BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No.568 of 2015
Date of Institution: 11.9.2015
Date of Decision: 22.7.2016
Shri Jaswinder Singh Chandi son of Shri Piara Singh resident of Nagina Avenue, Opp.Arora Market, Majitha Road, Amritsar
Complainant
Versus
- The Oriental Insurance Co. Ltd., through its Manager/General Manager/Officer Incharge/Authorized Signatory, Regd. & Head Office A-25/27, Asaf Ali Road, New Delhi.
- The Oriental Insurance Company Limited, through its Manager/Divisional Manager/Officer In Charge, Dwarka Deesh Complex, Queens Road, Amritsar
Opposite Parties
Complaint under section 12 & 13 of the Consumer Protection Act, 1986 as amended upto date.
Present: For the Complainant: Sh.Rajesh Bhatia, Advocate
For the Opposite Parties: Sh. Sandeep Khanna, Advocate
Coram
Sh.S.S.Panesar, President
Ms.Kulwant Kaur Bajwa, Member
Mr.Anoop Sharma, Member
Order dictated by:
Sh.S.S. Panesar, President.
1. Sh.Jaswinder Singh Chandi has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that complainant is permanent resident of Nagina Avenue, Opp.Arora Market, Majitha Road, Amritsar and is a law abiding citizen of India. The complainant purchased a mediclaim Insurnace policy bearing No. 233300/48/2014/5443 from the opposite party on 4.3.2014 and paid a sum of Rs. 3135/- to the opposite party for the said policy. The complainant was duly covered under the said policy w.e.f. 8.3.2014 to 7.3.2015. It is important to mention over here that originally the said policy was commenced in the year 2002 and thereafter it was being renewed and continued by the complainant from time to time. The complainant remained under the treatment of Swastik Eye Care Centre, Guru Gobind Singh Nagar, Opp.Tungbala Gate,Majitha Road, Amritsar for his treatment of Proliferative Diabetic Retinopathy of both eyes and where the operation of both eyes of the complainant was conducted . The complainant remained under treatment of said hospital w.e.f. 10.12.2014 to 3.3.2015. For the treatment and hospitalization, the complainant spent more than Rs. 53000/- and further a sum of Rs.6000/- for his treatment and the copy of certificate in this regard duly issued by hospital is annexed. Copy of insurance policy alongwith medical record of the complainant is attached. The complainant submitted his genuine claim with the opposite party within prescribed time period and all the relevant documents for the said claim were submitted by him to the opposite party within the prescribed time period, but the opposite party repudiated the claim of the complainant on the basis of lame excuses vide repudiation letter dated 19.6.2015. The complainant has paid so many personal visits to the office of opposite party but the office bearers of the opposite party did not adhere to the genuine requests of the complainant. About one week back they flatly refused to accept the genuine medical claim of the complainant without any plausible rhyme and reason. Hence, there is gross negligence and deficiency in service on the part of the opposite party. The complainant has sought for following reliefs vide instant complaint :
(i) Opposite party be directed to release the genuine claim of the complainant to the tune of Rs. 53000/- and Rs. 6000/- in all Rs. 59000/- alongwith interest @ 24% p.a.
(ii) Compensation to the tune of Rs. 20000/- may also be awarded to the complainant on account of deficiency of service on the part of the opposite party.
(iii) Litigation expenses to the tune of Rs. 11000/- may be awarded to the complainant.
Hence, this complaint.
2. Upon notice both the opposite parties appeared and contested the complaint by filing joint written version taking certain preliminary objections therein inter alia that in the present case it was observed that the complainant had taken treatment for correction of eye sight. Accordingly, the claim was considered as inadmissible by competent authority of opposite parties No.1 & 2 i.e. E-Meditek, TPA Services Ltd . Claim was repudiated vide letter dated 4.6.2015 in which it was clearly mentioned that “In view of the above, we regret to inform you that, as per instructions of the Oriental Ins.Co. Ltd., the claim is being denied on account of the abovementioned terms of the policy”. The claim was declined as per clause 4 of the terms and conditions of the insurance policy, which reads as under :-
“The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred with or in respect of (4.6) surgery for correction of eyesight, cost of spectacles, contact lenses, hearing aids etc.”
Therefore, the opposite party repudiated the claim on merits and in this regard repudiation letter was duly addressed to the complainant clearly stating that the claim was not payable ; that as per terms and conditions of the policy in question, the claim documents have to be submitted with the Insu. Company within 7 days of discharge from the hospital. However, complainant was admitted in hospital on 10.12.2014 and discharged on 4.3.2015, but the complainant submitted the documents with the opposite party on 14.5.2015 i.e. after unjustified delay of more than two months. Moreover complainant failed to give any explanation to the opposite party for the said delay . Hence, the complainant had failed to submit the requisite documents with the opposite party within the stipulated period, as such, the complainant has violated the basic terms and conditions of the policy and is not entitled to the relief claimed for ; that as per terms and conditions of the policy in question, the claim has to be reported within 48 hours of admission in a hospital but before discharge from the hospital. It is worthwhile to mention here that the alleged hospitalization of the complainant was neither in a situation of emergency nor in connection to any serious ailment, as such the complainant should have intimated the opposite party within the stipulated period as mentioned above. However, complainant has failed to intimate the opposite party regarding his hospitalization within the stipulated period . Hence, complainant has violated the basic terms and conditions of the policy and is not entitled to the relief claimed for ; that complainant has not approached this Forum with clean hands and is guilty of suppression of material facts ; that parties to the complaint are strictly governed by the terms and conditions of the policy in question as it has been held by the Hon’ble Supreme Court in various judgements. The contract of insurance is based on utmost faith and in this regard it is submitted that by concealing material facts, it is apparent that the complainant has used fraudulent means for getting wrongful claim ; that complainant has no locus standi to file the present complaint ; that complainant is estopped by his own act and conduct from filing the present complaint ; that as the claim already stands repudiated, therefore, no consumer dispute survives. Hence, the complainant has no right to file the present complaint ; that even otherwise as the claim already stands repudiated on merits and has been found not payable , therefore, there is not deficiency of service on the part of the opposite parties. Hence, the relief towards interest and damages is not payable. On merits facts narrated in the complaint have been specifically denied and a prayer for dismissal of the complaint with cost was made.
3. In his bid to prove the case Sh. Rajesh Bhatia,Adv.counsel for the complainant tendered into evidence affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-11 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence, Sh.Sandeep Khanna,Adv.counsel for opposite parties No.1 & 2 tendered into evidence affidavit of Sh.Gurdeep Singh,Divisional Manager Ex.OP1,2/1, copy of repudiation letter Ex.OP1,2/2, copy of policy schedule Ex.OP1,2/3, copy of terms and conditions Ex.OP1,2/4 and closed the evidence on behalf of the opposite parties.
5. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
6. On the basis of the evidence on record,ld.counsel for the opposite parties has vehemently contended that it is not disputed that the complainant was holder of mediclaim Insurance policy bearing No. 233300/48/2014/5443 issued by the opposite party on 4.3.2014 on payment of Rs. 3135/- as premium which was in operation w.e.f. 8.3.2014 to midnight of 7.3.2015. No doubt the complainant remained under the treatment of Swastik Eye Care Centre, Guru Gobind Singh Nagar, Opp.Tungbala Gate, Majitha Road, Amritsar for his treatment of Proliferative Diabetic Retinopathy of both eyes , where treatment of both the eyes of the complainant was conducted and he remained under the treatment of the said hospital w.e.f 10.12.2014 to 3.3.2015. It is the case of the complainant that he has spent more than Rs. 59000/- for the treatment of his eyes, copy of the certificate accounts for Ex.C-9. However, when the complainant filed the mediclaim for refund of the medical expenses incurred on medicines and hospitalization, but the same was repudiated in view of clause 4.6 of the terms and conditions of the insurance policy which reads as under :-
“The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred with or in respect of (4.6) surgery for correction of eyesight, cost of spectacles, contact lenses, hearing aids etc.”
Since the complainant has undergone treatment of the eyes of correction of eye sight, therefore, claim has rightly been repudiated by the opposite party. The terms and conditions of the Insurance policy are binding inter-se parties. It is also the case of the opposite parties that the complainant was under legal obligation to intimate the opposite parties regarding his admission in the hospital within 48 hours thereof and he was obliged to furnish mediclaim to the opposite parties within a period of 7 days from his discharge from the hospital. But , however, in this case complainant neither intimated regarding his admission within 48 hours nor he filed the mediclaim within 7 days of his discharge from the hospital. Rather the mediclaim was filed after two months of the discharge from the hospital and there is absolutely no explanation for the delay , so occurred in filing the mediclaim. There is no merit in the complaint and the same is liable to be dismissed and it is contended that complaint may be dismissed with cost.
7. But, however, from the appreciation of the facts and circumstances of the case, it becomes evident that the complainant had been obtaining the mediclaim policy ever since the year 2002 while the current insurance policy was effective w.e.f 8.3.2014 to 7.3.2015 which was a continuous policy which used to be renewed from time to time. It is also not disputed that the complainant was hospitalized for eye treatment at Swastik Eye Care Centre, Guru Gobind Singh Nagar, Opp.Tungbala Gate, Majitha Road, Amritsar for his treatment of Proliferative Diabetic Retinopathy of both eyes and he remained under the treatment/ hospitalization w.e.f 10.12.2014 to 3.3.2015. Medical record whereof accounts for Ex.C-9. It is also proved on record that the complainant spent an amount of Rs. 59000/- on hospitalization and eye treatment which he got from Swastik Eye Care Centre, Guru Gobind Singh Nagar, Opp.Tungbala Gate, Majitha Road, Amritsar . The only reason for repudiating the claim of the complainant has been that the treatment the complainant got pertained to correction of eye sight. But, however, same is not the case with the complainant. The complainant has produced on record expert opinion of the treating doctor which is Ex.C-9 which reads as under:-
“That the treatment for the eyes of the patient Jaswinder Singh S/o Piara Singh which is a potentially blinding disease. The treatment was not done for the correction of vision and or removal of any type of spectacles or lenses.”
8. Opposite party has failed to produce any counter expert report in this regard. In this scenario the stand of the complainant stands vindicated and the complainant has been able to prove on record that the mediclaim has been wrongfully repudiated by the opposite party.
9. The further contention that the complainant has failed to intimate the opposite parties regarding his admission in the hospital within 48 hours or that he has not filed the mediclaim within the period of 7 days from the date of his discharge from the hospital , are also not tenable because mere delay in filing the mediclaim, which is genuine, is no ground to repudiate the claim. The opposite parties are guilty of deficiency in service and they have indulged in unfair trade practice in denying the genuine claim of the complainant. As such the mediclaim for Rs. 59000/- succeeds and the opposite parties are directed to make the payment of the aforesaid amount of Rs. 59000/- alongwith interest @ 6% p.a. from the date of order until full and final recovery within a period of 30 days from the date of receipt of copy of order . If the opposite parties failed to comply with the order within the stipulated period, the complainant shall be at liberty to get the order executed through indulgence of this Forum. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated: 22.7.2016.
