Punjab

Fatehgarh Sahib

CC/7/2020

Bimla Rani - Complainant(s)

Versus

New India Assurance company limited - Opp.Party(s)

Shri Saurab Sharma

16 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

                             COMMISSION

                      FATEHGARH SAHIB

 

Complaint No.	:	CC/07/2020
Date of Institution	:	03/02/2020
Date of Decision	:	16.05.2023

 

Bimla Rani W/o Om Parkash Gupta, House no.64 , Sec-20D, Subash Nagar, Mandi Gobindgarh , Tehsil Amloh , District Fatehgarh Sahib..

                                                                                                     …………....Complainant

                                        Versus

 

1. The New India Assurance Co. Ltd,Branch office, G.T.Road, near Bus Stand Mandi Gobindgarh, through Branch Manager.
2. The New India Assurance Co. Ltd,  Divisional Office, G.T. Road, Khanna-141401 through Divisional Manager.
3. The New India Assurance Co. Ltd, registered 7 head office:87 , Mahatma Gandhi Road, Mumbai-400001.

               

                                                        ..………....... Opposite Parties

 

Complaint under Section 11 to 14of Consumer Protection Act 1986(Old)

Quorum

Sh. S.K. Aggarwal, President

Ms. Shivani Bhargava, Member

Sh.Manjit Singh Bhinder, Member.

Present: Sh. Saurabh Sharma , counsel for complainant.

              Pt. Narinder, counsel for Ops.

 

 

 

 The  complaint has been filed against the OPs (opposite parties) , Under Section 11 to 14 of Consumer Protection Act-1986 (old) alleging deficiency in service with the prayer for giving direction to the OPs  to reimburse  the Medical Claim of Rs.15,700/- along with interest to the complainant , to pay  Rs.25,000/-  as compensation for harassment to complainant.

1. Brief facts of the complaint are that the husband of  the complainant has been continuously taking the mediclaim Policy from Ops since 2012.  The husband  of the complainant was paying the premium of the Policy regularly. In 2018 , the complainant was insured for Rs.2 Lakh vide Policy no.36120034172800000174 from 1.3.2018 to 28.2.2019.  On 21/7/2018, the complainant felt acute pain in her body and the  family members of the complainant  admitted her to IVY hospital, Khanna. After examining her doctors found that the complainant is suffering from Calculus  of Gall Bladder with active Cholecystitis and treated the same.   The Hospital  made the bill of Rs.57,866/- for her treatment. Complainant applied for cashless claim to the Ops    but the same was not fully satisfied by the Ops. The Ops paid only Rs.42,166/- and the rest amount i.e Rs.15,700/- was declined by the Ops. The complainant requested the Ops to sanction the remaining  claim of the complainant. Ops demanded documents. Complainant submitted all medical bills and other documents through letter on 27.7.2018  but the Ops repudiated the claim of the complainant vide letter dated 3.8.2018 . The husband of the complainant filed an application to the office of the Insurance Ombudsman Chandigarh, which was dismissed by the Insurance Ombudsman Chandigarh  dated 27.12.2019.  Hence this complaint.  
2. Notice of the complaint was given to the OPs through registered Post, OPs appeared through their Counsel and filed their written version jointly.
3.    The complaint has been contested by the OPs by raising various preliminary objections. The Ops contested that  the amount of Rs.42,166/- was paid by the Ops as per terms and conditions of the Policy.  The Policy  clause 3.1(a),9 (d) provide that the amount to be paid in the head of room rent and anesthesia, blood, Oxygen  and other medical treatment expenses related to the treatment were paid  as per Policy. The Ops  rightly  denied the claim of the complainant and paid Rs.42,166/- to the complainant . Hence , the Ops have prayed for dismissal of complaint with cost.
4. In support of  her complaint ,  complainant filed Ex.CW1/A  her affidavit along with copies of documents i.e  Ex.C1 , Ex.C2, Ex.C3 Policy Schedule,  Ex.C4 to Ex.Ex.C6  Mediclaim schedule, Ex.C7 and  Ex.C8  Floater Mediclaim schedule,  Ex.C9 and  Ex.C10 medical record , Ex.C11 TPA Letter , Ex.C12 letter dated 27.7.2018 , Ex.C13 letter dated 3.8.2018,, Ex.C14 letter  dated 10.12.2018, Ex.C15  letter dated 2.11.2018, Ex.C16 letter dated  7.1.2019 , Ex.C17 letter of the Insurance Ombudsman , and closed her evidence
5. In rebuttal, the Ops tendered Ex.OP1 affidavit of Sanjeev Kumar Kalia, Deputy Manager, Ex.OP2 Policy Schedule  , Ex.OP3  Mediclaim Policy,   Ex.OP4 settlement of claim, Ex.OP5  decision of  Insurance  Ombudsman and closed their evidence.
6. Admittedly , the complainant’s husband  purchased a cashless Mediclaim Policy no.36120034172800000174 ,  w.e.f 1/3//2018 to 28/2/2019 from OPs. Complainant was admitted to IVY Hospital , Khanna on 23/7/2018. She spent his Rs.57,866/- as medical expenses on  her treatment. OPs approved cashless mediclaim amount of Rs.42,166/- as per Ex.C11. OPs rejected Rs.15,700/- on account of room rent/operation /doctor /fee/surgical services on proportionate basis vide Ex.C15.Complainant herself paid Rs.15,700/- to the hospital as per Ex.C10.
7. From the perusal of the record , we find that complainant claimed  for reimbursement against Rs.2 Lakh  insured amount as mentioned in Policy as per Ex.C7. However , the Ops accepted the claim against Rs.1,50,000/-  as per Ex.C16 saying that the  enhanced  sum  insured of the current Policy  year will not be applicable as period of 24 months  not completed , so the sum insured available would be Rs.1.5 Lakh only.
8. OPs can not go beyond the amount that is mentioned in the Policy  itself. Policy is in continuity .  The OPs  have not produced any cogent &  convincing evidence to show that the agent had disclosed the lesser insured amount to the complainant. The complainant being in old age  was led to believe that they had in fact  renewed a Pre-existing Policy on  the same terms with the  only  difference being the higher  coverage from Rs.1.50 Lakh to Rs.2 Lakh and more premium  had to pay . The denial of claim by Ops is not sustainable . Insurance  contracts are based on the principle of uberrima fides i.e utmost good faith. It is the  duty of the insurer to disclose all terms & conditions. All conditions which are generally  hidden need to be simplified .  So that these are  easily  understood by a person at the  time of buying  any Policy. Therefore, OPs are held liable for  deficiency in service.
9. As a corollary of our above discussion  and keeping in view the facts & Circumstances  of the present case , it emerges that rightful claim of the complainant has been wrongly repudiated by the OPs without any  rhyme or reason. Hence,  the present complaint is partly allowed. The OPs are jointly & severally directed as under:-

[a] To pay Rs.15,700/- i.e remaining amount of claim to the complainant along with interest @ 9% P. A from the date of filing of compliant within 30 days, failing which interest @ 12% shall be payable.

[b] To pay Rs. 15000/- as compensation and litigation expenses.

Compliance of the order be made by the OPs within a period of 30 days of receipt of certified copy of this order . Failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within the statutory period due to pandemic of Covid-19 and paucity of staff. File be consigned to record Room.

Pronounced 16 May 2023.

                               

                                        (S.K. Aggarwal)

                                                 President

                                                                      

    

                                               (Shivani Bhargava)

                                                   Member

 

                                               ( Manjit Singh Bhinder )  

                                                              Member