Punjab

Faridkot

CC/19/169

Yash Pal Bansal - Complainant(s)

Versus

New India Assurance Co. - Opp.Party(s)

Peush Jain

14 Jan 2020

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :              169 of 2019

Date of Institution:    10.07.2019

Date of Decision :     14.01.2020

 

Yash Pal Bansal son of Manohar Lal Bansal son of Bindra Das Bansal, resident of Old Cantt Road, Faridkot, Punjab.

                                                                                   .........Complainant

Versus

New India Assurance Company, G T Road Moga through its Divisional Manager.

.............OP

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt  Param Pal Kaur, Member.

 

Present: Sh Peush Jain, Ld Counsel for Complainant,

              Sh Atul Gupta, Ld Counsel for OP.

 

ORDER

(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 remaining payment of Rs.13,155/- on account of insurance claim with interest and for further directing OP to pay Rs.20,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.11,000/-.

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2                          Briefly stated, the case of the complainant is that complainant purchased a Senior Citizen Mediclaim Insurance Policy bearing number 30310034171600000004 from Opposite Party for sum assured of Rs.1,50,000/- valid for the period from 21.08.2018 to 20.08.2019. It is submitted that during the subsistence of Policy in question, complainant received injuries on his left ankle and he lodged claim with TPA Raksha and also submitted all original documents alongwith medical bills and x-ray and CT Scan films to them, but OP cleared claim only for Rs.3,451/- whereas expenses incurred by him on his treatment were Rs.16,606/-. As per insurance policy, complainant was entitled for full claim, but OP intentionally did not clear the full claim amount and deprived him for amount of Rs.13,151/-. Action of OP in not clearing the full claim amount amounts to deficiency in service on the part of OP and it has caused huge harassment and mental agony to complainant. Complainant has prayed for directing the OP to pay compensation alongwith litigation expenses besides the main relief of making payment of remaining claim amount. Hence, the complaint.

3                             The counsel for complainant was heard with regard to admission of the complaint and vide order dated 15.07.2019, complaint was admitted and notice was ordered to be issued to the OPs.

4                   On receipt of the notice, the OP filed reply taking preliminary objections that present complaint involves complicated

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question of law and facts requiring voluminous evidence, which is not possible in the summary proceedings of this Forum. It is further averred that insurance is a bilateral contract between insured and insurer and complainant is bound to abide by all the terms and conditions of the policy, but in present case there is violation of terms and conditions of the policy. Complainant has concealed the material facts from this Forum that claim of complainant was closed due to non submission of requisite documents. Vide letters dated 15.03.2019, 30.03.2019 and 15.04.2019 complainant was asked to provide copy of MLC, treating doctor’s certificate mentioning detailed circumstances and mode of accident. complainant was also sought to furnish his personal history, habits for example smoking, tobacco chewing, alcohol drugs, if any, but complainant did not supply the same to answering OP. Moreover, complainant is not their consumer. It is further denied that complainant is deprived of alleged amount of Rs.13,636/- because Rs.9,876/- were deducted for walker and amount of medicines which are not covered under the Policy. Complainant is also not entitled for any interest as sought by him. However, on merits, Opposite Party has denied all the allegations of complainant being wrong and incorrect and reiterated the same pleadings as taken in preliminary objections. There is no deficiency in service on the part of OP and all the other allegations alongwith allegation for relief sought too are denied being incorrect and prayed for dismissal of complaint with costs.

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5                           Parties were given proper opportunities to prove their respective case. Complainant Counsel tendered in evidence affidavit Ex.C-1 and documents Ex C-2 to C-12 and then, closed the evidence.

6                           In order to rebut the evidence of the complainant, Counsel for OP tendered in evidence affidavit of Sandeep Jaiswal Ex OP-1 and then, closed the evidence on behalf of OP.

7                           We have heard the ld counsel for complainant as well as OP and have carefully gone through evidence and documents placed on record by respective parties.

8                           From the careful perusal of the record and after going through the evidence and documents, it is observed that case of the complainant is that complainant was insured under the policy in question and during the subsistence of policy in question, he met with an accident and received injuries on his left ankle. He got treatment for his ankle from Deepak Hospital, Ludhiana and spent Rs.16,606/-. Complainant completed all formalities and submitted requisite documents to OP, but OP cleared the claim only for Rs.3,451/-and intentionally did not clear the entire claim amount, which amounts to deficiency in service on the part of OP. He has prayed for accepting the present complaint. In reply, plea taken by OP is that despite issuance of letters, complainant did not submit documents required for processing his claim and there is no deficiency in service on the part of OP. To prove his pleadings, complainant has placed

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on record his affidavit Ex C-1 in which he has narrated his entire grievance. Document Ex C-2 copy of Policy Schedule for  Senior Citizen Mediclaim Policy further proves the pleadings of complainant that he was insured with OP under present policy in question. Ex C-3 to Ex C-10 are copies of bills and envoice that prove on record that complainant incurred this amount on his treatment. Ex C-11 is copy of letter written by complainant to New India Assurance Company OP wherein he has requested OP to clear the remaining claim amount on account of expenses incurred by him on his treatment and in this letter, complainant has also cleared the point that documents sought by OP have already been supplied by complainant to them.

9                        It is observed that there is no dispute regarding insurance of complainant with OP. Opposite Party has admitted before the Forum that complainant was insured with them under Senior Citizen Mediclaim Insurance Policy in question. Grievance of the complainant is that he spent Rs.16,606/-on treatment of his left ankle, but OP made payment of only Rs.3,451/- and did not clear the remaining claim amount of Rs.13,151/-. No plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement that how they calculated this amount on their own. Admittedly, the complainant spent Rs.16,606/- for treatment of his left ankle and paid this amount to hospital

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authorities. Insurance Companies cannot fix their own rates at their own free will than the actual expenses borne by the persons.

10                         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 them at the time of inception 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

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(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.

11                         From the above discussion and case law produced by the complainant, we are of considered opinion that OP has wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy for not paying the entire claim amount that he incurred on his treatment, which was covered under the Senior Citizen Mediclaim Insurance Policy. From the documents produced by the complainant it is proved that he spent Rs.16,606/-for his treatment, which is also admitted by the OP. The Opposite Party has failed to prove that how they assessed Rs.3,451/-as reasonable rate and moreover act of opposite party for deducting amount for walker and on account of medicines, does not seem appropriate and amounts to deficiency in service on their part. Hence, present complaint is hereby accepted and Opposite Party is directed to clear the remaining claim amount by making payment of Rs.13,151/-to complainant alongwith interest at the rate of 9% per anum from 9.05.2019 when OP made part payment of insurance claim to him. Opposite Party is

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further directed to pay Rs.5,000/- to complainant as compensation for harassment and mental agony suffered by him and Rs.3000/- for litigation expenses. Compliance of this order be made within prescribed period of 30 days of receipt of the copy of this order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 14.01.2019

 

(Param Pal Kaur)              (Ajit Aggarwal)

                                        Member                          President