DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

Tejbir Kaur wife of Sh.Gurwinder Singh & Gurwinder Singh son of Sh.Rawel Singh both residents of House No.16, Shri Niwas Colony, Patiala.

                                                                   …………...Complainants

                                      Versus

1. National Insurance Company Limited, Branch Office Factory Area, Patiala through its Branch Manager.
2. National Insurance Company Limited, Head Office # 3, Middleton Street Kolkata,700071.

                                                                   …………Opposite Parties

Complaint under the Consumer Protection Act

QUORUM

                                      Hon’ble Mr.S.K.Aggarwal, President

                                      Hon’ble Mr.G.S.Nagi,Member         

PRESENT:                   Sh.K.S.Pruthi, counsel for complainant.

                             Sh.Alok Mathur, counsel for OPs.   

 ORDER                                          

1. The instant complaint is filed by Tejbir Kaur wife of Sh.Gurwinder Singh & Gurwinder Singh son of Sh.Rawel Singh (hereinafter referred to as the complainant) against National Insurance Company Limited (hereinafter referred to as the OP/s) under the Consumer Protection Act ( for short the Act).
2. The averments of the complainant are as follows:

That Sh.Gurwinder Singh S/o Rawel Singh, took mediclaim policy No.401406/48/14/8500000078 on 27.6.2014 from OP No.2 through OP no.1 and has been paying premium regularly. Complainant Tejbir Kaur is also covered in the above said policy being wife of Gurwinder Singh.

Complainant Tejbir Kaur developed complications regarding her kidneys which became renal failure at a later stage for which she is taking regular treatment from Columbia Asia and PGI Chandigarh and she availed medical claim cashless facility from Columbia Asia, for an amount of Rs.2,20,000/- for her dialysis and hospital emergency admission. However, the last bill for an amount of Rs.31,129/- wasrejected by OPs on illegal grounds. Due to denial of OPs complainant was forced to pay cash amount to the hospital for getting her treatment done. It is mentioned that due to denial of OPs complainant till the next policy renewal cycle is liable to pay claimed expenses such OPs are denying rightful alongwith complainant. As such rejection of above mentioned claim by the OPs vide their email communicated to the hospital dated 1.1.2020 is illegal, null and void. Complainant requested OPs many times to provide cashless facility to the complainant and also to pay the bill to the hospital as per policy but OPs did not adhere to the request of complainant. Complainants served legal notice dated 12.1.2020 to the OPs who gave baseless reply without any grounds. There is thus, deficiency in service on the part of OPs, which caused mental agony and harassment to the complainants. Consequently, prayer has been made for acceptance of complaint.

3. Upon notice, OPs appeared through counsel and filed written statement having raised certain preliminary objections.
4. On merits, it is submitted that Parivar Mediclaim policy No.401406501910000049 was issued by OPs in the name of Gurwinder Singh for a period from 27.6.2019 to midnight of 26.6.2020, which was duly supplied to the complainant alogwith terms and conditions. Coverage of Tejbir Kaur in the said policy is also admitted. It is submitted that company liability would arise only if the treatment of deceased or injury contracted /suffered is during the policy period and total expenses incurred for any one illness is limited to 50% of SI per family. As per the record, sum insured under the policy is rs.4 Lakhs and hence liability of OPs is limited to Rs.2Lakhs for any one illness. One illness means continuous period of illness and it includes relapse within 45 days from the date of last consultation with hospital where treatment has been taken. As per record, complainant was suffering from chronic kidney disease and has taken treatment from Columbia Asia Hospital, Patiala. During the policy period, Medi Assist TPA Private Ltd. received the claims approximately to the tune of Rs.1,90,111/- and approved claim No.20842843 (claim amount of Rs.32,008/-) but the amount was not disbursed, including claim of Rs.31,129/-which was repudiated as the same exceeds 50% of total sum insured i.e. Rs.2lakhs against the sum insured of Rs.4Lakhs. Hence the claim for an amount of Rs.31,119/- is not admissible under the policy terms and conditions and the TPA has repudiated the same vide email dated 3.1.2020.Now the complainant is not entitled for any claim from the OPs. Reply to the show cause notice is admitted by the OPs. It is denied that there is any deficiency in service on the part of OPs. Other averments of complainants have also been denied and OPs prayed for dismissal of complaint.
5. In evidence, complainant furnished his affidavit,Ex.CA alongwith documents,Exs.C1 to C30 and closed evidence.
6. On the other hand, ld. counsel for OPs furnished affidavit, Ex.OPA of Bhupinder Singh Malik, Branch Manager, Ex.OPB affidavit of Sh.Dayanand Kallianpur, authorized signatory alongwith documents (copies) Exs.OP1 policy , OP2 terms and conditions, Ex.OP3 reply to notice,Ex.OP4 postal receipt,Ex.OP5 email and closed evidence.
7. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
8. The complainant had taken a mediclaim policy No. 401406/48/14/8500000078   dated 27.6.2014,Ex.C1 from the OPs.The policy was continuously extended by paying the premium annually and the policies for the subsequent years are Exs.C2 to C7. The complainant was holding  policy bearing No.401406501910000049, which was valid for the period 27.6.2019 to 26.6.2020 during which period wife of complainant developed complications and was hospitalized. She was also covered under the said policy which was issued for an amount of Rs.4 Lakh. Wife of the complainant developed some complications and had to take treatment from Columbia Asia Hospital, Patiala and PGI Chandigarh. The cashless facility, as per the provision of the policy, was provided to the complainant and bills amounting to Rs.1,90,111/- were reimbursed by the OPs. However, the cashless facility/reimbursement of Rs.31,129/- was repudiated  on flimsy grounds vide  communication dated 1.1.2020,Ex.C30 and  subsequent bills were also denied by the OPs.
9. OPs have admitted that the complainant was holding a Parivar Mediclaim policy which was valid for 27.6.2019 to 26.6.2020 and the wife of the complainant was also covered under the said policy.Ld. counsel for the OPs has argued that as per clause 1.2(E) Coverage of the said Mediclaim policy, the liability of the OPs related to hospitalization expenses of a person is limited to 50% of the sum insured for any one illness. As per clause 3.1 of the said policy any one illness means continuous period of illness and which includes re-lapse within 45 days from the date of last consultation with the hospital where treatment has been taken. As such, ld. counsel for the OPs has argued that the sum insured under the policy was Rs.4lakh and liability of the OPs is limited to Rs.2lakh under the said clause for anyone illness. He has further argued that five claims amounting to Rs.81640/- + 17664/- + 31430/-+26520/-+32857/- were settled, whereas the claim amounting to Rs.31,129 was not settled and repudiated as per terms and conditions of the policy.
10. Ld. counsel for the complainant has argued that no such pre conditions were disclosed to the complainants at the time of taking the policy in the year 2014 or during the yearly renewal of the same and also no such documents were issued by the OPs to the complainant. Ld. counsel for the complainant relied upon the judgment issued in Civil Appeal No.4071 of 2020, decided on 20.5.2022 by the Hon’ble Supreme Court of India in the case titled as Gurmel Singh Vs. Branch Manager, National Insurance Co. Ltd., wherein it has been held that the Insurance companies are refusing the claim on flimsy grounds and / or technical grounds. While settling the claims the insurance companies should not be too technical and has allowed the appeal.
11. Moreover, OPs were bound to disclose all the terms and conditions of the policy to stake holder as per the guidelines issued by IRDA. However, no such policy document was issued to the complainant by the OPs.
12. As such, we are of the considered opinion that the complainant has taken the Parivar Mediclaim Insurance policy in the year 2014 and was continuing with the same policy till the year 2020. The clause relied upon by the OPs was never brought to the notice of the complainant and also terms and conditions of the policy were never delivered to the complainant. Moreover,  said clause is arbitrary and has been inserted by the OPs being the insurer and controlling the terms and conditions of the policy on which the complainant had no control as the terms and conditions are framed and controlled by the OPs. As such complainant was left with no other option but to accept the same. OPs were therefore, bound to settle the claim of the complainant upto an amount of Rs.4lakh i.e. sum insured.
13. Complaint is accordingly partly allowed and we direct the OPs to settle the claim of the complainant to the tune of Rs.31,129/- alongwith interest @ 6% per annum from the date of filing of this complaint i.e. 18.3.2020 till realization within 30 days from the date of receipt of certified copy of this order failing which OPs shall pay interest @9% per annum on the said amount till realization. OPs are also directed to pay Rs.2000/-as compensation which is inclusive of costs for the mental agony and harassment caused to the complainant.      
14.           The instant complaint could not be disposed of within stipulated period due to Covid protocol and for want of Quorum from long time.
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                                              G.S.Nagi                           S.K.AGGARWAL

                                              Member                          President