Punjab

Ludhiana

CC/14/729

Mohinder Pal Singh - Complainant(s)

Versus

Oriental Ins.Co.Ltd - Opp.Party(s)

Deepak Mukhreja

11 Jun 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

 

          C.C.No: 729 of 21.10.2014

                                                                                              Date of Decision:11.06.2015

 

Mohinder Pal Singh s/o Shri Jagdish Singh, resident of House No.673/15-A, Street No.18, Jawaddi Road, Punjab Mata Nagar, Ludhiana. 

                                                                                          … Complainant

                                      Versus

1.Oriental Insurance Company Limited, 146, Industrial Area-a, Cheema Chowk, Ludhiana, through its Branch Manager Shri Yashpal.

2.Oriental Insurance Company Limited, having its registered & Head Office:A-25-27, Asaf Ali Road, New Delhi-110002, through its Zonal/Divisional Manager.

3.Rajiv Gupta, Employee, Oriental Insurance Company Limited, 146, Industrial Area-a, Cheema Chowk, Ludhiana.

                                                                             … Opposite parties

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986. 

 

Quorum:   Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member.

 

Present:       Sh.Deepak Makhija, Advocate for complainant.

                   Sh.Gursewak Singh, proxy counsel for OP1 and OP2.

                   OP3 ex-parte.

 

 

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

1.                Present complaint under section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Mohinder Pal Singh(herein-after in short to be referred as ‘Complainant’) against Oriental Insurance Company Limited and others(herein-after in short to be referred as ‘OPs’)- directing the OP1 and OP2 to make the payment of Rs.66,000/- alongwith interest @18% p.a. and damage to the tune of Rs.25,000/- sustained by the complainant due to their intentional default for non-payment of claim amount and compensation and Rs.7500/- as litigation expenses to the complainant alongwith any other additional or alternative relief to which the complainant is found entitled to.

2.                Brief facts of the complaint are that firstly, the complainant had got issued the following medical/health insurance policies having Gold Plan for self and for his family members from Reliance General Insurance:-

Insurance Policy No.                                                          Period of Insurance

1.282550105810                                                                  6.6.2008 to 5.6.2009

2.282510626071                                                                  6.6.2009 to 5.6.2010

3.2001702825000625                                                         6.6.2010 to 5.6.2011

4.2001712825000307                                                         6.6.2011 to 5.6.2012

 

Therefore, the complainant had been getting the policies from the Reliance General Insurance Company continuously and during the tenure the said policies, neither the complainant nor any family members ever lodged any claim with the said company nor did they ever receive any amount as claim under the said policies. Thereafter, the officials of Ops including OP3 himself approached and allured that the policies being issued by the Ops are having much more benefits than the benefits provided by the Reliance General Insurance Company and under the portability scheme, he and his family members will get the benefits under the previous policies as well as the previous policies shall be deemed to be in continuation of the policies to be issued by the Ops. The Ops further allured that the claim process of the Ops is faster than any other insurance company and the formalities required for completion of portability shall be dealt by them at their own and the complainant or any of his family members would not have to worry for completion of any such formalities. The complainant had completed all the formalities for availing portability by conveying about the change of insurer and other formalities as desired by the Ops and provided all the details of his address, names of family members, Id proofs and other documents in order to complete the formalities required under the portability scheme and after obtaining the signatures of the complainant on the requisite documents/forms, the OP1 and OP2 issued/renewed the Health Insurance Policy vide policy No.233905/48/2013/329 which was valid w.e.f.6.6.2012 to 5.6.2013 under the head “Happy Family Floater Policy Schedule” with sum assured upto Rs.4 lakh and against the said policy, premium amount of Rs.8305/- was paid by the complainant. After the issuance of policy, the officials of Ops including OP3 told that the portability scheme is applicable to the abovesaid policy. Thereafter, the complainant got the abovesaid policy renewed from the Ops vide policy No.233905/48/2014/354 effective from 6.6.2013 to 5.6.2014. Thereafter, the complainant suffered health problem i.e. a stone was found in his kidney and accordingly, he got himself checked up and operated upon for the same from R.G.Stone Hospital, Model Town, Ludhiana and he remained admitted in the said hospital from 30.9.2013 till 3.10.2013 and was spent an amount of Rs.66,000/- on his treatment. Thereafter, the complainant intimated the Ops about the treatment and lodged his claim bearing No.233905/48/2014/000038 with the Ops alongwith all the medical bills, medical record and other documents. However, instead of processing and sanctioning the claim, the Ops started lingering on the matter on one or the other false pretext and ultimately, vide letter dated 13.5.2014, the OP1 repudiated the claim of the complainant on false ground that the disease of the complainant is covered after 2 years of regular policy without any gap and hence, the claim is not payable because policy has not completed 2 years as on the date of loss. On receipt of letter dated 13.5.2014, the complainant visited the Op1 and officials of OP1 and OP3 himself informed that the portability was not done by them due to oversight and rush of work and as the complainant is taking policies continuously for the last 6 years without any gap and as such, they will recommend the case of the complainant for processing and sanctioning as there is no fault on the part of the complainant at all. However, despite repeated requests and approaches, the Ops failed to pay any heed to the requests of the complainant and also failed to reconsider the approval of claim of the complainant. Hence, this complaint.

3.                Upon notice of the complaint, OP1 and OP2 were duly served and appeared through their counsel Sh.Rajeev Abhi, Advocate and filed their written reply, whereas, despite service through notice, OP3 failed to appear and as such, OP3 was proceeded against ex-parte vide order dated 1.12.2014 by this Forum.

4.                OP1 and OP2 filed their written reply, in which, it has been submitted in the preliminary objections that the present complaint is barred u/s 26 of the Consumer Protection Act. The present complaint is not maintainable since immediately on the receipt of the claim, it was duly registered, entertained and processed. The complainant had obtained Happy Family Floater Policy from the answering Ops. Insurance policy is a contract in itself and the parties are bound by the terms and conditions of the insurance policy. Nothing can be added or abstracted out of it. As per the terms and conditions of the policy, the deceased calculus is not covered under the first 2 years of the policy i.e. to say the expenses on the treatment of calculus is covered after the expiry of two years of the policy i.e. in the 3^rd year of the policy, if the same is without any gap. The said exclusion clause of the policy i.e. 4.3(xix) is reproduced as under:-

“4.3 The expenses on treatment of following 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 and exclusion no.4.1 for pre-existing condition shall be applicable in such cases.

(xix) Calculus diseases         2 years.”

 

            After the receipt of the claim papers from the complainant in respect of his treatment from RG Stone & Super Speciality Hospital, 510-L, Model Town, Ludhiana with date of admission as 30.9.2013 and date of discharge as 3.10.2013, the claim file of the complainant was sent to Dr.Tarsem Lal Gupta, Gupta Clinic, Ghumar Mandi Chowk, Ludhiana, who after scrutinizing the entire claim file including the discharge summary and other medical papers of the complainant, has submitted his opinion that as per policy clause 4.3 (xix) expenses on calculus disease is excluded for 2 years and as such, the claim does not fall within the purview of the insurance policy since in the opinion of Dr.Tarsem Lal Gupta. After the receipt of the opinion of Dr.Tarsem Lal Gupta of Gupta clinic dated 9.12.2013 and after scrutinizing the documents placed in the claim file and after applying the mind by the officials of the respondent, the claim file of the complainant was repudiated as ‘No Claim’ by the answering Ops vide their letter dated 13.5.2014 on the ground that as per the terms and conditions, the disease of calculus is covered  after 2 years of regular policy without any gap and as such, the claim is not payable because the policy has not completed 2 years as on the date of admission of the complainant in the hospital. The complainant is estopped by his own act and conduct from filing the present complaint since the complainant is not coming to this Hon’ble Forum with clean hands and has concealed the material facts that his claim does not fall within the purview of the policy and falls in the exclusion clause of the policy. On merits, it is submitted that no particular of the insurance having been obtained by the complainant from Reliance General Insurance Company Limited has been disclosed in the complaint. Even the copies of the previous insurance policies alleged to be taken by the complainant are not produced on the record of this Hon’ble Forum to show that the complainant has been obtaining the policies for the last so many years from the Reliance General Insurance Company as alleged by the complainant. The facts regarding obtaining of insurance policy, sum insured and payment of premium, renewal of policy, lodging of claim, submission of claim form and certain bills and repudiating the same as alleged by the complainant are admitted. However, it is submitted that the reimbursement of the medical expenses of calculus is excluded in the first 2 years of the policy and is payable in the 3^rd year of the policy, if the renewal is without any gap. Similar pleas were taken as taken in the preliminary objections. At the end, denying any deficiency in service and all other allegations of the complainant leveled in the complaint, answering Ops prayed for the dismissal of the complaint.

5.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of Sh.Mohinder Pal Singh Ex.CA, wherein the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C21. Ld. counsel for OP1 and OP2 has adduced the evidence by way of duly sworn affidavit of Sh.Yash Pal, Branch Manager, Oriental Insurance Co. Ltd., 146, Industrial Area-A, Opp. Allahabad Bank, Cheema Chowk, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and affidavit of Dr.Tarsem Lal Gupta, Gupta Clinic, Ghumar Mandi Chowk, Ludhiana Ex.RB and also attached documents Ex.R1 to Ex.R11.

6.                Ld. counsel for the complainant has filed the written arguments, whereby submitted that complainant had earlier taken four medical/health insurance policies having Gold Plan for self and for his family members from Reliance General Insurance. Thereafter at the allurement of the OPs, complainant shifted his policy from Reliance General Insurance to Ops company under portability scheme. Thereafter OPs issued/renewed the health insurance policy, vide policy no.233905/48/2013/329 for the period 6.6.12 to 5.6.13 under the Head “Happy Family Floater Policy Schedule” with sum assured upto Rs.4.00 lac. The complainant got the abovesaid policy renewed from the OPs for the period 6.6.13 to 5.6.14. During the tenure of above said 6 policies i.e.Ex.C6 the complainant suffered health problem i.e. a stone (calculus) was found in his kidney and he was operated upon for the same from R.G.Stone Hospital, Model Town, Ludhiana, where he remained admitted from 30.9.13 till 3.10.13 and complainant spent an amount of Rs.66,000/- approx. But the claim of the complainant was repudiated, vide letter dated 13.5.14 on the ground that the disease of the complainant is covered after 2 years of regular policy without any gap, hence the claim is not payable because the policy has not completed 2 years as on the date of hospitalization. The OPs also assigned the reason of not completion of regular two years policies from their company and the policies has been issued to the complainant without portability. Although his claim was falls in the 6^th Health Insurance policy of the complainant, as the complainant had taken the four policies from Reliance Insurance Company and tow from the OPs. Further submitted that only ground of the not getting portability taken by the OPs is not sustainable as the Ops themselves did not get done the portability further, as such they are negligence for the same so they cannot take this ground in order to avoid the claim.

7.                Refuting the allegations leveled by the complainant, Ld. counsel for OP1 and OP2 filed written arguments, wherein he has reiterated all the contents of the written reply filed by the OP1 & OP2 and further, it has been submitted under the head of “Points of Arguments” that the insurance policy is a contract in itself and the parties to the contract of insurance are bound by the terms and conditions of the policy. As per policy exclusion clause 4.3 it is clearly stated as under:-

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

(xix)   Calculus diseases    2 years.”

 

                   The simple reading of the said exclusion clause 4.3 clearly states that the reimbursement of the medical expenses for the treatment of calculus is excluded in the first 2 years of the policy and is payable in the 3^rd year of the policy, if the renewal is without any gap. No copy of insurance policy for the last 6 years having been obtained from Oriental Insurance Co. Ltd. without any gap/break is produced on the record of the Forum. There is no fault of the OPs in issuing the policy as the insurance has not come to Oriental Insurance Co. Ltd. through portability. There is no deficiency in service on the part of the OPs. The wording of the e-mail by the OPs dated 29.4.14 of Kanchan is re-produced as under:-

“As per above said claim, the insurance not come to us through portability. So, it is considered as fresh insurance and as per policy terms and conditions, the disease is covered after 2 years of regular policy, so the claim is not payable because policy has not completed 2 years on the date of loss.”.

                   The grounds of repudiation are legal, valid and enforceable and are in accordance with the terms and conditions of the policy. Ld. counsel for OP1 and OP2 also relied upon the judgements passed in case titled as New India Assurance Co. Ltd. Vs Dr.Girish Chandra Palival- 2003 (II) CPJ 311 passed by Uttar Pardesh State Commission, Lucknow, New India Assurance Co. Ltd. Vs Dr.(Mrs) Renu Chugh- 1008 (III) CPJ 126 passed by Haryana State Commission, Chandigarh, United India Insurance Co. Ltd. Vs Harchand Rai Chandan Lal- 2004 (IV) CPJ 15 passed by Hon’ble Supreme Court of India, New India Assurance Co. ltd. Vs Deepak Anand- 2014 (III) CPJ 373 passed by Hon’ble National Commission, New Delhi, National Insurance Co. Ltd. Vs Vinod Puri and another- 2014 (I) CPJ 341 passed by Hon’ble National Commission, New Delhi, Ind Swift Ltd vs. New India Assurance Co.Ltd.- 2012 (IV) CPJ 148 passed by Hon’ble National Commission, New Delhi.

8.                We have gone through the pleading of the complainant and written arguments submitted on behalf of the parties as well as defence taken by the OPs and have also perused the entire record placed on file.  

9.                It is evident that complainant availed four policies from Reliance General Insurance having Gold Plan for self and his family members, vide no.282550105810 for the period 6.6.08 to 5.6.09, which was renewed for the period 6.6.09 to 5.6.10, 6.6.10 to 5.6.11, 6.6.11 to 5.6.12. Thereafter the complainant shifted his insurance policy from Reliance General Insurance to Oriental Insurance Company i.e. OP1 and OP2 by way of portability and OP1 and OP2 issued/renewed the Health Insurance policy, vide policy no.233905/48/2013/329 for the period 6.6.12 to 5.6.13 under the head “Happy Family Floater Policy Schedule” with sum assured upto Rs.4.00 lac, the said policy was renewed for the period 6.6.13 to 5.6.14, meaning thereby that the complainant was covered under this policy since the year 2008 and the OPs failed to consider all these policies in spite of the fact that the policy given by the Ops to the complainant in continuance of the previous policies of Reliance General Insurance Company and under the rule of portability as such the complainant is entitled to the medical reimbursement since the complainant was under insurance cover for the period more than 2 years.

10.              In view of the above discussion, the present complaint is allowed and OPs are directed to settle and pay the claim of the complainant as per the terms and conditions of the policy. Further OPs are directed to pay Rs.2500/-(Two thousand five hundred only) as compensation and litigation expenses compositely assessed to the complainant. Compliance of order be made within 30 days from the date of receipt of copy of this order which be made available to the parties free of costs. File be consigned to record room after due completion.

 

 

                 (Sat Paul Garg)                                (R.L.Ahuja)

                   Member                                        President 

Announced in Open Forum.

Dated:11.06.2015

Hardeep Singh