BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.85 of 2019
Date of Instt. 19.03.2019
Date of Decision: 31.10.2022
1. Ramesh Kakkar S/o Sh. Hans Raj Kakkar resident of 15, Sat Nagar, Sodal Road, Jalandhar.
2. Kiran Kakkar W/o Ramesh Kakkar resident of 15, Sat Nagar, Sodal Road, Jalandhar.
..........Complainants
Versus
1. Oriental Insurance Co. Ltd. (233108), C. B. O-2, Jalandhar, SCO-50, PUDA Complex, Opposite Tehsil Complex, Ladowali Road, Jalandhar-144001 through its Branch Manager.
2. Oriental Insurance Co. Ltd., Divisional Office, 32, G. T. Raod, Opposite Narinder Cinema, Jalandhar through its Divisional Manager.
3. Medi Assist Insurance TPA Pvt. Ltd., 8 B, Tej Building, 2nd Floor, Bahadur Shah Zafar Marg, Next to Times of India, Delhi- 110 002.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member) Sh. Jaswant Singh Dhillon (Member)
Present: Sh. R. K. Sharma, Adv. Counsel for the Complainants. Sh. A. K. Arora, Adv. Counsel for OPs No.1 & 2.
OP No.3 exparte.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainants, wherein it is alleged that the complainants have been taking the Medi Claim Polices since 06-07-2012 without any break and the Medi Claim Insurance Policy bearing No.233108/48/2017/1131 was issued by opposite party No. 1 for the period 06-07-2016 to 05-07-2017 covering the risk of the complainant No.1 and his spouse Kiran Kakkar Complainant No. 2 is the policy in which the claim arose. The premium paid was Rs.6,990/-. As per policy schedule issued, the total sum insured was Rs.Five lacs. No Policy wordings were supplied to the complainants, only policy schedule was provided. During the currency of the Medi Claim policy, the complainant No.2 was admitted to Shriram Cardiac Centre on 15-04-2017 for Chest pain, sweating along with pains in the hands. The complainant No.2 was recommended CABG (Coronary Artery Bypass Grafting) after angiography with triple vessel block. The complainant No. 2 was shifted to Hero DMC Heart Institute, Ludhiana on 16-04-2017, where the complainant No.2 underwent surgery on 18-04-2017 and was discharged on 25-04-2017. After the Discharge of Complainant No.2 from the Hospital, claim was lodged on 14-05-2017 with Medi Assist India TPA Pvt. Ltd Opposite Party No. 3 for the re-imbursement of medical expenses of Rs.3,66,089/- and all the original medical record and original payment receipts were given to the opposite party No.3. The opposite parties vide letter dated 07-08-2017 have approved the claim of Rs.2,32,994/- only instead of claim of Rs.3,66,089/- filed by the complainant No.2 after making deductions of Rs.1,33,695/- without any justification arbitrarily and unilaterally. The Medi Claim insurance of the complainant No.2 was to the tune of Rs. Five Lacs for the period 06-07-2016 to 05-07-2017 as per Policy of Insurance bearing No. 233108/48/2017/1131 and as such the opposite party has no right whatsoever to deduct any amount from the claim of Rs.3,66,089/- lodged by the complainants. Thus the opposite parties have wrongly deducted a sum of Rs.1,33,695/- from the legal and lawful claim of the complainants without any right to authority. The complainant No.1 raised objections to the deductions vide letter dated 10-08-2017 stating therein that the deductions are illogical and mentioning the Voucher No. of receipt of Rs. 18,000/- and that ballooning is a part of treatment demanding the spilt of expenses treated as Non Payable and under which rule or terms and conditions of the insurance policy, but the opposite party No. 3 did not respond. Another Letter dated 21-09-2017 2017 was sent to the opposite party No. 3 stressing the issue of wrong deductions and copies of the same were also sent to Head office of opposite parties as well as Grievance redressal Officer, but the opposite parties again did not respond. The complainant No.1 once again sent letter dated 16-10-2017 to opposite party No. 3 along with the certificate from the Surgeon making clear that the patient (Complainant No. 2) needed Intra Aortic balloon pump (IABP). The expenses incurred above the package is towards ballooning i.e. Intra Aortic balloon pump (IABP) which was a requirement for the treatment for making the patient fit for CABG as such those expenses are part of the treatment and cannot be put into non-payable expenses. Moreover, the sum insured in Five Lacs and the claimed amount on treatment is well within the limits of sum insured, but the opposite parties again did not respond. The objections raised by the complaints against the wrong deductions made by the opposite parties are un-answered and un-explained despite repeated requests and letters, as such evidently the services provided by the opposite parties are deficient and defective in nature. The opposite parties are indulging in unfair trade practice and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the balance amount of Rs.1,33,695/- alongwith interest @ 12% per annum from the date of lodging the claim till the date of payment to the complainants being the amount wrongly deducted from the claim of the complainants. Further, OPs be directed to pay Rs.1,00,000/- on account of providing deficient and defective services to the complainant and Rs.25,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, but despite service OP No.3 failed to appear and ultimately OP No.3 was proceeded against exparte, whereas OPs No.1 & 2 appeared through its counsel and filed joint written reply and contested the complaint by taking preliminary objections that there is no deficiency of service or unfair trade practice on the part of answering opposite parties and that being so the present complaint is not maintainable. It is further averred that the complainants have purchased OIC PNB Royal Mediclaim Policy No.233108/48/2014/919 having validity from 06.07.2013 to 05.07.2014 for a sum of Rs.5 Lacs, which was subsequently renewed vide policy no. 233108/48/2015/1069 and thereafter vide policy no. 233108/48/2016/931 and finally vide policy no. 233108/48/2017/1131 for the period 06.07.2016 to 05.07.2017 from Oriental Insurance Company Limited i.e. opposite party no.1. During the validity of above said policy of insurance Smt. Kiran Kakkar admitted at Dayanand Medical Collage and Hospital, Ludhiana on 15.04.2017 with chief complaints of Coronary Artery Disease. As per submitted discharge summary by the complainant, she was diagnosed a case of CAD, ACS, NSTEMI, LVEF- 45% with TVD discharge summary and was advised to undergo Coronary Artery Bye Pass Surgery. After discharge from the Hospital, the insured submitted the claim documents for reimbursement So expenses incurred on treatment amounting to Rs.366089/-. As per policy terms and conditions and the rates agreed with the hospital for the surgical management of coronary artery grafting, the agreed package rates with the hospital and accordingly payment of Rs.232394/- was made as per policy condition 3.12.
The claim received under the aforesaid policy was processed as per policy terms and conditions and that being so the present complaint is liable to be dismissed against the answering opposite parties. On merits, the factum with regard to taking insurance policy by the complainant from OP No.1 is admitted and it is also admitted that the claim was lodged by the complainant with OP, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder not filed by the complainant.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. The complainants have alleged that they have been taking medi-claim policies since 06.07.2012 without any break, whereas the OPs have denied that the complainants have been taking policies of insurance from 06.07.2012 and have alleged that the complainants have been taking policies of insurance from 06.07.2013 onwards. This fact has been admitted that the complainants were issued medi-claim insurance policy for the period 06.07.2016 to 05.07.2017, which has been proved as Ex.C-1. The sum insured was Rs.5,00,000/. It has been alleged that during the currency of the medi-claim policy, the complainant No.2/Kiran Kakkar was admitted to Shriram Cardiac Centre for chest pain and she was recommended CABG i.e. Coronary Artery Bypass Grafting after angiography with triple vessel block. Thereafter, she was shifted to Hero DMC Heart Institute, Ludhiana for 16.04.2017, where she underwent surgery on 18.04.2017 and was discharged on 25.04.2017. He has proved on record the discharge summary issued by Shriram Cardiac Center Joshi Hospital, Jalandhar ExC-10. He has also proved on record the certificate of the doctor showing that the complainant No.2 was admitted in DMC Hospital on 16.04.2017 with diagnose of CAD. CABG was done on 18.04.2017 and she was discharged on 25.04.2017. It is admitted that the complainant had applied for reimbursement of medical expenses of Rs.3,66,089/-. The complainant has proved on record the receipts and bills of payments made to Shriram Cardiac Center Joshi Hospital Ex.C-3 to Ex.C-8. Copy of final bill is Ex.C-9. Copies of payment receipts issued by Hero DMC Heart Institute Ex.C-11 to Ex.C-22 and Copy of Inpatient Final Bill dated 24.04.2017 Ex.C-23, copy of detail of final bill Ex.C-24 and copy of detail of CABG package is Ex.C-25. This is not disputed that the complainant after paying the bill has submitted medical form for reimbursement Ex.C-2. The complainant did not seek cashless amount from the medi-claim rather sought reimbursement as per Ex.C-2. The claim has been approved vide Ex.C-26 for Rs.2,32,394/-. The total amount as per Ex.C-23 was paid by the complainant as Rs.3,66,089/-. The amount of Rs.2,32,394/- has been paid to the complainant, but the amount of Rs.1,33,695/- was deducted vide letter Ex.C-26. Now the complainant has challenged the deductions made by the OPs out of the amount of the claim made by the complainant.
7. The contention of the OPs is that the complainant is not entitled to the remaining amount as alleged as the amount has been settled as per policy terms and conditions and the rates agreed with the hospital for surgical management of coronary artery bypass grafting. The agreed package rates with the hospital and accordingly, payment has rightly been made by the OP. The OPs have referred policy condition 3.12. Perusal of the policy condition 3.12 of Ex.OP1/2, which is the part of this document shows that there is head under hospitalization, whereas in the written statement the condition no.3.12 is regarding reasonable and customary charges whereas in this column under 3.12, there is no such head rather the same has been mentioned under the head 3.26 on page No.8 in this terms and conditions schedule. Perusal of this PNB-Oriental Royal Mediclaim Prospectus shows that this pertains to the period 2017, whereas the present claim was made for the insurance which was alive for the period from 2016 to 2017. So, these terms and conditions are not applicable to the terms and conditions of the insurance policy purchased by the complainant. No other terms and conditions have been filed on record by the OP to show that these terms and conditions were well within the knowledge of the complainant, whereas the complainant has alleged that he was never supplied with any terms and conditions. It has been held in a case titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Rajwant Kaur and Other”, 2021 (3) CLT 540 (CHD) that the onus is on the appellant insurance company to prove that it provided the terms and conditions of the policy to the complainant and the same were in her knowledge. It has been held in a case titled as “National Insurance Co. Ltd. & Ors Vs. M/s Saraya Industries Ltd”, 2020 (1) CLT 278 (NC) that it is the duty of the insurance company to supply all the terms and conditions of an insurance policy to the policy holder-there cannot be any presumption under law on the terms and conditions. It has been held in a case titled as “Bhanwar Lal Vishnoi Vs. Oriental Insurance Co. Ltd.”, cited in 2017 (1) CLT 401, that the insurance co. has to prove that the exclusion clause under which the claim is sought to be repudiated was communicated to the complainant.
8. It is not disputed that the amount was settled for Rs.2,32,000/-. The complainant has sent number of emails to the OP giving detail of the amount spent by him. The CABG package for Four Bedding, was for Rs.2,25,000/- as per Ex.C-25. In the emails Ex.C-27, Ex.C-28 and Ex.C-29, he has clarified that there was a requirement of ballooning as per the doctor’s advise at Hero DMC Heart Institute, Ludhiana for which they charged extra as is clear from the pamphlet. So, the additional cost involved is out of the package of CABG, but is a part of treatment. The pamphlet which has been proved as a part of Ex.C-28 gives detail of additional charges to be taken from the patient apart from the package of Rs.2,25,000/- and the charges taken for Intra aortic balloon pump are additional charges as per this schedule. The complainant has clarified and proved the receipt of Rs.18,000/- which show the number and detail vide which the amount was paid by the complainant to the Shriram Cardiac Centre. It is not disputed that the complainant was insured for Rs.5,00,000/- and the amount claimed by the complainant is within the limit of his insurance amount. It is also proved that the complainant did not opt for cashless treatment rather paid the amount of Rs.3,66,000/-, which has been proved by the complainant. So, the deductions done by the OP are without any basis. The terms and conditions have not been proved. So, the order deducting this amount is set-aside. The amount of Rs.2,32,394/- already paid and OPs are directed to pay the remaining amount of Rs.1,33,695/- alongwith interest @ 6% per annum from the date of lodging claim till realization and as such, the complaint of the complainant is partly allowed. Further, OPs are directed to pay a compensation of Rs.10,000/- to complainant for causing mental tension and harassment and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
31.10.2022 Member Member President
