Punjab

Faridkot

CC/21/10

Parmod Kumar - Complainant(s)

Versus

National Insurance Co. Ltd and another - Opp.Party(s)

Anil Kumar Chawla

23 Aug 2023

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FARIDKOT

 

Complaint No. :       10 of 2021

Date of Institution:   08.01.2021

Date of Decision :    23.08.2023

 

Parmod Kumar aged about 58 years son of Babu Ram, resident of Dr. Harnam Singh Street, Near Red Light Chowk, Jaitu Road, Kotkapura , Tehsil Kotkapura, District Faridkot.

                                                                           .........Complainant

Versus

1. National Insurance Co. Ltd. 1^st Floor, Shop No.11, Jublie Cinema Market, Near Punjab National Bank, Faridkot through its Branch Manager.
2. Vipul Med Crop Insurance TPA Private Ltd 515, Udyog Vihar, Phase-V, Gurgaon (Haryana-122016)

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

(now, under Section 35 of the C.P. Act 2019)

 

Quorum: Smt Kiranjit Kaur Arora, President,

               Sh Vishav Kant Garg, Member.

 

Present:  Sh Anil Chawla, Ld Counsel for Complainant,

               Sh Ashok Monga, Ld Counsel for OPs.

 

ORDER

(Kiranjit Kaur Arora, President)

                                             Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against  OPs seeking directions to OPs to make payment of insurance claim of Rs.31,803/-with interest and for further directing OPs to pay Rs.50,000/-

 

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as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.10,000/-.

2                                   Briefly stated, the case of the complainant is that complainant purchased a family medicare insurance policy bearing no.406005501910000001 from OPs valid from 05.04.2019 to 4.04.2020 for a sum of Rs.1,00,000/- and said policy covered the risk of complainant and his family. It is submitted that on 22.06.2019 Kanish Mittal, son of complainant suffered knee joint injury as the two wheeler which he was driving, slipped suddenly and he was taken to Apollo Hospital, Bangalore where he spent Rs.24,866/- and Rs.6937/-over his treatment. After that complainant submitted claim for Rs.31,803/- before OPs and on their demand, submitted all the requisite and relevant documents to the office of OP-1, but till date, OPs paid nothing on account of insurance claim. Complainant made several requests to OPs to make payment of his genuine insurance claim but all in vain, rather they repudiated the claim of complainant by declaring it as ‘No Claim’ vide letter dated 04.03.2020. Despite repeated requests, OPs have not made a single penny on account of insurance claim of complainant, which amounts to deficiency in service and has caused harassment and mental tension to him. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

 

 

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3                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 19.01.2021, complaint was admitted and notice was ordered to be issued to the OPs.

4                                     On receipt of the notice, the OPs filed written statement wherein asserted that there is no deficiency in service on the part of OPs and have denied all the allegations of complainant being wrong and incorrect. It is averred that complainant has concealed the material facts regarding his injuries and the accident and present complaint involves complicated questions of law and facts requiring lengthy evidence that is not permissible in the summary procedure of this Commission. Moreover, complainant did not provide any intimation regarding alleged accident to answering OP thereby preventing them to gather first hand information about said accident. Alleged treatment taken by insured was taken as an outdoor patient and it does not fall within the purview of hospitalization and therefore, claim of complainant is not payable as per clause 2.0, 3.9 and 3.12 of the policy in question. Claim of complainant has been rightly declined by answering OP as per terms and conditions of the policy after carefully going through the merits of the case. Moreover, complainant has not provided requisite documents. However, on merits, OPs have denied all the allegations of complainant being wrong and incorrect and prayed for dismissal of complaint with costs. It is denied that insured son of complainant suffered any knee injury in alleged accident as no intimation regarding said accident was given to Police or to the

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answering OP. Alleged injury occurred on 22.06.2019 and injured got initial treatment and dressings from a local hospital but failed to disclose about the details of said hospital and name of doctor is also not mentioned. It is averred that since he was having pain in left knee and he visited Apollo Hospital, Bangalore on 24.06.2019 where he underwent MRI and other investigations. He was diagnosed “Fracture of Intercondylar Eminence of Tibia and Lateral Meniscus tear” for which he was advised conservative treatment with brace and medication and physiotherapy and from the documents produced, it is clear that he was neither admitted in any hospital nor he underwent any treatment as an indoor patient. Complainant is not entitled for relief sought. There is no deficiency in service on their part and made prayer for dismissal of complaint with costs.

5                                              Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-10 and then, closed their evidence.

6                                              In order to rebut the evidence of the complainant, ld counsel for OPs tendered in evidence affidavit of Satish Chander Ex OP-1 and document Ex OP-2 to 13 and then, closed the same on behalf of OPs.

7                                              We have carefully examined all the documents/evidence produced on record for its contained statutory merit

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and have also judiciously considered and perused the arguments duly put forth by the learned counsels for the parties.

8.                                    The case of the complainant is that he is insured under the policy in question and during the subsistence of said policy, Son of the complainant suffered knee joint injury as the two wheeler which he was driving, slipped suddenly and he was taken to Apollo Hospital, Bangalore where he spent Rs.24,866/- and Rs.6937/-over his treatment. and thereafter, he lodged claim with OPs, completed all the formalities and also submitted all the requisite documents to them. But opposite parties repudiated the claim of complainant by declaring it as ‘No Claim’ vide letter dated 04.03.2020. All other documents required for processing the claim have already been furnished by the complainant to them and nothing more is required to be submitted by complainant to OPs. Act of OPs amounts to deficiency in service .

9                                   It is admitted case of the opposite parties that intimation with regard to treatment was given by the complainant to the opposite party No.1. The stand of the Opposite party no.1 is that as per the preview of the policy, OPD treatment is not covered under the policy as such the claim was rightly rejected.

10                                            The Ld. counsel for the complainant argued that Opposite party no.1 wrongly and illegally repudiated the claim of the complainant on the lame excuse and flimsy ground/remarks. Moreover policy terms and conditions were not supplied to the

 

 

 

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complainant; as such the terms and conditions are not binding upon the complainant.                            

11                                         From the above said discussion, it is clear that there is no dispute as regards to the policy particulars, period of policy, sum insured. Due to the new technology, sometimes patients are treated in less time even or without hospitalization, if the patient is not admitted or is treated within a short time after admission due to new techniques, the insurance company cannot reject the claim on the ground that the patient was not admitted. It transpires that the genuine claim of the complainant has been repudiated by the opposite parties without any reasonable excuse. It is usual with the insurance companies to show green pastures to the consumers when they are to sell their policies. But however when it comes to the payment for claim, they invent all sort of excuses to deny the claim. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claim. In similar set of facts the Hon‟ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111went on to hold as under:-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All 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 clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy".

 

 

 

 

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                      The commission observed that  the opposite parties repudiated the claim vide leter dt.04-03-2020 which is Ex.OP-13 on the basis of clause 5.6.3 for non compliance of query reply, but in  the file  the complainant gave satisfactory reply of the query of the opposite parties which is Ex.C-7 and C-8 .The copies of medical bills and receipts which are placed on file are of Rs.24,866/-, reveal the fact that complainant spent amount on treatment from his own pocket. Even then the opposite party rejected the genuine claim of the complainant which amounts to deficiency in service on the part of opposite parties.

12                               Therefore, as a sequel of the above discussion considering the facts and circumstances of the case and relying upon the above quoted judgments, this Commission is of considered opinion that the rejection of the medical claim of the complainant is not justified. Hence, the complaint in hand is hereby partly allowed and the claim rejection letter dated 04.03.2020 of opposite parties (Ex.C-9) is hereby  set aside. Further, opposite party No.1 is directed to pay Rs.24,866/- along with interest @ 6% P.A. from filling of the present complaint i.e. 18.01.2021 till its realization within forty five days from the date of receipt of copy of this order, failing which opposite parties shall pay the said amount along with interest @ 9% P.A. to the complainant , in addition to this opposite party no.1 is directed to pay Rs.5000/- in lump sum as deficiency in services and litigation charges to the complainant. Complaint against opposite party No.2 stands hereby dismissed.

13                            The complaint could not be decided within the

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stipulated period due to heavy pendency of cases and incomplete of quorum. A copy of this order be communicated to the parties concerned free of costs.  File be consigned to the record room.

Announced in Commission

Dated : 23.08.2023

 

Member                             President

         (Vishav Kant Garg)         (Kiranjit Kaur Arora)