Before the District Consumer Disputes Redressal Forum, Room No. 208 2nd Floor, District Administrative Complex, Tarn Taran
Consumer Complaint No : 56 of 2018
Date of Institution : 24.05.2018
Date of Decision : 06.11.2019
Sukhdev Singh (UIC No. 8916 7458 7200) son of Hardial Singh (since deceased) through his legal representatives:- 1(i), Gurjit Kaur widow of Sukhdev Singh resident of House No. 350/2, Kulla road, Patti, Tehsil Patti, District Tarn Taran, 1(ii) Ratinder Kaur wife of Gurmail Singh daughter of Sukhdev Singh resident of village Maujewala Tehsil Dharamkot District Moga, 1(iii) Dhanwant Kaur wife of Balpreet Singh daughter of Sukhdev Singh resident of village Gandiwind Saran Tehsil & District Tarn Taran, 1(iv) Simratpal Kaur wife of Gurjit Singh daughter of Sukhdev Singh resident of village Kallah Tehsil Khadoor Sahib district Tarn Taran.
…..Complainant
Versus
- The New India Assurance Company Limited through its branch Manager, having its branch office at Jandiala road, Tarn Taran District Tarn Taran, State: Punjab
- Medi Assist Insurance TPA Private Limited through its Manager, having its corporate office at SCO 19, 2nd Floor Cabin No. 207, Sector 7C, Madhya Marg, Chandigarh.
…Opposite Parties
Complaint Under Section 12 of the Consumer Protection Act .
Quorum: Sh. Charanjit Singh, President
Smt. Jaswinder Kaur, Member
For Complainants Sh. H.S. Sandhu Advocate.
For Opposite Parties Exparte.
ORDERS:
Charanjit Singh, President;
1 The Sukhdev Singh (now deceased) original complainant has filed the present complaint under Section 12 of the Consumer Protection Act (herein after called as 'the Act') the New India Assurance Co. Ltd. and another (Opposite parties) on the allegations the opposite party No. 1 is a company incorporate under the Companies Act, 1956 and having its branch office at Tarn Taran and carries on the business of insurance. The opposite party No. 2 is a company incorporated under the companies Act, 1956 and having its corporate office at Chandigarh and carries on the business of assistance to the opposite party No.1. The opposite party No. 2 provides third party administrator (TPA) services for health insurance related claims. The medi claim file of the complainant was processed by the opposite party No.2. The complainant is working as insurance agent with LIC of India vide agent code 2098-137 of BO-137 under Amritsar Division. He is also a member of ZM Club of LIC of India. The complainant is a member of Group Medical claim insurance policy of LIC of India since 1.9.2013 onwards which is administered by the OP No. 1 vide policy Number 120300. The Medi Assist Id of the complainant provided by the OP No. 2 is 4018799137. During the policy period, the complainant fell ill and admitted to CMC Super Specialty Hospital Private Limited, Green Avenue, Amritsar from 1.10.2016 to 4.10.2016 and on 4.10.2016, the complainant admitted to Smt. Paarvati Devi Hospital Ranjit Avenue, Amritsar and he remained admitted in this hospital from 4.10.2016 to 8.10.2016 for his treatment. The complainant spent Rs. 2,02,052/- on his treatment. On 10.10.2016, the wife of the complainant duly informed to the Branch Manager of LIC of India regarding the treatment of the complainant in the hospital. After getting discharge from the hospital, the complainant approached the opposite party No. 1 for his medical insurance claim. The opposite party No. 1 advised the complainant to fill the claim form and also directed to enclose the original discharge card from the hospital alongwith bills, receipts and cash memos from the hospital/ chemist and also directed to disclose the receipt and pathological test reports from pathologist. As per advice given by the opposite party No. 1, the complainant submitted the duly filled in claim form dated 8.11.2016 in the office of opposite party No. 1 alongwith other relevant documents in original as advised by the opposite party No.1. At the time of submission of claim form, the OP No. 1 told the complainant to visit their office only after one month. After passing of one month period, the complainant approached the OP No. 1 and enquired about his medi-claim. On inquiry, the complainant came to know that the OP No. 1 sent the claim file of the complainant to the OP No. 2 for investigation. The dealing official of the OP No. 1 told the complainant that he has no need to visit their office again and again as the medi claim amount will be directly transferred in the bank account of the complainant within 2 months. After passing of 2 months period, the complainant did not receive any payment from the OP Nos. 1 and 2. Thereafter, the complainant again went to the office of OP No. 1 and enquired about the payment. The concerned officer of OP No.1 told the complainant that they did not receive the final report from TPA i.e. from the OP No. 2 and after receiving the final report, they will transfer the claim amount in the account of complainant. Later on after passing of another 3 months period, the complainant again visited the office of OP No.1 and received the same answer. Thereafter, the complainant several times visited the office of the OP No. 1 and always received the same answer. In the month of July 2017, the son in law of the complainant checked the claim status of the complainant from the website of the OP No. 2 and came to know that the claim of the complainant has already repudiated by the OP No.2 as per the provisions of clause 4.4.6 of policy terms and conditions. No terms and conditions were ever served to the complainant by the OP No.1. No such terms and conditions were ever contracted between the complainant and OP No. 1. After came to know about the status of his claim, the complainant immediately approached at the office of the OP No.1 and met with the branch manager and told him that the claim of the complainant is genuine one and also told to him that the allegations of consumption of the alcohol are totally false and baseless one as the complainant is teetotaler, but the branch manger of the OP No.1 did not bother the said request of the complainant. Till date of filing the present complaint, the OP No. 1 did not bother & issue any letter to the complainant regarding the repudiation of claim. Since 1.9.2013 i.e. from the date of inception of policy, the complainant never filed any claim with the OP No. 1 except the present claim in question. Thereafter the complainant again visited the office of OP No.1 but they did not listen anything. The complainant has prayed as follows:-
- The opposite parties may kindly be directed to pay the sum of Rs. 2,02,052/- to the complainant jointly or severally on account of insurance claim which is illegally repudiated by the opposite party Nos. 1 and 2 and also directed to pay the said amount alongwith interest thereon at the rate of 12% per annum w.e.f. 8.11.2016 till the date of realisation of said amount.
- A compensation to the tune of Rs. 50,000/- on account of mental agony harassment etc. and Rs. 11,000/- as litigation expenses.
Alongwith the present complaint the complainant has tendered in evidence affidavit of complainant Ex. CW1/A, self attested copy of reputation letter Ex. C-1, Self attested copy of Hospital Summery Ex. C-2, Self attested copies of collection receipts Ex. C-3, C-4, self attested copy of patient discharge Bill Ex. C-5, Self attested copies of Bills of receipts Ex. C-6, Ex. C-7, Self attested copies of Bill of Drugs Ex. C-8 to Ex. C-24, Self attested copies of the receipts Ex. C-25 to Ex. C-28, Self attested copy of Bill Ex. C-29, Self attested copy of Bill of test Ex. C-30, Ex. C-31, Self attested copy of Bill of Blood Ex. C-32, Self attested copy of Bill of Drugs Ex. C-33, Self attested copy of IPD receipt Ex. C-34, Self attested copy of pathology receipt Ex. C-35, Self attested copy of IPD receipts Ex. C-36, Ex. C-37, Self attested copies of the Dungs Bill Ex. C-38 to Ex. C-40, Self attested copy of collection receipt E. C-41, Ex. C-42, Self attested Copy of Drug Bill Ex. C-43, Self attested copy of document Index sheet Ex. C-44, Self attested copy of claim form Ex. C-45, Self attested copy of settlement of claim Ex. C-46, Self attested copy of application Ex. C-47, Self attested copy of pass book Ex. C-48, Self attested copy of Payment by NEFT Ex. C-49, Self attested copy of Adhar Card Ex. C-50, Self attested copy of voucher Card Ex. C-51, Self attested copy of application Ex. C-52, Self attested copy of discharge summery Ex. C-53, Self attested copy of Prescription Ex. C-54, Self attested copy of Test report Ex. C-55, Self attested copy of ABG Report Ex. C-56, Self attested copies of Patient Laboratory Test Ex. C-57 to Ex. C-59, Self attested copy of Prescription Ex. C-60, Self attested copy of Patient Laboratory Test Ex. C-61, Self attested copy of Insurance Card No. 62.
2 Notice of this complaint was sent to the opposite parties but no one appeared on behalf of opposite parties and consequently, the opposite party No. 2 was proceeded against exparte vide order dated 10.7.2018 and opposite party No. 1 was proceeded against exparte vide order dated 18.1.2019 by this Forum.
3 We have heard the Ld. counsel for complainant and have also carefully gone through the evidence and documents on the file.
4 The complainant has produced on record affidavit of Sukhdev Singh complainant Ex. CW1/A and declared that the complainant is working as insurance agent with LIC of India vide agent code 2098-137 of BO-137 under Amritsar Division. He is also a member of ZM Club of LIC of India. The complainant is a member of Group Medical claim insurance policy of LIC of India since 1.9.2013 onwards which is administered by the OP No. 1 vide policy Number 120300. The Medi Assist Id of the complainant provided by the OP No. 2 is 4018799137. He further declared that during the policy period, the complainant fell ill and admitted to CMC Super Specialty Hospital Private Limited, Green Avenue, Amritsar from 1.10.2016 to 4.10.2016 and on 4.10.2016, the complainant admitted to Smt. Paarvati Devi Hospital Ranjit Avenue, Amritsar and he remained admitted in this hospital from 4.10.2016 to 8.10.2016 for his treatment. The complainant spent Rs. 2,02,052/- on his treatment. On 10.10.2016, the wife of the complainant duly informed to the Branch Manager of LIC of India regarding the treatment of the complainant in the hospital. After getting discharge from the hospital, the complainant approached the opposite party No. 1 for his medical insurance claim. He further declared that the opposite party No. 1 advised the complainant to fill the claim form and also directed to enclose the original discharge card from the hospital alongwith bills, receipts and cash memos from the hospital/ chemist and also directed to disclose the receipt and pathological test reports from pathologist. As per advice given by the opposite party No. 1, the complainant submitted the duly filled in claim form dated 8.11.2016 in the office of opposite party No. 1 alongwith other relevant documents in original as advised by the opposite party No.1. At the time of submission of claim form, the OP No. 1 told the complainant to visit their office only after one month. After passing of one month period, the complainant approached the OP No. 1 and enquired about his medi-claim. On inquiry, the complainant came to know that the OP No. 1 sent the claim file of the complainant to the OP No. 2 for investigation. He further contended that the dealing official of the OP No. 1 told the complainant that he has no need to visit their office again and again as the medi claim amount will be directly transferred in the bank account of the complainant within 2 months. After passing of 2 months period, the complainant did not receive any payment from the OPs No. 1 and 2. Thereafter, the complainant again went to the office of OP No. 1 and enquired about the payment. The concerned officer of OP No.1 told the complainant that they did not receive the final report from TPA i.e. from the OP No. 2 and after receiving the final report, they will transfer the claim amount in the account of complainant. He further declared that later on after passing of another 3 months period, the complainant again visited the office of OP No.1 and received the same answer. Thereafter, the complainant several times visited the office of the OP No. 1 and always received the same answer. In the month of July 2017, the son in law of the complainant checked the claim status of the complainant from the website of the OP No. 2 and came to know that the claim of the complainant is already repudiated by the OP No.2 as per the provisions of clause 4.4.6 of policy terms and conditions and repudiation letter is Ex. C-1. He further declared that no terms and conditions were ever served to the complainant by the OP No.1. No such, terms and conditions were ever contracted between the complainant and OP No. 1. After came to know about the status of his claim, the complainant immediately approached at the office of the OP No.1 and met with the branch manager and told him that the claim of the complainant is genuine one and also told to him that the allegations of consumption of the alcohol are totally false and baseless one as the complainant is teetotaler, but the branch manger of the OP No.1 did not bother the said request of the complainant. Till date of filing the present complaint, the OP No. 1 did not bother & issue any letter to the complainant regarding the repudiation of claim. He further declared that since 1.9.2013 i.e. from the date of inception of policy, the complainant never filed any claim with the OP No. 1 except the present claim in question. Thereafter the complainant again visited the office of OP No.1 but they did not listen anything. The complainant has also placed on record Hospital Summery, collection receipts, discharge Bills, Bills of Drugs, Bills of Test Claim form, Settlement of claim, Application, passbook, payment by NEFT, Adhar Card, Voter card prescription slip, Insured card etc. Ex. C-1 to Ex. C-62 and the complainant prayed that the present complaint may be allowed.
5 The evidence led by the complainant on the file goes unchallenged and unrebutted as Opposite Parties are proceeded against exparte in the present complaint and there is no reason on the file as to why the evidence produced by the complainant be not believed. Otherwise also, due notice was issued to the Opposite Parties and opposite parties did not appear in the Forum in order to contest the complaint which shows that the Opposite Parties have nothing to say upon the allegations leveled against them by the complainant. As such, the complainant is entitled to the relief claimed in the complaint and it stands established on record that the complainant is approaching the opposite parties several times but he opposite parties did not care to resolve the matter, not only committed deficiency in service, but also indulged in an unfair trade practice.
6 Vide repudiation letter Ex. C-1 the opposite party has denied the claim as per clause 4.4.6 of the policy terms and conditions. But the case of the complainant is that terms and conditions were not read over and explained and supplied to the complainant by the opposite parties. It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein 10 the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent cannot claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.” Our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.871 of 2014 decided on 03.02.2017 in case titled as Veena Mahajan (Widow) and others Vs. Aegon Religare Life Insurance Company Limited in para No.5 has held that
“Counsel for the appellant argued that copy of insurance policy was not supplied to the appellant and hence, the exclusion clause in the contract of the insurance policy is not binding upon him. He further argued that no proof of sending of insurance policy was ever produced by the respondent despite specific contention raised by the complainant that the insurance policy was never received by him. He argued that though there is an averment of the OP that the policy in question was delivered through Blue Dart Courier to the complainant. In order to prove their contention, no affidavit of any employee of Blue Dart was produced who would have made a statement to have the effect that the policy was delivered to the complainant nor any acknowledgement slip for having received the article by the complainant through courier company was produced by the insurance company. He argued that since no policy document 11 was received by the insured and argued that the terms and conditions as alleged to be part of the insurance policy were not binding upon the insured. He argued that policy was issued in the name of deceased Sh.Vijinder Pal Mahajan with his wife Mrs.Veena Mahajan as beneficiary and the same was never refused by the OP and the proper premium for insurance was paid by late complainant. He argued that as per the specific allegations made in the complaint in para No.4, no rebuttal to that contention was specifically there in their written reply in para No.2 and para No.4 in the reply filed by OP in the District Forum. He argued that Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case of "Ashok Sharma Vs. National Insurance Co. Limited", in Revision Petition No. 2708 of 2013 held in para No.8 to the point of nondelivery of terms and conditions of the policy. He also cited Hon'ble Supreme Court's decision given in the matter of "United India Insurance Co. Limited Vs. M.K.J.Corporation" in Appeal (civil) 6075-6076 of 1995 (1996) 6 SCC 428 wherein the Apex court held that a fundamental principle of Insurance Law makes it that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose, "similarly, it is the duty of the 12 insurers and their agents to disclose all material facts within their knowledge, since obligation of good faith applies to them equally with the assured and further argued that since the terms and conditions were not supplied even on repeated requests the same cannot be relied upon by the opposite party in order to report to repudiate the genuine claim of the wife of the deceased policy holder.”
Moreover, it is usual with the insurance company to show all types of green pesters to the customer at 13 the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This take it or leave it‟, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. 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 111 went on to hold as under:-
“It seams 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 14 time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.”
Furthermore the entire record on the file related to medical history of the deceased do not prove that person was alcoholic.
7 During the pendency of the present complaint, Sukhdev Singh original complainant in this case has since died and after his death Gurjit Kaur complainant No. 1(i) is widow, Ratinder Kaur complainant No. 1(ii) is his daughter, Dhanwant Kaur complainant No. 1(iii) is his daughter and Simratpal Kaur complainant No. 1 (iv) is his daughter and they have been impleaded in the present complaint.
8 In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainants No. 1(i) to 1(iv) and against the Opposite Parties. The opposite parties are directed to make the payment of Rs. 2,02,052/- (Rs. Two Lacs two hundred and fifty two only) to the complainant. The complainant has been harassed by the opposite parties unnecessarily for a long time. The complainant is also entitled to Rs.10,000/- ( Rs. Ten Thousand only) as compensation on account of harassment and mental agony and Rs 5,000/- ( Rs. Five Thousand only) as litigation expenses. The complainants are entitled to the awarded amount as follows:-
Gurjit Kaur : 25%
Ratinder Kaur : 25%
Dhanwant Kaur : 25%
Simratpal kaur : 25%
Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainants are entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.
