Punjab

Faridkot

CC/16/86

Prem Kumar Bansal - Complainant(s)

Versus

National Insurance Company - Opp.Party(s)

Manjit Singh Sodhi

18 Oct 2016

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      86

Date of Institution: 1.04.2016

Date of Decision :   18.10.2016

 

Prem Kumar Bansal, s/o Sh Manohar Lal Bansal, Sh Bindra Das Bansal, #47, Adarsh Nagar, Old Cantt  Road, Faridkot.

...Complainant

Versus

National Insurance Company, Krishana Street, Fauji Road, Kotkapura, Tehsil Kotkapura, District Faridkot.

 .....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Sh P Singla, Member.

 

Present: Sh  M S Sodhi, Ld Counsel for complainant,

              Sh Ashok Monga, Ld Counsel for Ops.

.

(Ajit Aggarwal, President)

                                         Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of Rs.24,703/-on account of medical claim of complainant and for further directing OPs to pay Rs 50,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs10,000/-.

2                               Briefly stated, the case of the complainant is that complainant purchased a medi-claim insurance policy bearing no. 401702/8500000106/2016 got insured himself, his wife, his son and daughter under said policy. Policy was being purchased for the last four years and  it is still continuous without any break. It is submitted that son of complainant developed defect in vision and on consultation, doctor advised that his son needed surgery and for this purpose, son of complainant was admitted in Dr Daljit Singh Eye Hospital on 18.06.2015 and surgery was conducted on 19.06.2015 and they charged Rs.21,900/- and Rs.2,803/-from complainant on account of medicines. Thereafter, complainant submitted his claim alongwith all original record including medical bills to OP, but complainant was surprised to receive a letter dt 14.08.2015, vide which OP repudiated the claim of complainant on flimsy grounds as no terms and conditions of policy were supplied to complainant. Complainant made many requests to OP to make payment of his genuine claim, but despite repeated requests by complainant, they have not even paid single penny to him. All this amounts to deficiency in service and trade mal practice on the part of Ops and it has caused harassment and mental agony to complainant for which he has prayed for directions to OP to pay Rs.50,000/-as compensation alongwith cost of litigation besides the main relief. Hence, the present complaint.

3                                       The counsel for complainant was heard with regard to admission of the complaint and vide order dated 8.04.2016, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                                     On receipt of the notice, OPs filed written statement taking preliminary objections that complainant has concealed the material facts regarding alleged ailment of his son from answering OP and now, he has filed the present complaint with malafide intention with a view to extract money from OP. It is averred that complaint involves complex questions of law and facts, which require voluminous evidence and it can not be decided by this Forum having limited jurisdiction and limited time span and therefore, it is liable to be referred to competent Civil Court. It is further averred that claim regarding diseases is covered after four continuous claim free years and surgery for correction of the eye sight is specifically excluded as per terms and conditions of the Policy. The Insurance Policy in question is in the  4^th year of inception of Insurance Cover and therefore, claim is not payable and thus, present complaint is liable to be dismissed being not maintainable.  Claim of complainant has been declined after due enquiry and due application of mind and also on merits and as per terms and conditions of the policy and it can not be reopened before any Forum or channel. It is further submitted that there is no deficiency in service on the part of OP. However, on merits, ld counsel for OP have denied all the allegations being wrong and incorrect and reiterated that there is no deficiency in service or unfair trade practice on the part of OP. The allegations with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                               Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-11 and then, closed his evidence.

6                                In order to rebut the evidence of the complainant, the opposite party tendered in evidence, affidavit of Kamaljeet Singh, Div. Manager as Ex OP-1 and documents Ex OP-2 to 7 and then, closed the same on the part of Ops.

7                              Ld Counsel for complainant has vehementally argued that complainant purchased a medi-claim insurance policy  and got insured himself, his wife, his son and daughter under said policy. Policy was being purchased by complainant for the last four years and it is still continuous without any break. It is contended that son of complainant developed defect in vision and on recommendation of doctor that his son needed surgery, son of complainant was admitted in Dr Daljit Singh Eye Hospital on 18.06.2015 and surgery was conducted on 19.06.2015 and Hospital authorities charged Rs.21,900/- and Rs.2,803/-from complainant on account of medicines. Thereafter, complainant submitted his claim alongwith all original record including medical bills to OP, but vide letter dt 14.08.2015, OP repudiated the claim of complainant on flimsy grounds as no terms and conditions of policy were supplied to complainant. Complainant made many requests to OP to make payment of his genuine claim, but despite repeated requests by complainant, they have not made payment of his genuine claim. All this amounts to deficiency in service and trade mal practice on the part of Ops and it has caused harassment and mental agony to complainant.  He has prayed for accepting the present complaint alongwith compensation and cost of litigation. He has stressed on documents Ex C-1 to 11.

8                          To controvert the allegations of complainant, ld counsel for Ops asserted before the Forum that complaint filed by complainant is false and wrong and there is no deficiency in service on the part of Ops. Ld Counsel for OP stressed mainly on the point that claim regarding diseases is covered after four continuous claim free years and surgery for correction of the eye sight is specifically excluded as per terms and conditions of the Policy. The Insurance Policy in question is in the  4^th year of inception of Insurance Cover and therefore, claim is not payable and thus, present complaint is liable to be dismissed being not maintainable.  Claim of complainant has been declined after due enquiry and due application of mind and also on merits and as per terms and conditions of the policy and it can not be reopened before any Forum or channel. It is further submitted that there is no deficiency in service on the part of OP. Therefore, complainant is not entitled for any claim as sought by him. He has prayed for dismissal of complaint. He has stressed on documents Ex OP-1 to 7.

9                             We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

10                        The case of the complainant is that he purchased an insurance policy from OP and got insured himself, his wife, his daughter and his son. Policy purchased by complainant was continuous for last four years. Son of complainant developed some defect in his right eye and on recommendation of doctor, he was admitted in hospital for eye surgery on 18.06.2015 and surgery was conducted on 19.06.2015.Complainant paid Rs.21,900/- and Rs.2,803/-as charges for medicines to hospital authorities and thereafter, submitted claim alongwith all requisite documents to OP, but instead of making payment of genuine claim of complainant, Op repudiated the same vide letter dated 14.08.2015 on flimsy grounds, which amounts to deficiency in service. In reply, OPs refuted all the allegations levelled by complainant being wrong and incorrect and reiterated that there is no deficiency in service on their part and stressed mainly on point that claim of complainant is not covered under the policy in question till completion of four years. He has prayed for dismissal of complaint.

11                              Ld Counsel for complainant argued that the case of the complainant does not fall under the alleged Exclusion Clause, neither under the Exclusion Clause 4 nor under the Exclusion Clause 4.6. As per Exclusion Clause 4, the Company shall not be liable to make payment for disease/injuries which are pre-existing when the cover incepted for the first time till 4 continuous claim free Policy years and in the present case, the disease of the son of complainant is not of pre-existing nature. OPs have not produced any evidence that this disease was pre-existing at the time of purchasing the policy for first time. As per Exclusion Clause 4.6, the surgery for correction of eye-sight, spectacles, contact lenses etc are not covered, but treatment taken by son of complainant is not for correction of eye-sight or cost of spectacles etc. In the case of complainant, the disease was “PSEUDOPHAKIA WITH MYOPIA LEFT EYE DIAGNOSED AS A HIGHER CASE OF REFRACTIVE ERROR” and does not for the correction of eye-sight; the surgery for correction of eye-sight is    where it was conducted for removing the spectacles. So, Ops illegally and wrongly repudiated the claim of complainant on false grounds. Moreover, the OPs cannot reject the claim of complainant on the ground of alleged terms and conditions and exclusion clause, which are never supplied or explained to him at the time of purchase of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any Policy. The Insurance Companies in such cases, rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

12                               From the above discussion and case law produced by the complainant, we are of considered opinion that Ops have wrongly and illegally repudiated the claim of complainant on false grounds. The present complaint is hereby accepted. Ops are directed to pay Rs.24,703/-to complainant on account of medi-claim of the son of complainant alongwith interest at the rate of 9 % per anum from 14.08.2015 when they repudiated the claim of complainant till final realization. Ops are further directed to pay Rs.5,000/-to complainant as compensation for harassment and mental agony suffered by him including litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated :18.10.2016                  

                                 Member                          President

   (P Singla)                      (Ajit Aggarwal)