Punjab

Sangrur

CC/280/2018

Vinod Kumar - Complainant(s)

Versus

National Insurance Company Ltd. - Opp.Party(s)

Sh.Neeraj Kalra

20 Feb 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                              

                                                Complaint No.    280

                                                Instituted on:      20.06.2018

                                                Decided on:       20.02.2020

 

Vinod Kumar son of Beli Ram, resident of Prem Basti, Street No.3, Opp. DC Office, Tehsil and District Sangrur.

                                                        …Complainant

                                Versus

1.     National Insurance Company Limited, Division Office through its Divisional Manager, Opposite Kaula Park, Dhuri Gate, Sangrur.

2.             Rakhsa TPA Pvt. Ltd. through its MD. SCO No.359-360, 1^st Floor, Sector 44-D, Chandigarh.

                                                        …Opposite parties

 

For the complainant    :               Shri Neeraj Kalra, Adv.

For OPs                    :               Shri Ashish Grover, Adv.

 

Quorum:    Shri Amrinder Singh Sidhu, President

                  Shri V.K.Gulati, Member

 

Order by : Shri Amrinder Singh Sidhu, President.

1.             Shri Vinod Kumar, complainant  has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant availed the services of the OPs by getting a medical insurance policy bearing number 404200/48/17/8500000012 and at the time of issuance of the policy the authorised agent of the Ops assured the complainant that every disease or any type  of medical problems shall be covered under the policy and all the expenditure spent on the medical will be borne by the company.  The case of the complainant is that the complainant suffered with the problem of organic catatonia and the complainant remained admitted in Max Super Speciality Hospital at Mohali for the period from 11.1.2018 to 22.1.2018 and spent an amount of Rs.2,48,083/-.  Thereafter the complainant sent his claim for payment to the OPs and submitted all the documents and the Ops issued claim number 58517184224925 but the Ops demanded the documents such as treating doctor certificate mentioning history of organic catatonia clearly specifying duration, prescribe investigation report of the patient supporting treatment taken for present organic catatonia, prior to admission if any and original pre-numbered, preprinted duly signed and stamped receipt against final bill of the hospital. Further case of the complainant is that it is the duty of the Ops to collect the documents from the hospital as it was a cashless mediclaim policy but even then the complainant submitted all the necessary documents to the OPs, but the claim was not paid. Thus, alleging  deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the claim amount of Rs.2,48,083/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by the OPs, legal objections are taken up on the grounds that the complainant has concealed material facts from this Forum and has not come to the Forum with clean hands, that the complainant has no cause of action to file the present complaint and that the complaint is not maintainable. On merits, it is admitted that the complainant had purchased the policy in question from the OPs.  The case of the OPs is that OP number 2 issued letter to Max Super Speciality Hospital, Mohali and it was clearly mentioned in the said letter that cashless facility cannot be accorded to the complainant as the policy of the complainant is in second year and organic catatonia is not covered in second year policy as per terms and conditions of the policy. It is stated further that the complainant was asked to submit the documents such as treating doctor certificate mentioning history of organic catatonia clearly specifying duration, prescribe investigation report of the patient supporting treatment taken for present organic catatonia, prior to admission if any and original pre-numbered, pre-printed duly signed and stamped receipt against final bill of the hospital, but the same were not submitted by the complainant  despite letters dated 22.2.2018, 6.3.2018 and 26.4.2018. Any deficiency in service on the part of the Ops has been denied.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-29 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for OPs has produced Ex.OP/R-1 to Ex.OP/R-10 copies of the documents and affidavit and closed evidence.

4.             We have carefully perused the complaint, version of the opposite parties and heard the arguments of the learned counsel for the parties.

5.             The learned counsel for the complainant has contended vehemently that the complainant availed the services of the OPs by obtaining a medical insurance policy bearing number 404200/48/17/8500000012 and at the time of issuance of the policy the authorised agent of the Ops assured the complainant that every disease or any type  of medical problems shall be covered under the policy and all the expenditure spent on the medical will be borne by the company.  Further the learned counsel for the complainant has contended that the complainant suffered with the problem of organic catatonia and the complainant remained admitted in Max Super Speciality Hospital at Mohali for the period from 11.1.2018 to 22.1.2018 and spent an amount of Rs.2,48,083/-.  Thereafter the complainant sent his claim for payment to the OPs and submitted all the documents and the Ops issued claim number 58517184224925 but the Ops demanded the documents such as treating doctor certificate mentioning history of organic catatonia clearly specifying duration, prescribe investigation report of the patient supporting treatment taken for present organic catatonia, prior to admission if any and original pre-numbered, pre-printed duly signed and stamped receipt against final bill of the hospital. Further the learned counsel for the complainant has contended that it is the duty of the Ops to collect the documents from the hospital as it was a cashless mediclaim policy but even then the complainant submitted all the necessary documents to the OPs, but the claim was not paid to the complainant, which is a clear cut deficiency in service on the part of the Ops.

6.             On the other hand, the learned counsel for the OPs has contended vehemently that OP number 2 issued letter to Max Super Speciality Hospital, Mohali and it was clearly mentioned in the said letter that cashless facility cannot be accorded to the complainant as the policy of the complainant is in second year and organic catatonia is not covered in second year policy as per terms and conditions of the policy. It is stated further that the complainant was asked to submit the documents such as treating doctor certificate mentioning history of organic catatonia clearly specifying duration, prescribe investigation report of the patient supporting treatment taken for present organic catatonia, prior to admission if any and original pre-numbered, pre-printed duly signed and stamped receipt against final bill of the hospital, but the same were not submitted by the complainant  despite letters dated 22.2.2018, 6.3.2018 and 26.4.2018.  As such, the learned counsel for the Ops has contended that the claim is not payable to the complainant.

7.             A bare perusal of the file shows that the complainant along with his family members got an insurance policy in question for the period from 22.7.2017 to 21.7.2018 for Rs.2,50,000/- on floater basis from the Ops by paying the requisite premium.  In the present case it is an admitted fact that the complainant suffered with the problem of organic catatonia and took treatment from Max Super Speciality Hospital Mohali and remained admitted for the period from 11.1.2018 to 22.1.2020 where he spent an amount of Rs.2,48,083/-, as is evident from the bill of Max Healthcare, which is on record as Ex.C-19. Ex.C-7 to Ex.C-18 is the copy of medical record which shows that the complainant took treatment from Max Healthcare at Mohali.  The grievance of the complainant is that the OP did not pay the claim amount on flimsy grounds that the claim is not payable in the second year of the policy.   The learned counsel for the complainant has contended that at the time of issuance of the insurance policy, it was told by the Ops to the complainant that every disease or any type of medical problems are covered and the expenses incurred on the same will be borne by the company.   The learned counsel for the Ops has contended that cashless facility cannot be accorded to the complainant as the policy of the complainant is in second year and organic catatonia is not covered in second year policy as per terms and conditions of the policy. It is stated further by the learned counsel for the Ops that the claim has rightly been rejected by the Ops.  It is worth mentioning here that though the Ops have contended that the claim is not payable to the complainant as the policy of the complainant is in second year and organic catatonia is not covered under the policy.  But no such condition in the terms and conditions of the policy has been shown to us nor it is shown that such terms and conditions were ever provided to the complainant, whereas the fact remains that the complainant is insured under the policy and spent an amount of Rs.2,48,083/- vide bill Ex.C-19 during the subsistence of the insurance policy in question.  As such, we find it to be a clear cut case of deficiency in service on the part of the Ops.

8.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

9.             In the sequel of above discussion, we allow the complaint and direct the OPs to pay to the complainant an amount of Rs.2,48,083/- within forty five days from the date of order failing which OPs shall be liable to pay interest @ 8% per annum from the date of order till actual date of realisation.  We further order OPs to pay to the complainant an amount of Rs.2,000/- in lieu of consolidated amount of compensation.

10.            A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                February 20, 2020.

 

        (Vinod Kumar Gulati)       (Amrinder Singh Sidhu)

                 Member                            President