Delhi

North

CC/1/2019

DHARAMVEER VERMA - Complainant(s)

Versus

NATIONAL INSURANCE COMPANY LTD. - Opp.Party(s)

SAURABH DUGGAL

02 Feb 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Consumer Complaint No.:1/2019

In the matter of

Sh. Dharamveer Verma

S/o Late Sh. Dhan Singh Verma,

362, Pocket-9,

 Sector-21, Rohini,

Delhi-110086.                                                                 …                      Complainant

                                                          Vs

National Insurance Co. Ltd.,

Direct Agent Branch: II,

21 Daryaganj,

New Delhi-110002                                                        …                  Opposite Party No.1

 

Sh. Vijay Singh Rajput,

Agent Code-259,

Direct Agent Branch: II,

21 Daryaganj,

New Delhi-110002.                                                      …                 Opposite Party No.2

ORDER

02/02/2024

Ashwani Kumar Mehta, Member:

1.       The details of facts, as alleged in the present complaint filed under Section 12 of the Consumer Protection Act, 1986, are that on 30.04.2014, the complainant procured a mediclaim policy (Parivar Mediclaim Policy) for the sum insured of Rs.2,00,000/- through opposite party no.2 who is the authorized agent of opposite party no.1. On 03.02.2018, the complainant got a Cardiac Arrest and was admitted to Apollo Hospital, New Delhi. At the time of discharge, the hospital raised a total bill of Rs.2,13,080/- out of which Rs.1,00,000/- only, was paid by the opposite party no.1 to the hospital directly and the balance amount was paid by the complainant for discharge from hospital. Thereafter, on 05.03.2018, the complainant has submitted the  requisite documents for reimbursement of the remaining bill of medical expense of Rs.113080/- from the  O.P. no. 1.

 

2.       It has been alleged that the O.P. No.1 rejected the claim of the complainant stating that "sub-limit of total expenses incurred for any one illness is limited to 50% of sum insured". Therefore, the claim has been settled for Rs.100000/- i.e. 50% of the sum assured. It has further been alleged that the opposite party has referred to a condition of the said policy  that "sub-limit of total expenses incurred for any one illness is limited to 50% of sum insured", however, neither the agent conveyed the said condition nor the policy issued by the Opposite party-1 contains the said condition. The complainant has never been supplied terms and conditions applicable  to the instant insurance policy. The Opposite party has miserably failed to pay the aforesaid amount to the complainant till date in spite of its repeated requests. The said activities on the parties of opposite parties are highly illegal, unlawful, unjustified and against the principle of Natural justice which cannot be sustained in the eye of law.

3.       The Complainant has also filed the copies of Insurance policy dated 27.04.2017, ECG report, In patient bills, cash deposit receipts, medicine bills, discharge summary, reimbursement claim form, emails exchanged between the parties, grievance/complaint alongwith courier receipts, repudiation letter, envelope and communications between the Ombudsman and him alongwith the complaint with the prayer for directions to the OPs:-

1. To pay the balance amount Rs.1,13,080/- which was paid by the complainant in the Hospital or the balance amount of the said policy i.e. Rs.1,00,000/-.
2. To pay a sum of Rs.50,000/- (Rupees Fifty Thousand only) as compensation for loss and injury, harassment, mental agony. Inconvenience and loss of entertainment suffered by the complainant due to the negligence of the opposite party.
3. Cost of litigation Rs.25,000/- (Rupees Twenty Five Thousand only) and interest @ 18% (eighteen percent) per annum on the aforesaid claimed amount from the date of filing of the present complaint till its realization.

4.       Accordingly, notices were issued to the OPs and in response, the OP-1 has filed its reply denying each and every allegation/claim of the complainant. The OP-1 has stated that the present complaint against the OP is not maintainable and liable to be dismissed. No cause of action has arisen against OP-1. It is Further stated that complainant has admitted in the complaint that Rs.1,00,000/- has been paid by OP as per policy’s terms and conditions which provided that total expenses incurred for any one illness is limited to 50% of sum insured.  Since Rs.1,00,000/- has already been paid  and complainant is not entitled any more claim by the complainant as per  policy terms and conditions. As per the claim settlement letter of the TPA dated 14/06/2018, the claim has been settled for Rs.1,00,000/- on account of Chronic Ischaemic Heart Disease.

5.       The OP-2 has neither appeared nor filed any reply despite service. Hence, OP-2 was proceeded ex-parte vide our order dated 11.04.2019.

6.       The Complainant has also filed rejoinder and evidence reiterating the facts of the complaint and refuting the averments of the OP-1. Both the parties have also filed their respective evidences and written arguments.

7.       Accordingly, the complaint has been examined in view of the facts of the case and averments/documents/Evidence put forth by the parties and it has been observed that the Complainant has contended at Para 10 of the complaint that the Complainant asked for the terms and conditions of the Policy numerous times but no terms and conditions were provided by the OP-1. However, in the written statement filed by the OP-1, the OP-1 has simply denied the contents of Para 10 as wrong and has not filed any evidence to prove that the terms and conditions were duly supplied to the Complainant which is sufficient to conclude that no such terms & conditions were supplied by the OP-1 to the complainant.

8.       In this regard, It has also been held in the judgment passed  by the Hon’ble Supreme Court of India in the matter of Texco Marketing Pvt Ltd Vs Tata AIG General Insurance Co. Ltd & others - (2023) I SCC 428 that the Insurance Company cannot rely upon the terms and conditions  if the same had not been supplied to the insured.

9.       The following observations of the Hon’ble NCDRC in the matter of M/S. Anjaneya Jewellery vs New India Assurance Co. Ltd. & 2 Ors. Passed on 14 February, 2023 in CC/1094/2018 are also relevant:-    

“Applying the Principles laid down by the Hon’ble Supreme Court referred to above, to the facts of the present case, we find that there is no material on Record to establish that the Opposite Party Insurance Company had given the Terms and Conditions of the Special Package Insurance Policy or at any point of time or ever informed the Complainant about the same. Thus, the Exclusion Clause on the basis of which the Opposite Party Insurance Company had repudiated the Insurance Claim of the Complainant, cannot be sustained as the Opposite Party Insurance Company could not rely upon the same. The Repudiation letter is, therefore, set aside.There had been Deficient in Service by the Opposite Party Insurance Company in repudiating the genuine claim of the Complainant.”

 

10.     In view of the above observations, we are of the considered view that the complainant has suffered directly due to deficient service of the OP-1 (M/s National Insurance Co. Ltd.) in terms of the deficiency defined in the Act which includes  any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained in relation to any service and includes any act of negligence or omission or commission by such person which causes loss or injury to the consumer. Therefore, we feel appropriate to direct the OP-1 to:-

1. pay Rs.100000/- (Rupees One Lakh only) to the Complainant within thirty (30) days from the date of this order, with interest at the rate of 9% p.a. from 14-06-2018 (date of settlement letter of the TPA) till the date of the payment; and

 

2. pay Rs.50000/-(Rupees fifty Thousand only) as compensation to the Complainant, for the mental pain, agony and harassment caused by the OP.

 

11.     It is clarified that if the above said amount is not paid by the OP-1 to the Complainant within the period as directed above, the OP-1 shall be liable to pay interest @12% per annum from the date of expiry of 30 days period.

 

12.     We also feel appropriate to impose cost of Rs.20000/- (Rs. Twenty Thousand only) upon the OP-2 (Sh. Vijay Singh Rajput, Agent Code-259) out of which Rs.10000/- (Rs. Ten Thousand only) shall be paid to the complainant and remaining Rs.10000/- (Rs. Ten Thousand only) shall be deposited in the “ State Consumer Welfare Fund (L/Aid), SBI Account No.10310544717, IFSC No.SBIN0018175” within 30 days from the receipt of this order failing which this cost would be paid with interest @ 9% per annum till the date of payment.

 

11.     Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

ASHWANI KUMAR MEHTA                                              HARPREET KAUR CHARYA

                                                   Member                                                                                       Member       

                                           DCDRC-1 (North)                                                                        DCDRC-1 (North)

DIVYA JYOTI JAIPURIAR  

President

                                                                                              DCDRC-1 (North)