Haryana

Ambala

CC/199/2018

Parkash Chand - Complainant(s)

Versus

OIC - Opp.Party(s)

V.K.Marvha

25 Nov 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

                                                          Complaint case No.:   199 of 2018.

                                                          Date of Institution           :    19.06.2018.

                                                          Date of decision    :    14.11.2019.

Shri Parkash Chand, R/o 27, Ranjit Nagar, Behind Seva Samiti School, Ambala Cantt (Haryana).

                                                                                      ……. Complainant.

1. The Oriental Insurance Company Limited, Ground Floor, LIC Building, Ambala City 134002.
2. The Medi assist India TPA Pvt., Ltd., SCO No-521, 2^nd Floor, Near JLPL Office, Sector 70, Mohali-160070.

    ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.         

Present:       Shri V.K.Marwah, Advocate, counsel for complainant.

Shri R.K.Vig, Advocate, counsel for OPs.

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To reimburse the amount of Rs.1,73,698/- incurred by the complainant upon his treatment along with interest @ 24% per annum w.e.f 08.04.2016.
2. To pay Rs.4,00,000/- on account of metal agony, harassment & emotional distress suffered by him along with litigation expense.

                   Any other relief which this Hon’ble Forum may deem fit.

          Brief facts of the case are that the complainant initially on 11.03.2013 at 16:22 hrs, got himself insured with The Oriental Insurance Company Ltd., Ambala City, under PNB-Oriental Royal Mediclaim Policy having policy number 261101/48/2013/2401. He got renewed the said policy regularly and was duly insured vide policy No.261101/48/2016/1871 for sum of Rs.4,00,000/- for the period from 11.03.2016 to midnight of 10.03.2017. Vide cheque No.10077 dated 10.03.2016, he paid the premium amount of Rs.5,890/-, which was duly encashed by The Oriental Insurance Company Ltd. on 14.03.2016. On 28^th March 2016, he informed the OPs that he got admitted in Govt. Medical College & Hospital, Sector-32, Chandigarh, and Doctor advised for treatment/surgery for hip replacement. On 29.03.2016, hip replacement surgery was conducted and he was discharged from the hospital on 04.04.2016. On 07.04.2016, he submitted the claim form along with all bills, treatment record and required documents with The Medi assist India TPA Pvt., Ltd., SCO No-521, 2^nd Floor, Near JLPL Office, Sector 70, Mohali-160070 i.e OP No.1 through registered post vide postal Receipt No.EH741132994IN dated 7.04.2016 for settlement of the claim and for reimbursement of the amount of Rs.1,73,698/- incurred upon his treatment. He received a letter dated 03.05.2019 & reminder dated 04.05.2016 from OP No.2, for furnishing more documents, which were duly supplied by him on 02.06.2016, through Trackon Courier vide receipt No.49013096 dated 02.06.2016. X-Ray film was also forwarded on 27.07.2016, vide registered post receipt No.EH760040394IN dated 27.07.2016. Thereafter, he requested to OPs, several times for reimbursement of the amount, which he incurred on his treatment, but of no avail. He had also sent Emails, through his son Mohit Malhotra, on 30^th May 2016 to nd June 2016 to th June 2016 to th July, an agent of OPs visited him and after verifying all the documents had taken away the photocopies & also got signed few blank forms and documents. On 22^nd July 2016, received a mail from nd July 2016 informing them that the documents had already been sent to them on 02^nd June 2016. Since, the complainant was unable to travel much, therefore on 26.07.2016, his son Mohit Malhotra visited the OP No.2, and requested to release/reimburse the claim amount at the earliest. The official of OP No.2 assured that the claim would be paid within a short time. But when he did not receive the claim amount, then on 26^th July, 2016 he sent mails to st August 2016 to st August 2016 to nd August 2016, he made a complaint to csd@orientalinsurance.com.in, and to nd August 2016 itself the same message was forwarded to nd August 2016 to 02^nd August 2016, he received an email on his son’s mail id from nd August 2016 to

3.                Complainant tendered his affidavit and affidavit of Shri Mohit Kumar son of Shri Parkash Chand, aged 26 years, R/o 27, Ranjit Nagar, Behind Seva Samiti School, Ambala Cantt (Haryana) as Annexures CA-1 & CA-2 alongwith documents as Annexure C-1 to C-175 and closed the evidence on behalf of complainant. On the other hand, learned counsel for OPs No.1 & 2 tendered affidavit of Shri Ashish Bhatnagar, aged 56 years, Branch Manager, # Oriental Insurance Company Limited, Ambala City and affidavit of Shri S.K.Gupta, aged 63 years, Medi Assist Insurance TPA Private Limited, 8-B, 2^nd Floor, Tej Building Bahadur Shah Zafar Marg, New Delhi as Annexures OP1/A & OP1/B  along with documents Annexure OP1/1 to OP1/6, and closed the evidence on behalf of OPs No.1 & 2.     

4.                  We have heard the learned counsel of parties and carefully gone through the case file and the case laws referred by the learned counsel for the parties.

5.                Admittedly, the complainant was duly insured with the Ops for a sum of Rs.4,00,000/- for the period from 11.03.2016 to 10.03.2017, vide policy schedule Annexure OP1/5. From the discharge and follow up card Annexure C-96, it is evident that the complainant on 28.03.2016, got admitted in Govt. Medical College and Hospital, Sector-32, Chandigarh for hip replacement. As per the complainant he spent Rs.1,73,698/- on his treatment. He lodged the claim with the OPs for reimbursement of the said amount, but they refused to reimburse the said amount. By not paying the genuine claim amount the OPs have committed deficiency in rendering services.  He placed reliance upon the case law titled as ICICI Prudential Life Insurance Vs. Preeti Prasad, Petition No.4505 of 2013, decided by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi on 16.03.2015, LIC of India Versus Joginder Kaur and Ors., II (2005) CPJ 78 NC.  Whereas, the stand of the OPs is that the complainant was suffering from diabetes, hypertension and was taking treatment for the said diseases, prior to taking of this policy. He was chronic alcoholic since 1995 and was consuming alcohol 200ml per day, but he did not disclose the said fact at the time of taking the policy. Therefore, as per terms and conditions of the policy, the complainant is not entitled for reimbursement of the amount, which the complainant incurred on his treatment and the OPs have rightly repudiated the claim vide letter dated 27.10.2016 (Annexure OP1/4). OPs have placed reliance upon case laws titled as Satwant Kaur Sandhu Versus New India Assurance Company Ltd., Vol. IV (2009) CPJ 8 (SC) and Life Insurance Corporation of India Versus S.S. Jamuna I (2014) CPJ 496 (NC).  

6.                It may be stated here that in the case of Satwant Kaur Sandhu Versus New India Assurance Company Ltd. and Life Insurance Corporation of India Versus S.S. Jamuna (supra), the issue was that the insured was suffering from pre-existing disease but he had given wrong answers to the questions about his health mentioned in the proposal form. However, in the present case the OPs have not placed on record the proposal form, on the basis of which they have issued the policy in question to the complainant. In the absence of the proposal form, the bald assertion of the OPs that at the time of taking the policy in question, the complainant did not disclose that he was suffering from pre-existing disease and was chronic alcoholic, cannot be taken as a gospel truth. In this situation, it can easily be said that the OPs have not been able to prove the allegation on the basis of which they have repudiated the claim of the complainant. Thus, the repudiation of the claim done by the OPs is held to be unjustified and amounts to deficiency in service on their part. The OPs are thus not only liable to reimburse the amount, which the complainant had actually spent on his treatment, but are also liable to compensate the complainant for the mental agony and physical harassment suffered by him alongwith litigation expenses.

7.                In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs in the following manner:-  

1. To reimburse the actual amount, which had been spent by the complainant on his treatment along with interest @ 7% per annum w.e.f 27.10.2016 i.e the date of repudiation till its realization.
2. To pay Rs.5,000/- as compensation for mental agony and physical harassment suffered by the complainant.
3. To pay Rs.3,000/- as litigation expenses.

8.                The OPs are further directed to comply with the aforesaid directions within the period of 45 days from the date of receipt of the certified copy of this order. Certified copies of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :14.11.2019.

(Vinod Kumar Sharma)            (Ruby Sharma)               (Neena Sandhu)

            Member                          Member                        President