Punjab

Fatehgarh Sahib

CC/100/2016

Darshan Lal Sabharwal - Complainant(s)

Versus

OIC - Opp.Party(s)

Sh. N.K Parashar

29 Sep 2017

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                      Consumer Complaint No.100 of 2016

                                                            Date of institution:  14.10.2016                                                

                                                             Date of decision  :   29.09.2017

1. Darshan Lal Sabharwal aged about 62 years son of Sh. Amar Nath, resident of House No.35, Block D, Sector 20,  Mohalla Subhash Nagar, Mandi Gobindgarh, Tehsil Amloh, District Fatehgarh Sahib.(Insurer)
2. Shammi Rani W/o Darshan Lal  Sabharwal, resident of House No.35, Block D, Sector 20, Mohalla Subhash Nagar, Mandi Gobindgarh, Tehsil Amloh, District Fatehgarh Sahib.(Beneficiary)

……..Complainants

Versus

1. The Manager, The Oriental Insurance Company Ltd; branch office, Sirhind, District Fatehgarh Sahib.
2. The Divisional Manager, The Oriental Insurance Company Ltd; Divisional Office, Caliber Market, Patiala road, Rajpura, District Patiala.
3. TPA Medi Assist India TPA Pvt. Ltd; Tower "D", 4^th Floor, 1BC Knowledge Park, 4/1, Bannerghatta Road, Banglore 560 029 through its Authorized Representative.

…..Opposite Parties

Complaint under Sections 12 to 14  of the Consumer Protection Act 1986.

Quorum

Sh. Ajit Pal Singh Rajput, President                                       Sh. Inder Jit, Member     

                                               

Present :        Sh. N.K. Prashar, Adv., counsel for complainant.

                      Sh. Amit Gupta, Adv.Cl. for OPs No.1 & 2

                      Opposite Party No.3 exparte.

ORDER

By Ajit Pal Singh Rajput, President.

                      Complainants, Darshan Lal and Shammi Rani,  both resident of House No.35, Block D, Sector 20,  Mohalla Subhash Nagar, Mandi Gobindgarh, Tehsil Amloh, District Fatehgarh Sahib, have filed this complaint against the Opposite parties (hereinafter referred to as “the OPs”) under Section 12 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.         Complainant No.1 purchased a policy bearing No.233606/48/2016/164 from OP under PNB Royal Mediclaim Policy Schedule on 26.09.2015 for himself and his wife, complainant No.2, for a sum assured of  Rs.5,00,000/-. Complainant No.1 is a regular insurer of the OPs, vide previous policy No.233606/48/2014/144 valid from 26.09.2013 to 25.09.2014 at Sr. No.11998 and  he deposited Rs.6830/-, the same was further extended vide policy No.233606/48/2015/173 for the period from 26.09.2014 to 25.09.2015 at Sr. No.115385 for the sum assured of Rs.5 lacs and the complainant again deposited Rs.6830/- with the OPs.  Further the same was extended vide policy, in question, bearing No.233606/48/2016/164 for the period from 26.09.2015 to 25.09.2016 and Rs.6930/- were paid as premium amount and further the same was extended vide policy No.233500/48/2017/1984 for the period from 26.09.2016 to 25.09.2017. The wife of the complainant, complainant No.2, had suffered from heart problem and was admitted in Fortis Hospital, S.A.S.Nagar, Mohali on 25.07.2016 for her medical treatment. After treatment she was discharged from the said hospital on 02.08.2016. Complainant No.1 informed the OPs regarding the admission of complainant No.2 in the said hospital.  The said hospital issued adhoc bill of treatment for Rs.8,10,639/- dated 02.08.2016 and after discount, the bill amount came to be Rs.7,72,259/-. The said bill was sent to OP No.3 by the Fortis Hospital directly for payment of the said amount but OP No.3 gave only Rs.2 lacs to the hospital instead of insured amount of Rs.5 lacs, which was payable by the OPs under the said insurance policies.  The complainant No.1 deposited the remaining amount of Rs.5,63,039/- plus Rs.15,000/-, total Rs.5,78,039/- to the said hospital at the time of discharge of his wife. The complainant requested many times to OPs for payment of remaining amount of Rs.3 lacs but they did not listen to the genuine request of the complainant and put the matter off on one pretext or the other. Previously also, the complainant No.2 had fallen ill due to Angina problem and was admitted in Jiwan Jot Hospital Khanna on 05.01.2016 and discharged on 08.01.2016. The complainant spent Rs. 23,581/- on her treatment, which were also not reimbursed by the OPs till date. The act and conduct of the OPs amounts to deficiency in service on their part. The complainants so many times requested the OPs to pay the insured amount and also served a legal notice on the OPs but in vain. Hence, this complaint for giving directions to the OPs to pay Rs.6,95,840/- Plus Rs.23,581/-, insurance claim and Rs.1,00,000/- as compensation for mental agony and harassment suffered by the complainants.

3.                   Notice of the complaint was issued to the OPs, but OP No.3 chose not to appear to contest this complaint. Hence, OP No.3 was proceeded against exparte.

4.                   The complaint is contested by OPs No.1 & 2, who filed joint written reply. In reply to the complaint, OPs No.1 & 2 stated that the wife of the complainant had requested for cashless hospitalization with the probable date of hospitalization w.e.f.25.07.2016 at 3:50 PM for three days of expected stay with the past history of chronic ailments as: i) Diabetes 3 years, ii) Hypertension 3 years and iii) Heart disease 3 years, which means that the heart disease was contracted during the subsistence of Ist policy for Rs.2 Lacs and later on the insurance cover was enhanced. The claimant has sought the treatment of heart disease, which as per the policy was pre-existing for the enhanced portion and accordingly, the claim of the complainant was settled for Rs.2,00,000/- as the remaining portion was not payable on account of clause 4.1 and 4.2, which reproduced as under:-

4.1. Pre-existing health condition or disease or ailment/injuries: Any ailment/disease/injuries/health condition which are pre-existing (treated/ untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 3 years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered provided the renewals have been continuous and without any break in period, subject to portability condition. This exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries. Such complications shall be considered as a part of the pre-existing health condition or disease.

4.2. The expenses on treatment of certain ailment/diseases/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy. If these diseases are pre-existing at the time of proposal the exclusion No.4.1 for pre-existing condition shall be applicable in such case.

Hence, there is no deficiency in service on the part of the OPs. After denying the other averments made in the complaint, OPs prayed for dismissal of the complaint.

5.                   In order to prove their case, the complainants tendered in evidence copies of policies as Ex. C-1 to Ex. C-4,  copy of adhoc bill Ex. C-5, copy of final bill Ex. C-6, copy of legal notice Ex. C-7, postal receipt Ex. C-8, reminder Ex. C-9, postal receipt Ex. C-10, affidavit of complainant No.1 Ex. C-11 and closed the evidence. In rebuttal, OPs No.1 & 2 tendered in evidence affidavit of S.K. Sharma Ex. OP1/1, true copies of documents i.e. insurance policy with terms and conditions Ex. OP1/2, claim form Ex. OP1/3, certificate Ex.OP1/4, letter dated 26.10.2016 along with discharge summary Ex. OP1/5 and closed the evidence.

6.                    Learned counsel for the complainant has submitted that as per the affidavit Ex.OP1/1, sworn by S.K.Sharma,Divisional Manager of OPs in paragraph No.1  policies were being renewed from the year 2013 till 25/09/2016, but no terms and conditions/prospectus were supplied to the complainant while sending the policies. He has further submitted that the OPs have neither disclosed nor explained about the condition No.4.1 and 4.2. Learned counsel pleaded that the OPs have miserable failed to place on record any document, which could prove that the said terms and conditions/prospectus alongwith the policy was explained and delivered to the complainant. He argued that even in the year 2013, when medical tests were conducted by the doctors of the OPs, no such condition was informed. Learned counsel further argued that had the said conditions been disclosed to the complainant, the complainant would have never opted for renewal of the polices till the year 2016. Learned counsel also argued that no benefit of no claim bonus had been given to the complainant till date and it also amounts to deficiency in service.  He has further argued that in view of a number of judgements of Hon’ble Supreme Court and Hon’ble National Commission, in the present case also adverse inference may be drawn against the OPs. The ld.counsel relied on the judgement of Hon’ble National Commission in the case titled as Ms.Shefali Bhargava Vs Indraprastha Appollo Hospital & Anr,2003(1)CPJ 216 NC, wherein, it was held by the Hon’ble National Commission that “where party was in a position to produce evidence, if not produced the same, must suffer from adverse inference”.

7.          On the other hand, learned counsel for OP No.1 & 2 has stated that OP No.1 & 2 had rightly reimbursed the claim of the complainant keeping in view the condition No. 4.1 and 4.2 of the terms and conditions and the pre-existence of the disease. Learned counsel for OPs No.1 & 2 has submitted that the complainant did not at any stage raise the dispute with regard to non- delivery of the terms and conditions. Learned counsel in support of his contentions placed reliance on the citation titled as Chandubhai C.Shah Vs. United India Insurance Co. Ltd. and anr. in Revision Petition No.4658 of 2009 decided on 28.01.2011 by Hon'ble National Commission.

8.           After hearing the Learned Counsel for the parties and going through the pleadings, evidence produced by the parties and the oral arguments and written submissions, we find that there is force in the contentions of the Learned Counsel for the complainant. OPs No.1 & 2 have not been able to rebut the case of the complainant with regard to disclosure of the condition No.4.1 and 4.2 i.e pre-existing health condition alongwith “expenses on treatment of ailment/diseases/surgeries for specified periods are not payable if contracted and /or manifested during the currency of policy”. OPs No.1 & 2 have failed to place on record any material which can prove that the terms and conditions/prospectus documents were delivered and explained to the complainant. It is also established that the complainant had been renewing his policy since 2013(Ex.C-1) and till the filing of the present complaint, complainant was not informed about the terms and conditions. The case law relied upon by the learned counsel for the OPs is not applicable to the facts and circumstances of the present case, as in the present case no terms and conditions were supplied to the complainant nor the same was explained in detail.

9.                   Accordingly, in view of aforesaid discussion, and the judgement of Hon’ble National Commission in the case titled as Ms.Shefali Bhargava Vs Indraprastha Appollo Hospital & Anr(Supra), we find that OPs had failed to provide the terms and conditions to the complainant nor ever explain the clauses of the conditions. Hence due to the negligent act and conduct of the OPs, the complainant had to suffer unnecessary mental as well as physical harassment. Thus we find that complainant is entitled to Rs.3,00,000/-(Rs. Three Lakhs) towards reimbursement of medical expenses. We further find that complainant is also entitled to compensation of Rs.15,000/- alongwith litigation cost of Rs.5000/-.   The complaint stands accepted.  

10.                 OPs are directed to comply with the order of this Forum within a period of 45 days from the date of receipt of this order. In case the OPs fails to comply with this order, the OPs shall also be held liable to pay 9 % P.A. interest on the awarded amount till its realization.

11.                The arguments on the complaint were heard on 15.09.2017 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated: 29.09.2017

(A.P.S.Rajput)

President

 

(Inder Jit)         

    Member