Punjab

Faridkot

CC/18/74

Darshan Singh - Complainant(s)

Versus

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

Ashu Mittal

04 Sep 2019

ORDER

    DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :               74 of 2018

Date of Institution:    01.05.2018

Date of Decision :      04.09.2019

 

Darshan Singh aged about 59 years, son of Jit Singh, resident of Village Sukhan Wala, Tehsil and District Faridkot.

                                                                          .........Complainant

Versus

1. Oriental Insurance Company Ltd.  Branch Office Near Old Grain Market, Kotkapura, Tehsil Kotkapura District Faridkot through its Branch Manager.
2. Oriental Insurance Company Ltd. through its MD c/o M D India, Health Care Services (TPA) Pvt Ltd, Max Pro. Info Park, D-38, Industrial Area, Phase-I, Mohali, Chandigarh.
3. M D India, Health Care Services TPA Pvt Ltd, Max Pro. Info Park, D-38, Industrial Area, Phase-I, Mohali (Punjab).

                                                                       .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum:  Sh Ajit Aggarwal, President,

                Smt Param Pal Kaur, Member.

 

Present: Sh Ashu Mittal, Ld Counsel for Complainant,

             Sh Vinod Monga, Ld Counsel for OPs.

 

 

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ORDER   

(Ajit Aggarwal, President)

 

                                             Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make payment of insurance claim of Rs.74,615/-with interest and for further directing OPs to pay Rs.20,000/- as compensation for deficiency in service and harassment alongwith litigation expenses.

2                                   Briefly stated, the case of the complainant is that being a government employee, complainant was insured under Punjab Government Employees and Pensioners Health Insurance Scheme having ID No.MD15-08146184700. Policy was valid for the period from 1.01.2016 to 31.12.2016 and as per terms and conditions of the policy in question, complainant his wife and his mother were entitled for treatment of any disease upto Rs.3 lacs and as per policy, complainant was entitled for cashless treatment and OPs are liable to pay the insurance claim. Premiums on account of Insurance Policy were paid by Punjab Government to OPs on behalf of complainant. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant. It is further submitted that mother of complainant suffered from Cancer and she undertook treatment from Care Hospital, Bathinda and spent Rs.10,790/-for this. She further took treatment from Guru Gobind Singh Medical College and Hospital, Faridkot and complainant paid Rs.99,000/-to hospital authorities for treatment of his mother. Mother

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of complainant died on 24.06.2016 and thereafter, he lodged claim with OPs and submitted all the requisite documents for reimbursement of amount spent by him on treatment of his mother. On 20.11.2016, OPs deposited Rs.24,385/-out of Rs.99,000/-on account of reimbursement of medical claim and deposited Rs.10,790/- on 3.01.2017 and thereafter, did not reimburse any amount to him. In January, 2017 complainant approached OP-3 and requested them about reimbursement, then, OP-3 told him that inadvertently, bill for Rs.99,000/-was wrongly considered as Rs.29,000/- and assured to reimburse the remaining amount within short period, but till now, OPs have not reimbursed the remaining amount and are kept lingering on the matter on one pretext or the other. Complainant issued letters to OPs in the months of July, 2017 and August, 2017 to make payment of remaining claim amount, but all in vain. Despite repeated requests, and issuance of letters, OPs have not cleared his claim, which amounts to deficiency in service and trade mal practice and has caused harassment and mental tension to complainant. He has prayed for directing OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                               The counsel for complainant was heard with regard to admission of the complaint and vide order dated 2.05.2018, complaint was admitted and notice was ordered to be issued to the OPs.

4                                              On receipt of the notice, the OPs filed written statement wherein asserted that there is no deficiency in service on

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the part of OPs as per terms and conditions of PGIPHIS and after considering and processing the claim of complainant, they have already made payment of Rs.24,385/- to complainant against claim of Rs.99,000/- and Rs.10,790/- on 3.01.2017 in respect of Gurdial Kaur under non cashless scheme and therefore, present complaint is liable to be dismissed and he is not entitled for any relief. It is admitted that complainant lodged two claims in respect of Gurdial Kaur with Ops and they processed and allowed the claim for Rs.24,385/- and Rs.10,790/- to complainant as per schedule of rates under PGEPHIS vide UTR paid on 28.01.2016 and 3.01.2017 respectively. As per terms and conditions of policy, complainant has been paid the amount admissible to him as reimbursement of expenses incurred by him  on treatment of his mother. It is admitted by OPs that mother of complainant was covered under the policy in question. He is not entitled for more amount as sought by him. It is reiterated that there is no deficiency in service on the part of OPs. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                    Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-12 and then, closed their evidence.

6                                     In order to rebut the evidence of the complainant, ld counsel for OPs tendered in evidence affidavit of

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Ashwani Kumar Ex OP-1 and document Ex OP-2 to 3 and then, closed the evidence.

7                           We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

8                           The case of the complainant is that being a government employee, he alongwith his wife and dependent mother was insured with OPs under the policy in question. His mother undertook treatment of Cancer from Care Hospital, Bathinda and complainant spent Rs.10,790/-for this. She further took treatment from Guru Gobind Singh Medical College and Hospital, Faridkot and complainant paid Rs.99,000/-to hospital authorities for her treatment. After death of his mother, he lodged claim with OPs, but OPs deposited only Rs.24,385/-out of Rs.99,000/-on account of reimbursement of medical claim and deposited Rs.10,790/- on 3.01.2017. Grievance of complainant is that despite issuance of two letters and repeated requests OPs have not reimbursed the remaining amount to him, which has caused harassment and mental agony to him. He has prayed for accepting the complaint. On the other hand to controvert the allegations of complainant, ld counsel for OPs stressed mainly on the point that claim filed by complainant has already been paid to him as per rules and regulations of PGEPHIS and nothing is due to be paid. There is no deficiency in service on their part and prayed for dismissal of complaint with costs.

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9                            Now, it is admitted case of the parties that Punjab Government launched a scheme for the cashless medical treatment of their employees, officials and pensioners namely Punjab Government employees and pensioners health Insurance scheme and made a contract with opposite parties. Being the employee of Punjab Government, the complainant was beneficiary under this scheme. It is further admitted that mother of complainant was suffering from Cancer and she took treatment from Guru Gobind Singh Medical College and Hospital, Faridkot and complainant spent Rs.99,000/-on her treatment, but complainant is entitled for only Rs.24,385/- which have already been paid to him. Another claim of complainant for Rs.10,790/-has already been paid by them and now, nothing is due to be paid and he is not entitled for any other relief as sought by him.

10                            From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that his mother was also insured with them as per Cashless Health Insurance Scheme launched by Punjab Government. It is also admitted that complainant lodged claim with them. As per OPs, complainant lodged two claims in respect of expenditure incurred on treatment of her mother Gurdial Kaur with Ops and they allowed the claim for Rs.24,385/- and Rs.10,790/- to complainant as per schedule of rates under PGEPHIS vide UTR paid on 28.01.2016 and

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3.01.2017 respectively. As per terms and conditions of policy and scheduled rate, he has been paid the amount admissible to him as reimbursement of expenses incurred by him on treatment of his mother and now, he is not entitled for any other relief as sought by him. OPs have made payment of Rs.24,385/- against lodged claim of Rs.99,000/-to complainant, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement to show that how they calculated this amount on their own. Admittedly, the complainant spent Rs.99,000/- for treatment and paid this amount to hospital authorities, the Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the persons.

11                                Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1) CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as

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New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The 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 the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon andothers, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal–Validity–Mediclaim Policy-Exclusion Clause–Pre Existing Disease-Exclusion Clause is standard form of contracts–when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

12                          From the above discussion and case law produced by the complainant, we are of considered opinion that OPs  have wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy out of entire amount, spent on treatment of his mother by complainant, who was covered under the insurance policy in

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question. The present complaint is hereby accepted with direction to Ops to reimburse the remaining amount of claim lodged by complainant as per PGI rates, which was wrongly deducted by them out of amount spent by him on treatment of his mother alongwith interest at the rate of 9 % per anum from the date of filing the present complaint till final realization. They are further directed to pay Rs.5,000/- to complainant as consolidated compensation for harassment and mental agony suffered by him including litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 04.09.2019

(Param Pal Kaur)         (Ajit Aggarwal)

                                       Member                      President