| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA RBT/Consumer Complaint No.195 of 2018 Date of institution: 20.03.2018 Date of Decision: 18.05.2022 Narinder Kaur aged about 57 years wife of Shri Karnail Singh, resident of House No.10/30, PAU Campus, Ludhiana, at present resident of B-1, Near Balaji Prem Ashram, Thakur Colony, Lalton Kalan, Pakhowal Road, Ludhiana ….Complainant Versus - National Insurance Company Limited, registered office: 3, Middleton Street, Post Box No.9229, Kolkata-700071, through its Director/MD
- National Insurance Company Limited, SCO 38, IInd Floor, Feroze Gandhi Market, Ludhiana, through its Manager
……..Opposite Parties Complaint under Consumer Protection Act. Quorum: Shri Ranjit Singh, President. Mrs. Ranvir Kaur, Member Present: Sh. Kawaljit Singh, Advocate, for complainant Sh. G.S. Kalyan, Advocate, for Ops
Order dictated by :- Shri Ranjit Singh, President Order The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Parties on the ground the husband of the complainant namely Shri Karnail Singh, availed the services of the opposite parties in the shape of Parivar- Mediclaim for family policy vide policy No.404502/48/17/8500000202, date of proposal and declaration 16.5.2014, valid from 19.05.2017 to 18.5.2018 for a sum assured of Rs.2,00,000/- and paid a sum of Rs.8255/- as premium of the policy. During the continuation of the insurance policy, Shri Karnail Singh unfortunately met with an accident on 16.7.2017 and suffered serious injuries on this body. A FIR no.118 dated 20.07.2017 under Section 279, 338, 427 IPC regarding this accident was registered at PS Sarabha Nagar, Ludhiana. The complainant spent Rs.5,92,225.72 p on the treatment of his husband. Information regarding admission of husband of the complainant was given to the opposite parties well within time as required as per the terms and conditions of the policy and requisite claim documents were submitted. The opposite parties approved the claim of husband of complainant for a sum of Rs.1,00,000/- only and the amount of Rs.1,00,000/- was paid which is 50% of the sum assured but the opposite parties denied the claim in respect of balance amount of Rs.1,00,000/- because for one disease only 50% of the sum insured is paid by the company as per terms and conditions of the policy. It is further alleged that again on 10.01.2018, Shri Karnail Singh was got admitted in Medical Department of DMC Hospital, Ludhiana and he was discharged on 25.1.2018 and during this span Shri Karnail Singh was diagnosed for chronic bed ridden state, 2’o to head injury DM2c Severe Sepri c Ketpatorenal` involvement (recovered) i.e. gallbladder perforations. Shri Karnail Singh was admitted in the hospital with the complaint of fever and sensorium inability to tolerate feeds and he spent Rs.1,86,972/-. Again the information regarding admission of Shri Karnail Singyh was given to the opposite parties well within time required as per the terms and conditions of the policy and the requisite claim documents were submitted. Initially the claim of Shri Karnail Singh was approved for a sum of Rs.50,000/- but subsequently it was reduced to Rs.20,000/- and the reasons were given applicable sum insured for policy period exhausted vide letter dated 25.1.2018. However, this letter is beyond any reasoning and does not stand for reason as to how the claim of Shri Karnail Singh was reduced. The aforesaid act of the opposite parties amounts to deficiency in service, unfair trade practice and it has caused mental as well as physical agony and also caused inconvenience to the complainant. Vide instant complaint, the complainant has sought the following reliefs:- - To pay the remaining claim amount to the complainant
- To pay Rs.1,00,000/- to the complainant as compensation
- To pay Rs.21,000/- as litigation expenses.
- Any other additional or alternative relief to which the complainant may be found entitled, may also be granted
- Upon notice, the O.Ps. No.1 & 2 have filed written reply taking preliminary objections; that the present complaint is legally not maintainable and is liable to be dismissed; that the complainant has not come before this Commission with clean hands; that the complainant has misrepresented and concealed the material facts from this Hon’ble Commission with an ulterior motive to secure the pecuniary gains by overreaching the judicial process; that the complainant being guilty of suppressio very and suggestion falsi have no right of maintaining the present complaint against the answering Ops. On merits, it is stated that the complainant has approached the Ops for health cover. The opposite parties explained the entire terms and conditions to the complainant. After understanding the terms and conditions, the complainant filled the proposal form and obtained the policy subject to policy terms and conditions. The OP has settled the claim of the complainant as per policy terms and condition. Thus, alleging no deficiency in service on their part has prayed for the dismissal of complaint in total.
- In support of his claim, the complainant has tendered certain documents in the shape of evidence. On the other hand, the OPs has tendered certain documents in the shape of evidence.
- We have heard learned counsel for the parties at considerable length and have also examined the record of the case.
- It is important to mention here that the complainant was assured of the sum of Rs.2,00,000/-. Ist time the complainant was paid Rs.1,00,000/- against the bill of Rs.5,92,225.72/- on the ground as against one disease only 50% of the sum insured is to be paid by the company as per terms and conditions of the policy. However, during admission of the complainant in the hospital for 10.11.2018 to 25.01.2018, as against the amount incurred of Rs.1,86,972/- initially amount of Rs.50,000/- was approved, which was subsequently reduced to Rs.20,000/- due to the reason “applicable sum insured for policy period exhausted”. Here it comes out that the claim has been admitted, however, it has not been explained as to how the case of the complainant is reduced as per the terms and conditions of the policy or as to how the complainant is at fault for the same. Further, the same also goes against the policy of equity and natural justice. It is important to mention here that neither the OP has mentioned nor placed on record any document, which shows that second claim passed by the OP reducing 50% of the sum assured.
- In the light of aforesaid discussion and appreciating the facts and circumstances of the case in totality, the complainant is entitled to sum of Rs.1,00,000/- instead of the amount of Rs.20,000/- vide letter dated 25.1.2018. So, the complainant is entitled to the same from the date of due with 9% per annum interest till its payment. Further in the interest of justice, the complainant is also entitled to Rs.25,000/- due to mental agony and physical harassment and Rs.11000/- as litigation expenses along with 9% per annum interest from the date of decision till payment. This order is directed to be complied with within a period of thirty days from the date of receipt of copy of this order by the OPs. Free certified copies of this order be sent to the parties, as per rules. The files be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.Announced
May 18, 2022 (Ranjit Singh) President (Ranvir Kaur) Member CC No.195 of 2018 Present: Sh.Kawaljit Singh, Adv. for complainant Sh. GS Kalyan, Advocate, for Ops Arguments completed. Vide our separate detailed order of today, the complaint stands allowed. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the record room. May,18 2022 (Ranjit Singh) (Ranvir Kaur) | |
