Chandigarh

DF-II

CC/191/2022

Daksh Chopra - Complainant(s)

Versus

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

Ajay Kumar & Karamjit Sharma

19 Apr 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	191/2022
Date of Institution	:	25.02.2022
Date of Decision	:	19.04.2024

 

                                       

                       

Daksh Chopra (minor) S/o Sh. Yogesh Chopra, R/o H.No.1277, Sector 34-C, Chandigarh, presently residing at H.No.173, Sector 6, Panchkula, through its mother and natural guardian Ms. Geeta Chaudhri @ Chopra.

….Complainant

VERSUS

1.     Oriental Insurance Co. Ltd., SCO No.48-49, Sector 17-А, Chandigarh, through Senior Divisional Manager.

2.     Raksha Health Insurance TPA Pvt. Ltd., Regional Office: SCO No.39, First Floor, Madhya Marg, Sector 26, Chandigarh, through its Regional Manager.

…. Opposite Party.

 

BEFORE:
	SHRI AMRINDER SINGH SIDHU,	PRESIDENT
	SHRI B.M.SHARMA	MEMBER
Present:-
	Sh.Vinod Choudhary, Counsel for the complainant Sh.J.P.Nahar, Counsel for the OPs.

       

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.         The complainant has filed the present complaint pleading therein that the mother of the complainant Mrs. Geeta Chaudhri took the medical claim policy No.231290/48/2020/172 covering the risk of family members with effect from 01.05.2019 to 30.04.2020 and later renewed and the present claim relates to Claim Ref. No.55652021025102.  It has been averred that her son Daksh Chopra (minor son) suffered from high fever, severe cough & cold and vomiting and initially treated at home by consulting specialist doctors and ultimately when the home treatment gave no relief was admitted in Max Multispecialty Hospital on 11.04.2020 and discharged on 17.04.2020. He was initially admitted in the Intensive Care Unit and got treatment for pneumonia and she incurred Rs.1,30,000/- on her son’s treatment (i.e. Rs.1,01,490/- charged by the Hospital and Rs.30,000/- spent on his treatment prior to the admission to the hospital). Since the admission was done in a panic, the payment was made in cash to the hospital against various receipts.  As advised by OP No.1, the complainant approached OP No.2 i.e. Raksha TPA and reply dated 11.05.2020 in the following terms was received from OP No.2, "due to situation arisen due to COVID-19, our office is not open till 14 April. Kindly submit the claim only after the lockdown is over". Even after 14 April the office remained closed because of COVID-19 and lockdown was extended from time to time.  Immediately, on the opening of the office, the complainant filed the claim with OP No.2  along with all the original documents available with her and dropped the same in the cardboard box kept outside as the complainant was not allowed to enter the office. It has been averred that she could not retain the photocopies of the documents as the market were completely shut down due to lockdown.  In response to the letter dated 20.05.2020 of the OPs, the complainant gave reply dated 27.05.2020  stating that all original documents had been supplied to them and the complainant had not retained photocopies of the same and in case of any doubt, the same could be verified from the hospital and it was also opined that it should be appreciated that hospitals being over burdened with COVID-19 patients, it would not be possible to obtain fresh documents and at the same time the OPs in such hard times should refrain from burdening the complainant with such demands, when the people were in panic and movement restricted by government's order. It has further been stated that having exhausted all remedies, the Counsel of the complainant requested the OP No.2 to return all original documents so that he could move to the Court of competent jurisdiction to get his concerns redressed as the OPs failed to address the grievances and failed to remit the claim to the complainants. However the OP No.2 refused to return the documents to enable the complainant to do the needful and file a claim before this Commission. The complainant also addressed a detailed communication dated 07.10.2020 in this regard to the OPs but to no effect.  Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to refund the sum assured of Rs.1,01,490/- along with interest, compensation for mental agony and physical harassment as well as litigation expenses.
2.         After service of notice upon the OPs, they filed the written statement and admitted the factual matrix of the case. However it has been stated that the complainant is required to provide the relevant documents for settlement of the claim. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on their part, the OPs prayed for dismissal of the complaint.
3.         The parties filed their respective affidavits and documents in support of their case.
4.         We have heard the Counsel for the contesting parties  and have gone through the documents on record including written submissions.
5.         From the perusal of the rival submissions of the parties and the documentary evidence on record, it is observed that the complainant namely Daksh Gupta, who was duly insured under the policy in question took the treatment from M/s Max Super Speciality Hospital, Mohali during the covid period.  It is also observed from the medical bills of the hospital that he incurred a sum of Rs.1,01,490/- on his treatment.  It is further observed that as advised by OP No.1,  the claim along with the requisite documents was submitted with OP No.2 by dropping the same in box provided outside its office due to covid restrictions.  The OPs took the stand of non-submission of the relevant documents just to escape its liability under the policy as there was no reason with the complainant not to submit the relevant documents to the OPs especially when her son was duly insured under the policy and took the treatment from the hospital. If the OPs have any doubt regarding the documents submitted by the complainant they can easily get the same verified from the hospital from where the complainant took the treatment. Besides this, the complainant has annexed the photocopies of the medical record along with the relevant bills, discharge summary etc.  with the paper book/complaint, the copy of which was duly supplied to the OPs but despite receipt of the same, they did not take any step to settle the genuine claim which itself amounts to deficiency in service as well as adoption of unfair trade practice on their part.
6.         It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.

                In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

        “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

7.         Thus, non-settlement of the genuine claim of the complainant by the OPs amounts to deficiency in service as well as adoption of unfair trade practice on their part.
8.         In view of the above discussion, the present complaint deserves to be partly allowed and the same is accordingly partly allowed qua the OPs. The OPs directed to reimburse the mediclaim of Rs.1,01,490/- to the complainant along with interest @ 9% p.a. after two month’s of the discharge of the complainant from the hospital till the date  of its actual realization to the complainant.
9.         This order be complied with by the OPs, within ninety days from the date of receipt of its certified copy.
10.         The pending application(s) if any, stands disposed of accordingly.
11.         Certified copy of this order be communicated to the parties, as per rules. After compliance file be consigned to record room.

Announced in open Commission 19.04.2024
	Sd/- (AMRINDER SINGH SIDHU) PRESIDENT
	Sd/-
	(B.M.SHARMA) MEMBER