BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.276 of 2019

      Date of Instt. 22.07.2019

      Date of Decision: 17.02.2023

Hans Raj Arora (now deceased) through his LRs:-

1.       Sandeep Kumar, aged about 46 years, son of Late Sh. Hans Raj         Arora, R/o House No.38/1, Krishna Nagar, Near Adarsh Nagar,        Jalandhar.

2.       Sunil Kumar Arora, aged about 42 years, son of Late Sh. Hans          Raj Arora, R/o House No.30/5, New Ashok Nagar, Basti Sheikh   Road, Jalandhar.

..........Complainants

Versus

1.       National Insurance Company Ltd., Jalandhar Division-II, Panesar      Complex, 20, G. T. Raod, Jalandhar, Punjab-144001.

2.       Paramount Health Services and Insurance (TPA) Private Ltd,   Ludhiana. Third Floor, SCO-138, Feroze Gandhi Market,     Ludhiana, Punjab-144001.

3.       J. H. Cardiac Unit, Om Heart Care under Joshi Hospital,          Kapurthala Chowk, Jalandhar through its Principal Officer/Doctor-incharge.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)                                          Sh. Jaswant Singh Dhillon       (Member)   

Present:       Sh. R. K. Arora, Adv. Counsel for the Complainant.                         Sh. A. K. Arora, Adv. Counsel for OP No.1.

                   OP No.2 exparte.

                   Sh. G. P. S. Rana, Adv. Counsel for OP No.3.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant got medical insurance policy from National Insurance Company Ltd. i.e. OP No. 1 under policy No. 404300501810000079 effective from 15-07-2018 to 14-07-2019 after making a payment of Rs.12,274/- to the OP No.1. Under this medi-claim insurance policy, the sum insured was upto Rs.2,12,500/- i.e. 175,000/- + 37,500/-. Since the complainant had been getting this insurance policy since long and the same was renewed from time to time as such, the insured was getting Rs.37,500/- was bonus amount of sum insured with the policy cover with a sum insured of Rs.1,75,000/- and accordingly all the health ailments were covered in this policy, although, the complainant had always been hale and hearty as well as very active in his working as part time accountant with different concerns. Paramount Health Services and Insurance (TPA) Private Ltd, Ludhiana Le the opposite party is TPA of OP No.1 National Insurance Company Ltd., Jalandhar. In the first week of December, 2018, the complainant faced difficulty in breathing as such, on check up, heart problem was diagnosed by doctor and immediate heart surgery was advised. Accordingly, the Complainant informed the insurance company and got admission in J. H. Cardiac Unit, Om Heart Care under Joshi Hospital, Kapurthala Chowk, Jalandhar. The OP No. 1 through its TGA i.e. the OP No. 2 vide authorization letter authorized the said Hospital i.e. the OP No.3 for Cash Less treatment of the Complainant. After necessary medical tests, heart of the complainant was operated by Dr. Sameer Goel and his companions Doctors. The complainant was issued a medical bill of Rs.2,17,285/- for indoor admission as on 05-12-2018 till 14-12-2018 on account of heart surgery (CABG). Despite repeated requests and reminders to concerned officers of the OPs No.1 and 2, only an amount of Rs. 75,000/- was paid by the OPs No.1 and 2 to the said Hospital, towards the payment of said bill. The complainant suffered great financial hardship in paying the remaining amount and after arranging payment of his relatives, the complainant made a payment of Rs.1,05,000/- to the Hospital and availed a discount of Rs.37,285/- from the Hospital. Besides, the above hospital bill, the complainant had also made the payment of many other bills for tests and medicine. The total expenditure on heart surgery was about Rs.2,25,000/-, however, only bills worth Rs. 2,00,000/- were available with the complainant. As such, after getting discharge from the hospital, a claim of Rs.2,00,000/- was lodged with the OPs No.1 and 2. Some of the bills, available with the complainant, for the medical tests, blood units and medicines are on record. The complainant and family members were put in mental tension and torture by the OPs No.1 and 2 by not making the payment of the hospital bills especially at the time, health of the complainant was critical account of heart surgery. Even till today, the complainant and his family members are suffering mental agony and torture as they have to pay back the amount borrowed from different relations but the OPs No.1 & 2 have not cleared the payment of insurance claim of the complainant as per the terms and conditions and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs No.1 & 2 be directed to pay the remaining amount of Rs.1,25,000/- towards the hospitalization expenditures of complainant on account heart surgery. And in case, the OP No. 3 has charged any amount in excess of their mutually agreed terms and conditions with the OPs, then the OP No.3 may also kindly be directed to refund the amount to the complainant which was charged in excess in violation with the agreed terms and conditions with the OPs. Further, OPs be directed to pay Rs.2,00,000/- as compensation for causing mental tension and harassment to the complainant and Rs.23,000/- as litigation expenses.

2.                Notice of the complaint was given to the OPs, but despite service OP No.2 failed to appear and ultimately OP No.2 was proceeded against exparte, whereas OP No.1 appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that there is no deficiency of service or unfair trade practice on the part of answering OPs and that being so the present complaint is not maintainable. It is further averred that the complainant has purchased National Mediclaim Insurance Policy Individual from the opposite party for a sum of Rs.1,75,000.00 besides bonus of Rs.37,500.00 bearing no. 404303501810000079 for the period 15.07.2018 to 14.07.2019. It has been specifically mentioned in the policy schedule that the attached policy, the clauses, the endorsement and policy website i.e. www.nationalinsuranceindia.nic.co.in. It shall be read together as one contract and any word of expression to which the specific meaning has been attached. In any part of this policy or the schedule shall bear the same meaning wherever it may appear. That being so the policy schedule was subject to policy clauses as detailed above. As per law reported in M/s. Anjaneya Jewellery Versus New India Assurance Company Limited decided by the National Consumer Disputes Redressal Forum, Jalandhar decided on 22.05.2018, in para no.3 it has been held as under:-

                   ‘The contention of the Ld. Counsel for the complainant is that only a two page policy schedule available on page no.42 and 43 of the paper book was provided to them by the insurer and therefore the complainant was never aware of the terms and conditions/exclusions on the basis of which the claim has been repudiated. On being asked to how the policy schedule available on page no. 42 and 43 of the paper book was received by the complainant, Ld. Counsel submits that the same was left in the office of complainant without any forwarding letter and without any acknowledgement being taken. A perusal of the aforesaid policy schedule clearly shows that the policy was subject to package insurance policy, clauses attached therewith. This would mean that the policy clauses were actually attached to the aforesaid policy schedule. If the said clauses were not attached thereto, as it is claimed by the complainant, it either ought not to have accepted the policy schedule or it ought to have at least immediately written a letter to the insurer stating therein that no policy clauses were attached to the policy schedule received by them. It is unnatural for a person obtaining such a policy to remain silent on receiving the policy schedule without policy clauses when the policy schedule expressly states that the said clauses attached thereto. Therefore I am unable to accept the contention that the policy clauses were not attached to the policy schedule received by the complainant'.

                   That similar is the facts of the present case. In the present complaint, it has been specifically mentioned in the policy schedule that insurance policy schedule that the attached policy, the clauses, the endorsement and policy wording is available in the website i.e. www.nationalinsuranceindia.nic.co.in. It shall be read together as one contract and any word of expression to which the specific meaning has been attached. The complainant has not agitated the matter prior to the present claim that the policy clauses were not supplied to him and as such at this stage cannot agitate the said matter that the policy clauses were not binding upon him. The policy schedule along with its clauses is a contract of insurance, which is binding upon both the parties and all the clauses of policy of insurance are binding upon the complainant. That the similar matter came up before the National Consumer Disputes Redressal Commission in case Barak Cold Storage Pvt. Ltd. Versus United India Insurance Company Limited decided on 04.12.2018, in which it was disputed that the policy clauses were not supplied to the complainant and as of such the exclusion clauses and the National Commission after considering the entire matter and discussing the law laid down in Anjaneya Jewellery case referred above held that the policy clauses were binding upon the complainant. It is further averred that due and payable amount due under the policy of insurance has already been paid to the complainant. The opposite party received cashless claim from the hospital i.e. OP No.3 for Rs.2,19,201.00, which was settled by Paramount Health Services And Insurance TPA Pvt. Ltd. i.e. OP No. 2 and a claim of Rs.71,530.00 was settled as per terms and conditions of policy of insurance and after deducting a sum of Rs.7153.00 as TDS, an amount of Rs.64377.00 has been paid to the opposite party no. 3, from whom the complainant has taken treatment. Thus, an amount of Rs.71530/- - TDS of Rs.7153 i.e. an amount of Rs.64,377/- has been paid to OP No.3 from whom the complainant has taken treatment. On merits, the factum with regard to taking insurance policy by the complainant is admitted and it is also admitted that the treatment was taken by the complainant from OP No.3, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                OP No.3 filed its separate written reply and contested the complaint by taking preliminary objections that the present complaint is false and frivolous and is not maintainable against the answering OP No.3. It is further averred that the present complaint has been wrongly filed against OP No.3. The OP No.3 has no role in the present complaint as the present compliant is regarding insurance claim between complainant and OPs no.1 and 2. The OP No.3 is only the hospital who perform the surgery and gave treatment to the complainant. The OP No.3 has been unnecessarily impleaded as a party in the present complaint. The present complaint should be dismissed against the answering OP No.3 with special cost. On merits, it is admitted that the heart surgery was perfomed in the hospital of OP No.3 and it is also admitted that all dues of OP No.3 were cleared by the complainant as well as by the other OPs, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

4.                Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement. 

5.                We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.

6.                It is admitted that the complainant has purchased mediclaim insurance policy from the National Insurance Company for the period 15.07.2018 to 14.07.2019. It is also proved and admitted that as per the policy, sum insured was Rs.1,75,000/- besides bonus of Rs.37,500/-. As per the allegations of the complainant all the health ailments were covered in this policy. The policy has been proved as Ex.C-1/OP1-1. It has been alleged by the complainant that in the first week of December, 2018 he faced difficulty in breathing and he was diagnosed by the doctor having heart problem and immediate heart surgery was advised. He was operated by Dr. Sameer Goel. The OP No.1 through OP No.2 authorized the hospital i.e. OP No.3 for cashless treatment of the complainant. He has alleged that he was issued a medical bill Rs.2,17,285/- for indoor admission as on 05.12.2018 till 14.12.2018 on account of heart surgery. The OPs No.1 & 2 paid only Rs.75,000/- to the said hospital towards the payment of the bill, whereas the complainant himself made the payment of Rs.1,05,000/- to the hospital and availed a discount of Rs.37,825/- from the hospital. Since, the complainant was having bills of Rs.2,00,000/- only, therefore he lodged the claim of Rs.2,00,000/- with the OPs and the same bills have been proved by the complainant as Ex.C-4 to Ex.C-15. Despite reminders Ex.C-16, the OPs did not clear the bills.

7.                The OPs on the other hand denied that the complainant has ever lodged the claim of Rs.2,00,000/- as alleged. It has been alleged by the OPs that only the claim of Rs.2,19,201/- was lodged through OP No.3 and that claim has already been settled. It has been alleged by the OPs that the policy schedule is subject to the policy clauses and detail mentioned in Ex.OP1/1 and the amount of claim has been settled as per the policy schedule. It has further been alleged by the OPs that the amount of claim has been settled as per the policy clauses 1(A, B & C) of Ex.OP1/1. The charges mentioned in these clauses are not payable and has been paid as per the amount mentioned in the policy schedule. The terms and conditions of the policy schedule were well within the knowledge of the complainant, whereas the complainant has alleged that he was never supplied with any terms and conditions. In the written statement, it has been alleged by the OPs that the terms and conditions of the policy were available on the website, but this fact has not been proved by the OPs that the complainant was made known about the fact that the policy schedule can be read from the website available, nothing has been proved by the OP. Ex.C-2 shows that there are special remarks mentioned that claim will be settled as per agreed tariff list between the hospital and the PHS i.e. Paramount Health Services. Ex.C-3 shows that the complainant was authorized to receive cashless benefit as detailed mentioned in this document. The payment advice cum claim discharge voucher Ex.OP1/2 shows that the complainant has paid Rs.2,19,201/- and as per this document, the amount of Rs.1,44,201/- have been deducted as per Clause 1 (A, B & C). These exclusion clauses have not been proved to have brought to the notice of the complainant. In Ex.C-2, it has been alleged that the claim will be settled as per agreed tariff list between hospital and the PHS, but no tariff list has been proved by the OP to show that the claim has been settled for Rs.71,530/- and final payable Rs.64,377/- after deducting TDS amount is as per the tariff list between the hospital and the PHS. It has been held in a case titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Rajwant Kaur and Other”, 2021 (3) CLT 540 (CHD) that the onus is on the appellant insurance company to prove that it provided the terms and conditions of the policy to the complainant and the same were in her knowledge. It has been held in a case titled as “National Insurance Co. Ltd. & Ors Vs. M/s Saraya Industries Ltd”, 2020 (1) CLT 278 (NC) that it is the duty of the insurance company to supply all the terms and conditions of an insurance policy to the policy holder-there cannot be any presumption under law on the terms and conditions. It has been held in a case titled as “Bhanwar Lal Vishnoi Vs. Oriental Insurance Co. Ltd.”, cited in 2017 (1) CLT 401, that the insurance co. has to prove that the exclusion clause under which the claim is sought to be repudiated was communicated to the complainant.

8.                As per the law laid down by the Hon’ble Punjab State Commission and Hon'ble National Commission, the terms and conditions were never brought to the notice of the complainant and the OPs have not proved that the complainant was made aware about the exclusion clauses 1 (a, b & c) at the time of purchasing the policy. The OPs have also not proved the tariff list between the hospital and the PHS. So, the deductions done by the OPs are without any basis. So, the order for deducting the amount Ex.OP1/2 is set-aside.  

9.                In view of the above detailed discussion, it is clear that Rs.75,000/- has already been received by the complainant from the OPs No.1 and 2 by way of cashless facility. It has been alleged that he submitted bill of Rs.2,00,000/-, whereas this fact has been denied by the OP. No document has been proved to show that the claim was submitted for reimbursement. In such circumstances, the complainant is directed to submit the bills to the OPs for remaining payment made by him for his treatment within 10 days and then the OPs No.1 & 2 are further directed to settle the claim within 15 days from the date of submitting the bills. The OPs No.1 to 3 are directed to pay a compensation of Rs.10,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

10.              Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

17.02.2023         Member                          Member           President