Punjab

Faridkot

CC/16/169

Kuldeep Kumar - Complainant(s)

Versus

Near India Assurance Company Limited - Opp.Party(s)

Vinod Kumar Monga

06 Dec 2016

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      169

Date of Institution: 16.06.2016

Date of Decision :   06.12.2016

 

Kuldeep Kumar aged about 59 years  s/o Sh Krishan Gupta, c/o New Medical Hall, Faridkot Tehsil and District Faridkot.

...Complainant

Versus

1     New India Assurance Company Ltd, through its Branch Manager, Near, P S Kotwali, District Faridkot.

2        Raksha TPA Pvt Ltd SCO 350-360, 1^st Floor, Sector-44 (D), Chandigarh through its Authorized Signatory.

 .....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Sh P Singla, Member.

 

Present: Sh  Vinod Monga, Ld Counsel for complainant,

              Sh Atul Gupta, Ld Counsel for OP-1,

              OP-2 Exparte.

 

(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.48,707/-on account of medical claim of complainant and for further directing OPs to pay Rs.40,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.5,500/-.

2                               Briefly stated, the case of the complainant is that complainant purchased a cashless medi-claim insurance policy bearing no. 36070134152500000077 valid for a period from 23.03.2016 to 22.03.2017 covering limit of risk upto Rs.2,50,000/-. A similar policy for a period from 23.03.2015 to 22.03.2016 with maximum limited risk covering upto Rs2,50,000/-was also purchased by complainant. It is submitted that complainant was having some problem in his right knee and he got himself treated from the Fortis Hospital, Mohali for the period from 31.03.2016 to 2.04.2016 as indoor patient. Hospital issued bill of Rs.84,864/-for cost of treatment and bill alongwith relevant documents was handed over to OPs, but very strangely, OP-1 paid claim only to the tune of Rs.36,157 and did not make payment of remaining amount. Though at the time of purchase of said policy, complainant was told that in case of any problem, OP-1 would bear all the expenses of concerned hospital up to the limit of Rs.2,50,000/-, but complainant was forced to make whole payment and OPs paid claim amount of only Rs.36,157/-. Complainant requested Ops to make payment of total expenses of treatment, but OPs refused to do so saying that whatever was permissible was paid to him. OPs have wrongly and illegally deducted Rs.48,707/- and this act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for directions to OP to pay Rs.40,000/-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 24.06.2016, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                              On receipt of the notice, OP-1 filed written statement taking preliminary objections that complainant is not the consumer of OP-1 and therefore, present complaint is liable to be dismissed. 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 complainant is covered under the New Mediclaim 2012 Policy and he is bound by all its terms and conditions. Rs.33,726/-have been paid to complainant as full and final settlement of his claim and there was no grievance or protest ever raised by him. As per Claim Settlement Voucher, complainant did not raise any objection at that time. Moreover, complainant was entitled to room charges to the tune of Rs.3000/-, doctor’s fee Rs.600/-, Surgeon’s fee Rs.15,888/-, Investigation charges Rs.970/-, Medication Charges Rs.13,268/- as approved by OP-2 and thus, total amount of Rs.33,726/-, which was recommended by OP-2 after deducting TDS was paid to complainant. However, on merits, OP-1 admitted before the Forum  that complainant purchased the cashless insurance policy in question from them and said policy was subject to verification by their Surveyor and whole amount spent on his treatment is paid to him. It is denied that complainant is entitled for Rs.84,864/-, rather complainant was entitled to limited benefits as per terms and conditions of the policy and therefore, requisite amount to which he was entitled has already been paid to him. It is further averred that policy documents containing  terms and conditions of the policy in question were duly served to complainant at the time of purchase of policy and nothing was assured by agent regarding medical problem. It is denied that amount of Rs.48,707/-have been wrongly deducted by OPs, rather complainant is bound by terms and conditions of the policy and complainant was well conversant with these conditions. It is reiterated that there is no deficiency in service on the part of OP-1 and prayed for dismissal of complaint with costs.

5                             Notice of complaint was issued to OP-2 through registered post, but same did not receive back. Acknowledgment might have been mis-laid or lost in transit. OP-2 did not appear despite making several calls in the Forum on date fixed, therefore after waiting for long period till 4.00 pm, OP-2 was proceeded against exparte vide order dated 8.08.2016.

6                                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 6 and then, closed his evidence.

7                             In order to rebut the evidence of the complainant, the opposite party tendered in evidence, affidavit of D D Aggarwal, Div. Manager as Ex OP-1 and documents Ex OP-2 to 5 and then, closed the same on the part of Ops.

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

9                         Ld Counsel for complainant has vehementally argued that complainant purchased a cashless medi-claim insurance policy bearing no. 36070134152500000077 valid for a period from 23.03.2016 to 22.03.2017 covering limit of risk upto Rs.2,50,000/-. A similar policy for a period from 23.03.2015 to 22.03.2016 with maximum limited risk covering upto Rs2,50,000/-was also purchased by complainant. It is submitted that due to some problem in his right knee complainant got himself treated from the Fortis Hospital, Mohali from 31.03.2016 to 2.04.2016 as indoor patient. Hospital issued bill of Rs.84,864/-for cost of treatment and bill alongwith relevant documents was handed over to OPs, but very strangely, OP-1 paid claim only to the tune of Rs.36,157 and did not pay the remaining amount. Though at the time of purchase of said policy, complainant was told that in case of any problem, OP-1 would bear all the expenses of concerned hospital up to the limit of Rs.2,50,000/-, but complainant was forced to make whole payment and OPs paid claim amount of only Rs.36,157/-. Complainant requested Ops to make payment of total expenses of treatment, but OPs refused to do so saying that whatever was permissible was paid to him. OPs have wrongly and illegally deducted Rs.48,707/- and this act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for accepting the present complaint with main relief. He has stressed on document ExC-1 to 6.

10                              To controvert the allegations of complainant, ld counsel for OP-1 argued before the Forum that complainant is covered under the New Mediclaim 2012 Policy and he is bound by all its terms and conditions. Rs.33,726/- have been paid to complainant as full and final settlement of his claim and there was no grievance or protest ever raised by him. As per Claim Settlement Voucher, complainant did not raise any objection at that time. Moreover, complainant was entitled to room charges to the tune of Rs.3000/-, doctor’s fee Rs.600/-, Surgeon’s fee Rs.15,888/-, Investigation charges Rs.970/-, Medication Charges Rs.13,268/- as approved by OP-2 and thus, total amount of Rs.33,726/-, which was recommended by OP-2 after deducting TDS was paid to complainant. However, on merits, OP-1 admitted before the Forum  that complainant purchased the cashless insurance policy in question from them and said policy was subject to verification by their Surveyor and whole amount spent on his treatment is paid to him. It is denied that complainant is entitled for Rs.84,864/-, rather complainant was entitled to limited benefits as per terms and conditions of the policy and therefore, requisite amount to which he was entitled has already been paid to him. It is further averred that policy documents containing terms and conditions of the policy in question were duly served to complainant at the time of purchase of policy and nothing was assured by agent regarding medical problem. It is denied that amount of Rs.48,707/-have been wrongly deducted by OPs, rather complainant is bound by terms and conditions of the policy and complainant was well conversant with these conditions. It is reiterated that there is no deficiency in service on the part of OP-1 and prayed for dismissal of complaint with costs.

11                     After careful perusal of the record available on file and going through the evidence led by parties, it is observed that case of the complainant is that he purchased a cashless Mediclaim policy from OPs which covered risk upto treatment of Rs.2,50,000/-and during the existence of said policy, complainant got the treatment of his right knee and he remained admitted in Fortis Hospital, Mohali from31.03.2016 to 2.04.2016 as indoor patient. After receiving the bill of Rs.84,864/-from hospital authorities, complainant submitted the same with Ops for processing his insurance Mediclaim, but OPs against their assurance refused to make payment of entire bill amount and complainant was compelled to pay Rs.48,707/-and OPs paid only amount of Rs.36,157/-to complainant out of hospital bills. OPs have illegally deducted Rs.48,707/- and this act of Ops amounts to deficiency in service and trade mal practice, which caused harassment to him. 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 as per terms and conditions of the Mediclaim policy, complainant is not entitled to total bill of Rs.84,864/-, rather he was entitled to limited benefits. Amount of Rs.48,707/- has not been wrongly deducted as it is done as per terms and conditions of the policy. As per terms and conditions of the policy, complainant was entitled to room charges to the tune of Rs.3000/-, doctor’s fee Rs.600/-, Surgeon’s fee Rs.15,888/-, Investigation charges Rs.970/-, Medication Charges Rs.13,268/- as approved by OP-2 and thus, total amount of Rs.33,726/-, which was recommended by OP-2 after deducting TDS was paid to complainant and now, nothing is due to be paid to complainant.

12                              Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, 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.

13                            From the above discussion and case law produced by the complainant, we are of considered opinion that Ops have wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy  out of entire amount, spent on treatment by complainant, which was covered under the Mediclaim insurance policy. The present complaint is hereby accepted. Ops are directed to payRs.48,707/-to complainant, which was wrongly deducted out of his Mediclaim alongwith interest at the rate of 9 % per anum from 2.04.2016 when they made less payment till final realization. Ops are further directed to pay Rs.5,000/-to complainant as compensation for harassment and mental agony suffered by him besides Rs.2000/- as 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 :6.12.2016          

                                        Member                          President

          (P Singla)                      (Ajit Aggarwal)