Sh. Rakesh Kumar Singhal,
R/o C/o Kure Mal Bhagwat Prasad,
Chhoti Mandi, Hapur,
District- Hapur-245101 (U.P). …….. Complainant
VERSUS
- The Oriental Insurance Co. Ltd.,
Regd. Head Office: Oriental House,
P.B. No.7037, 25/27A, Asaf Ali Road,
New Delhi-110002.
- The Oriental Insurance Co. Ltd.,
Branch Office: Nehru Lane,
Railway Road, Hapur-245101 (U.P).
- E-Meditek (TPA) Service Ltd.,
Corporate Office: 577, Phase-V,
Udyog Vihar, Gurgaon-122016 (Haryana). ..…. Opposite Parties
O R D E R
K.S. MOHI, PRESIDENT
The complainant has filed the present complaint against the O.Ps u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken a mediclaim policy since year 2002 and the last premium was paid in December 2012 for the policy bearing No.254001/48/2013/2815 for the period from 05.12.2012 to 04.12.2013. It is alleged that the policy provided coverage to the complainant, his wife Mrs. Pushpa Jain and three children of the complainant i.e. Shubham Singhal, Shubhi Singhal and Ayush Singhal. On 03.02.2013 the wife of the complainant felt the severe headache and was admitted in Sir Ganga Ram Hospital, Delhi where on 04.02.2013 she was operated for brain tumor and the same was discharged from the hospital on 11.02.2013. It is alleged that the complainant thereafter spent about Rs.4,50,000/- approx. on the treatment of his wife. It is alleged that complainant submitted claim to the above O.Ps with all the relevant documents alongwith bills with the O.Ps company seeking the reimbursement of the same. It is further alleged that but only Rs.75,000/- were approved and after deduction of Rs.7,500/- only Rs.67,500/- were paid to the complainant though as per the policy the complainant was to be paid Rs.3,00,000/-. It is alleged that the O.Ps not only cheated the complainant but also breached the trust resulting the complainant suffered the financial loss. It is further alleged that the O.Ps grabbed Rs.2,32,500/- of the complainant by non-approval of his claim as per policy. Complainant as also sent a legal notice dated 16.09.2013 but to no avail. On these facts complainant prays that O.Ps be directed to pay the a sum of Rs.2,32,500/- alongwith interest and also to pay cost and compensation as claimed.
2. O.P-1 & 2 appeared and filed its written statement. In its written statement O.P-1 & 2 have not disputed that complainant had taken policy refer to above. It is alleged that as per the records of the complainant there was an individual policy for Rs.75,000/- since 2006 and thereafter from 05.12.2010 to 04.12.2011 the sum insured was enhanced to Rs.2,00,000/- under the Family Floater Policy and thereafter from 05.12.2011 the sum insured was enhanced to Rs.3,00,000/-. It is further alleged that as per the terms and conditions of the mediclaim policy, the claim if any is payable after four years of the insurance policy. It is alleged that the sum insured was Rs.75,000/- four years prior to the date of the hospitalization. It is further alleged that the insurance company has rightly paid Rs.75,000/- i.e. sum insured to the complainant in consonance with the terms and conditions of the policy. It is alleged that in case the person covered under the policy has lodged any claim during the current policy, i.e. 05.12.2012 to 04.12.2013 then the earlier limit of sum insured in the year 2008-09 shall be applicable and not the enhanced sum insured. It is further alleged that consequently the complainant has been paid Rs.67,500/- after deducting 10% from the limit of Rs.75,000/- as per the terms and conditions of the policy. Dismissal of the complaint has been prayed for.
3. Complainant has filed rejoinder reiterating all the facts as mentioned in the complaint. He has also filed his affidavit affirming the facts alleged in the complaint and has proved documents exhibited as Ex. CW-1/1 to CW-1/9. On the other hand Sh. S.S. Yadav, Dy. Manager has filed affidavit in evidence on behalf of O.P-1 & 2 testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case as well as written submission by O.P-1 & 2 and have heard submission of Ld. Counsel for the complainant.
5. The main controversy existing between the parties is to whether the deduction of claim amount by the insurance is justified or not. Admittedly the complainant had taken mediclaim policy for the relevant period during which wife of the complainant fell ill and got treatment in the hospital for a total sum of Rs.4,50,000/- approx. However, the insurance company reimbursed only a sum of Rs.75,000/- with further deduction of Rs.7,500/- and, in fact, paid Rs.67,500/-. The reply filed on behalf of O.Ps clearly indicates that the deduction was made on basis of terms and conditions which authorized the insurance company to give the reimbursement. Taking into the earlier limit of sum insured for the four previous insurance policies i.e. for the year 2008-2009 and during said period the limit was Rs.75,000/- as per the terms and conditions of the said policy and this was the reason the insurance company only process a sum of Rs.75,000/- instead of full claim amount to the insurer. Now it is to be seen whether the action of the insurance is justified or not. It is now well settled law that terms and conditions can be pressed into service by the insurance company only when they were duly communicated to the insured. The insurance company cannot take the insured by surprise by taking shelter under the said terms and conditions to repudiate the justified and valid claim of the insured. In case titled I (2000) CPJ 1 (SC) M/s Modern Insulators Ltd. Vs Oriental Insurance Co. Ltd., it was held that it is the fundamental principle of insurance law, that utmost good faith, must be observed by the contracting parties, and good faith forbids either party, from non-disclosure of the facts, which the parties knew. The insured has a duty to disclose all the facts, and similarly it was the duty of the insurance company, and its agents, to disclose all the material facts, in their knowledge, as obligation of good faith applies to both equally. In another case titled III (2009) CPJ 246 (NC) United India Insurance Co. Ltd. & Anr. Vs S.M.S. Tele Communications & Anr., it was held that being aware of the existence of the policy, is one thing, and being aware of the contents and meaning of the clauses of the policy, is another. The principle of law, laid down, in the aforesaid cases, is fully applicable to the facts of the instant case. Since the terms and conditions of the insurance policy were not supplied to the complainant, it was neither aware of the exclusions, nor was bound by the same.
6. Keeping in view of the discussion stated above and the law point discussed above, we are of the considered view that repudiation by insurance company is totally unjustified and devoid of any merits and accordingly it clearly amounted to deficiency in service. Accordingly we award a sum of Rs.2,32,500/- with interest @ 6% from the date of filing the present complaint i.e. 08.01.2014 till realization. We also award a sum of Rs.6,000/- towards harassment mental agony loss of time which will also include cost of litigation. Ordered accordingly.
Copy of this order be sent to the parties as per rules.
Announced this 26th day of May, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
