 12.8.2015 and hw as  got admitted in Ivy Hospital at Ajnala Road, Amritsar. The hospitalization started on 12.8.2015 and after various clinical tests got conducted on him. Thereafter, the complainant was advised by the doctors to conduct heart surgery to relieve from Heart ailment. The complainant was discharged on 15.8.2015. During this period of hospitalization, surgery of heart of complainant was conducted to install stent in blocked  veins of heart of complainant. During that period various medicines were given and various medical tests were conducted upon the person of complainant. During counseling before operation package was settled between complainant and hospital authority to the tune of Rs.2,32,968/-, Rs.1 lac was got deposited in cash by the complainant with hospital authority in advance. It is pertinent  to mention over here that the discount of Rs.62,968/- was got sanctioned with the intervention of political friends complainant which Opposite Party was required to appreciate this fact also, but the Opposite Party did not pay attention to it, instead Opposite Party are harassing and humiliating the complainant by refusing his genuine claim of Rs.54,000/-, Rs.70,000/- was again deposited by the complainant at the time of discharge from Ivy Hospital and the complainant was constrained to pay in cash of Rs.70,000/- in cash at the time of discharge since Ivy Hospital had informed that Opposite Party might not be on the panel of Ivy Hospital.  It is also important to mention over here for information of Opposite Party that complainant was also admitted previously on 16.10.2012 due to kidney problem at Ivy hospital, Chandigarh. During that period also, the complainant was harassed and humiliated at the hands of the Opposite Party. Since the Opposite Party had denied the genuine claim of the complainant at that time and Opposite Party affected a compromise with the complainant and made the requisite claim of the complainant before this District Forum. The Opposite Party paid Rs.75,000/- to the complainant after the claim was preferred to Opposite Party. Then again, Opposite Party created various objections for not settling the genuine claim of Rs.1,70,000/- and refused to pay genuine claim of the complainant. But however, after many visits and repeated representations, Opposite Party again made payment of Rs.41,008/- finally on 28.3.2016. Thereafter, the Opposite Party refused to pay  the genuine claim of the complainant on 28.3.2016 to the tune of Rs.54,088/-.              Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Party may kindly be directed to settle the balance claim of the complainant to the tune of Rs.54,088/- alongwith interest @ 24% per annum  till its actual realization.

b)      Opposite Party may kindly be directed to pay Rs.40,000/- to the complainant as damages and compensation to the complainant for causing mental harassment.

c)       Opposite Party may kindly be directed to pay complete costs of the present litigation.

d)      The complainant may kindly be awarded any other relief to which he is found legally entitled to under the law, equity and justice.   

Hence, this complaint.

2.       Upon notice, Opposite Party appeared and contested the complaint by filing  written statement taking preliminary objections therein inter alia that the complainant has not come to the court with clean hands and has tried to conceal the material facts from this Forum, hence the complainant is not entitled to any relief as the complaint is pre mature; that the complainant is estopped by his own act and conduct from filing the present complaint. It is submitted that TPA constituted under the IRDA expert reviewed the case and it has been perused that the insured filed three claims which have been duly complied with and the claims have been settled and given to the claimant when demanded. In the set of circumstances mentioned above, it is clear that there is no cause of action and there is no question of deficiency and lapse on the part of Opposite Party, hence he is neither to get any relief nor entitled to get any compensation and interest as claimed.  On merits, it is submitted that the claim submitted by the complainant under the insurance policy in question has been settled and paid Rs.75,000/- on 21.10.2015 vide NEFT and then the Opposite Party paid Rs.14,143/- on 21.12.2015 and then Rs.41,000/- on 23.3.2016 to the complainant. Hence the Opposite Party has settled three claims of the complainant and has no intention to harass and humiliate anyone.  It is denied that the Opposite Party is harassing the complainant by refusing the genuine claim of Rs.54,088/-. Remaining facts mentioned 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 tendered into evidence  affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2 to Ex.C17 and closed his evidence.

4.       On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.S.K.Sharma, Divisional Manager Ex.OP1 and closed the evidence on behalf of the Opposite Party.

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

6.       On the basis of evidence on record, ld.counsel for the Opposite Party has  vehemently contended that it is not disputed that the complainant is holder of insurance policy bearing No.404402/48/15/8500000288 to the tune of Rs.4 lacs for the period w.e.f. 14.5.2015 to 13.5.2016. It is also not disputed that the complainant during the operation of the policy suffered heart attack on 12.8.2015 and he had to be admitted in Ivy Hospital, Ajnala Road, Amritsar. The complainant remained admitted in the hospital w.e.f. 12.8.2015 to 15.8.2015. It is the case of the complainant that an amount of Rs.2,32,968/- was payable, however, with the intervention of the friends of the complainant, the said hospital authorities gave discount of Rs.62,968/- and as such, the complainant had to pay Rs.1,70,000/- on his treatment. The complainant filed  the claim, but however, the Opposite Party admittedly paid   Rs.75,000/- on 21.10.2015, Rs.14,143/- on 21.12.2015 and then Rs.41,000/- on 23.3.2016. The remaining amount comes to be Rs.39,857/-, but however, the complainant has claimed Rs.54,088/- which  was not payable to him as per the terms  and conditions of the insurance policy in dispute. The instant complaint is nothing, but an abuse of the process of law. The Opposite Party is not deficient in service and it is therefore, requested that the complaint is liable to be dismissed and the same may be dismissed accordingly.

7.       But however, from the appreciation of the facts and circumstances of the case, it becomes evident that the Opposite Party has failed to make the payment of Rs.39,857/- out of the medical claim payable to the complainant, after deducting three payments of Rs. Rs.75,000/- dated 21.10.2015, Rs.14,143/- dated 21.12.2015 and then Rs.41,000/- dated 23.3.2016. The Opposite Party has failed to specify the term/ clause of the insurance policy under which, the amount of Rs.39,857/- was excluded. The terms and conditions of the insurance policy are binding inter se parties and no party can be allowed to wriggle out therefrom We seek support on this point from M/s. V.K. Karyana Store Vs. Oriental Insurance Co. Ltd. 2014(3) CLT page 47 wherein it has been held that it is well settled principle of law that parties are bound by terms and conditions of the insurance policy and none of the parties can seek any  relief beyond those terms and conditions. Further in Prema & Ors- Petitioners  Vs. Life Insurance Corporation of India Ltd.-Respondent 2006(3) CLT 574 (NC), it has been laid down that “we need not say that the Insurance Contracts are ‘uberrima fides’ and are founded upon utmost good faith. If any party fails to observe this utmost good faith, the contract may be avoided by the other. This legal proposition has been reiterated time and again by the Supreme Court, this Commission as well as by various High Courts”. It was incumbent upon the Opposite Party to have specifically mentioned the clause under which the remaining amount of Rs. 39,857/- was denied to the complainant. Once the Opposite Party made the part payment out of the sum claimed, onus shifted upon the Opposite Party to prove why the remaining amount has not been paid to the complainant. In our considered opinion, the complainant has been able to make out his case for grant of balance medical claim to the tune of Rs.39,857/- from the Opposite Party. The Opposite Party is held to be deficient in service. As such, instant complaint succeeds and Opposite Party is directed to make the payment of balance medical claim to the tune of Rs.39,857/- alongwith interest @ 9% per annum from the date of filing the complaint until full and final payment. The costs of litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, the complainant shall be at liberty to get the order executed through the indulgence of this Forum.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