Punjab

Faridkot

CC/18/147

Rinku Goyal - Complainant(s)

Versus

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

Anil Kumar Chawla

03 Apr 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C.C. No. :                147 of 2018

Date of Institution:    11.09.2018

Date of Decision :        3.04.2019

 

Rinku Goyal aged about 40 years son of Prem Dass, resident of Gali No. 2, Lajpat Nagar, Kotkapura, Tehsil Kotkapura, District Faridkot.                      

 ...Complainants

Versus

1. The Oriental Insurance Company Ltd, Near Old Grain Market, Kotkapura, Tehsil and District Faridkot through its Branch Manager.
2. TPA Raksha Mediclaim Pvt Ltd, 15/5 Mathura Road, Faridabad 121003 through its Manager.

                     ....OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh  Ajit Aggarwal, President,

                Smt Param Pal Kaur, Member.

 

Present: Sh Anil Chawla, Ld Counsel for complainant,

              Sh Sandeep Sharma, Ld Counsel for OP-1,

              Representative on behalf of OP-2.

 

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

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claim of Rs.40,181/- alongwith interest and for further directing OPs to pay Rs.50,000/- as compensation for harassment, inconvenience, mental agony and Rs.9000/- as litigation expenses.

2                                            Briefly stated, the case of the complainant is that complainant purchased a mediclaim policy bearing no. 233200 /48 /2019 /188 for Rs.2 lacs and got continued the same for the period from 18.04.2018 to 17.04.2019.  It is submitted that complainant suffered some problem in his abdomen with anorexia and weight loss. He was admitted in Daya Nand Medical College and Hospital, Ludhiana on 20.04.2018 and after conduction of complete tests and diagnosis, it was found that he was suffering from disease of Ankylosing Spondylitis. Complainant was got admitted in Daya Nand Medical College and Hospital, Ludhiana on 20.04.2018 and was discharged therefrom on 25.04.2018 and he spent Rs.40,181/-on his treatment. After getting discharged from hospital, complainant lodged claim with OPs and submitted all the requisite documents to them, but OPs illegally and unlawfully repudiated the claim of complainant vide letter dated 5.06.2018, which amounts to deficiency in service and trade mal practice on the part of OPs. All this has caused harassment and mental agony to complainant. Prayer for accepting the complaint is made alongwith compensation and litigation expenses besides the main relief.

3                                             The counsel for complainant was heard with regard to admission of the complaint and vide order dated

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12.09.2018, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                            On receipt of the notice, OP-1 appeared in the Forum through Counsel and filed written statement taking preliminary objections that this Forum has no jurisdiction to hear and try the present complaint and it is not maintainable in this Forum. It is averred that lengthy evidence is required in present case and it should be sent to Civil Court for proper adjudication of the case. As per Ops they have rightly repudiated the claim of complainant in view clause 4.13, 4.14 and 4.15 of policy vide which expenses for investigation which are irrelevant to the disease in respect of which complainant was admitted and diagnosed. After careful   scruitinization of documents submitted by complainant, OP-2 opined that case of Anorexia, weight loss and Ankylosing Spondylitis, patient managed conservatively. As per clause 4.15, claim of complainant is not payable as Ankylosing Spondylitis is genetic disorder and is excluded permanently for relief purpose. Even as per clause 4.14 admission is done only for evaluation and there is no active line of management and thus, claim is recommended to be non payable. It is further averred that complainant is not their consumer. However, on merits Ops have denied all the allegations of complaint being wrong and incorrect and prayed for dismissal of complaint with costs. They have reiterated the same pleadings taken in preliminary objections and asserted that they have rightly repudiated the claim of complainant vide letter dated 5.06.2018. There is no deficiency in

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service on the part of answering OP-1 and prayed for dismissal of complaint with costs.

5                                              OP-2 filed reply wherein submitted that answering OP is only a facilitator for the processing of the claim and claim sought by complainant is to be issued by the Oriental Insurance Company/Op-1 and contract of insurance is between complainant and insurer and as per terms and conditions of contract, OP-2 Third Party Administrator is obliged to process the claim as per terms and conditions of the policy. It is admitted that complainant was insured under policy in question for the period from 18.04.2018 to 17.04.2018 and it is also admitted that he was admitted in Dayanand Medical College and Hospital, Ludhiana during 20.04.2018 to 25.04.2018 for the treatment of Anorexia, Weight Loss and Ankylosing Spondylitis and claim filed by him was recommended for repudiation as non payable to OP-1 in terms of policy clause no.4.10 and 4.15 vide which Expenses for investigation/treatment irrelevant to the disease for which admitted or diagnosed. Ankylosing Spondylitis is a genetic disorder and as per  terms and conditions of the policy, genetic disorders are permanent exclusion and therefore, claim of complainant was recommended to be non payable as per clause 4.15. It is further averred that complaint filed by  complainant is not maintainable against them and is liable to be dismissed. All the other allegations levelled by complainant are denied being wrong and incorrect and reiterated that there is no deficiency in service on their part. Prayer for dismissal of complaint is made.

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6                                              Parties were given proper opportunities to prove their respective case. The ld counsel for complainant tendered in evidence affidavit of complainant no. 1 as Ex.C-1, affidavit of complainant no. 2 as Ex C-2 and documents Ex C-3 to C-24 and then, closed his evidence.

7                                               In order to rebut the evidence of the complainant, ld counsel for opposite party 1 tendered in evidence affidavit of Vikas Kataria Ex Op-1/1 and documents Ex OP-1/2 to Ex Op-1/6 and closed the same. Counsel for 2 tendered in evidence, affidavit of Vinay Batra Ex OP-2/1 and closed the same on behalf of OP-2.

8                                              We have heard the arguments addressed by all the parties and have also gone through the evidence and documents led by the parties.

9                                          Ld Counsel for complainant argued that complainant purchased a family mediclaim policy for sum assured of Rs.2 lacs and got continued the same for the period from 18.04.2018 to 17.04.2019. During the subsistence of policy in question, complainant suffered some problem in his abdomen with anorexia and weight loss for which, he was admitted in Daya Nand Medical College and Hospital, Ludhiana on 20.04.2018 and it was found that he was suffering from disease of Ankylosing Spondylitis. He was admitted in Daya Nand Medical College and Hospital, Ludhiana on 20.04.2018 and was

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discharged therefrom on 25.04.2018 and he spent Rs.40,181/-on his treatment. Thereafter, complainant lodged his claim with OPs and submitted all the requisite documents to them, but OPs wrongly repudiated the claim vide letter dated 5.06.2018. He made several requests to Ops to make payment of insurance claim, but all in vain, which amounts to deficiency in service and has caused harassment and mental agony to complainants. Prayer for accepting the complaint is made alongwith compensation and litigation expenses. Ld counsel for complainant has stressed on documents Ex C-1 to 24.

10                                         To controvert the  arguments of complainant counsel, ld counsel for OP-1 argued that they have rightly repudiated the claim of complainant in view of clause no. 4.13, 4.14 and 4.15 of policy vide which expenses for investigation which are irrelevant to the disease in respect of which complainant was admitted and diagnosed. After careful   scruitinization of documents submitted by complainant, OP-2 opined that case of Anorexia, weight loss and Ankylosing Spondylitis, patient managed conservatively. As per clause 4.15, claim of complainant is not payable as Ankylosing Spondylitis is genetic disorder and is excluded permanently for relief purpose. Even as per clause 4.14 admission is done only for evaluation and there is no active line of management and thus, claim is recommended to be non payable. OP-1 denied all the allegations of complaint being wrong and incorrect and reiterated that there is no deficiency in service on the part of answering OP-1 and prayed for dismissal of complaint with costs.

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11                                       Ld counsel for OP-2 argued before the Forum that  OP-2 is a Third Party Administrator and acts only as a facilitator for the processing of the claim and claim sought by complainant is to be issued by the Oriental Insurance Company as contract of insurance is between complainant and insurer and as per terms and conditions of contract, OP-2 Third Party Administrator is obliged to process the claim as per terms and conditions of the policy. Ld counsel for OP-2 admitted that complainant was insured under policy in question and that he was admitted in Dayanand Medical College and Hospital, Ludhiana during 20.04.2018 to 25.04.2018 for the treatment of Anorexia, Weight Loss and Ankylosing Spondylitis and claim filed by him was recommended for repudiation as non payable to OP-1 in terms of policy clause no.4.10 and 4.15 vide which Expenses for investigation/treatment irrelevant to the disease for which admitted or diagnosed. Ankylosing Spondylitis is a genetic disorder and as per  terms and conditions of the policy, genetic disorders are permanent exclusion and therefore, claim of complainant was recommended to be non payable as per clause 4.15. It is further argued that complaint filed by  complainant is not maintainable against them and is liable to be dismissed. All the other allegations levelled by complainant are denied being wrong and incorrect and reiterated that there is no deficiency in service on their part. Prayer for dismissal of complaint is made.

 12                                      From the careful perusal of record and above discussion, it is observed that case of the complainant is that he was

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insured with Ops under policy in question and during the subsistence of insurance policy in question, he suffered some problem of Ankylosing Spondylitis for which he remained admitted in DMC, Ludhiana and took treatment therefrom and thereafter, he lodged claim with Ops but Ops repudiated the same without any reason, which amounts to deficiency in service. Grievance of complainant is that despite repeated requests OPs did not pay any heed to his genuine requests which caused him great harassment. In reply, stand of OP-1 is that they have rightly repudiated the claim of complainant as per terms and conditions of insurance policy in question. As per clause 4.15, claim is not payable as Ankylosing Spondylitis is genetic disorder and is excluded permanently for relief purpose and even as per clause 4.14 admission is done only for evaluation and there is no active line of management and thus, claim is non payable. OP-2 have also took the same plea and asserted that they opined OP-1 that claim filed by  complainant is non payable in terms of policy clause no.4.10 and 4.15 vide which Expenses for investigation/treatment irrelevant to the disease for which admitted or diagnosed and Ankylosing Spondylitis is a genetic disorder and as per  terms and conditions of the policy, genetic disorders are permanent exclusion and therefore, claim of complainant was recommended to be non payable as per clause 4.15 and recommended for repudiation of same. There is no deficiency in service on their part and prayed for dismissal of complaint with costs.

 

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 13                               Careful perusal of documents Ex C-2 to Ex C-21, which are copies of bills, payment receipts, discharge summary; radio diagnosis reports and endoscopy images it is clearly proved that complainant suffered from Ankylosing Spondylitis and he underwent treatment in DMC, Ludhiana and spent Rs.40,181/-on his treatment. Ex C-23 is repudiation letter dated 5.06.2018 vide which Ops rejected the claim of complainant as per clause 4.13, 4.14 and 4.15. On the contrary, Ops have placed on record no documentary evidence to prove that Ankylosing Spondylitis is a genetic disorder and moreover, at the time of purchase and issuance of insurance policy in questions, Ops did not supply any terms and conditions vide which genetic disorders are permanently excluded for the purpose of giving relief and reimbursement of such diseases. Ld Counsel for complainant argued that the OPs cannot deny the amount in dispute i.e 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 New India Assurance Company Ltd Vs Smt

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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 and others, 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.

14                                         From the above discussion and case law produced by the complainant, we are of considered opinion that OPs have wrongly and illegally refused to make payment of amount spent by complainant on his treatment on false grounds of terms and conditions of policy, which were never supplied to him though he was covered under the Mediclaim insurance policy. The present complaint is hereby

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accepted. Opposite parties are hereby directed to reimburse the claim amount of Rs.40,181/-to complainant, which was wrongly refused by them for amount spent by him on his treatment alongwith interest at the rate of 9 % per anum from the date of filing the complaint till final realization. They are further directed to pay Rs.3,000/-to complainant as consolidated compensation for harassment and mental agony suffered by him as well as for 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 : 3.04.2019

(Param Pal Kaur)              (Ajit Aggarwal)

                                        Member                                    President