PER:

Nidhi Verma, Member.

1        The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.

2        The complainants have filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11 and 12 against the opposite parties on the allegations that the impugned medi claim insurance was obtained by the complainant from opposite parties and in respect of the said insurance policy, opposite party No. 1 issued policy on 14.5.2013 and the same has been renewed from time to time against the payment of requisite premium and as such, the complaint is properly signed, verified and instituted signed, verified and instituted by a proper and competent person.  As the impugned insurance was obtained from opposite party No. 1 and the controversy relates to the opposite party No. 1 having its branch office at Kennedy Avenue Court Road, Amritsar and as such, the service of opposite party No. 1 may please be effected through its branch manager/ person over all incharge as envisaged under law.  The opposite party No. 2 is third party administrator (TPA) and the repudiation of the claim has been conveyed by opposite party No. 2 and as such, opposite party No. 2 has also been arrayed and the service of the same may please be effected through its manager/ authorized officer/ person over all incharge of opposite party No. 2. The impugned insurance was obtained in the name of complainant covering the medi claim risk of complainant and in respect thereof impugned policy was issued by the opposite party No. 1 and as such, complainant is the consumer of opposite parties within the purview of consumer Protection Act, having hired the services of the opposite parties. On 22.3.2015 the complainant met with an accident and he obtained first aid treatment from Dhan Dhan Baba Deep Singh Multispecialty Hospital, Amritsar and spent Rs. 2000/- and further he obtained treatment from Dr. Avinash C. Prabhakar, BDS where the complainant went on 25.3.2015 and obtained medical treatment and the complainant further spent Rs. 12000/- and in all the complainant spent Rs. 14000/- on his medical treatment due to injury received in the said road accident. Thereafter, the complainant lodged his claim before the opposite parties through agent Ashok Chatrath and has also supplied all the requisite documents to the opposite parties but the opposite parties have failed to pay the genuine claim of the complainant till date inspite  of repeated approaches and request made by the complainant. the opposite parties dilly delaying the matter on one pretext or the other by stating that the claim is under consideration, but however, no satisfactory reply was ever given by the opposite parties even till date the opposite parties have to pay the claim of the complainant. Keeping in view the aforesaid facts alongwith cumulative chain of circumstances as stated above it becomes quite evident that there is gross deficiency in service and unfair trade practice on the part of the opposite parties as the opposite parties refused to pay the genuine claim of the complainant which tantamount to deficiency in service and unfair trade practice on the part of the opposite parties and as such, it has necessitated to file the present complaint. Earlier the complaint was filed by the complainant in person before this commission bearing complaint No. 73/17 and the said complaint was dismissed in default due to some reason beyond the control of complainant vide order dated 14.2.2017. The complainant has prayed that the opposite parties may kindly be directed

(i)      To pay a sum of Rs. 14,000/- to the complainant being amount spent by the complainant on her treatment alongwith interest @18% per annum.

(ii)     To pay compensation to the tune of Rs. 25,000/- to the complainant on account of mental pain, agony and harassment caused by the opposite parties.

(iii)    To pay costs of litigation.

3        After formal admission of the complaint, notice was issued to Opposite Parties and opposite party No. 1 appeared through counsel and filed written version and contested the complaint by interalia pleadings that the complainant has only supplied copy of insurance policy starting from 14.5.2013 with ending period 13.5.2014; whereas the alleged occurrence in the complaint has been stated dated 22.3.2015 which does not fall in the aforesaid policy. Specific request was made to the counsel of the complainant that relevant policy for the period 2014-15 should be supplied but the same has not been supplied so far for the best reasons known to the complainant and his counsel. As per the case of the complainant, he met with an accident on 22.3.2015 and obtained first aid treatment from Dhan Dhan Baba Deep Singh Multiplicity Hospital and spent Rs. 2000/- but he has not produced any certificate dated 22.3.2015 nor any bill of Rs. 2000/-  has been placed on the court file. The complainant has further alleged that thereafter he again obtained treatment from Dr. Avinash C. Prabhakar, it is submitted that the said doctor is rendering services in Baba Deep Singh Hospital but in order to earn money instead of giving treatment in the hospital, he used to refer the the patients to his clinic where he charges expenses according to his own choice which are against the rules and norms of the said hospital. Even otherwise the claim of the complainant has already been repudiated by the concerned T.P.A. opposite party No. 2 for the reason that the entire treatment taken by the complainant was OPD treatment and after scrutinizing the papers the said TPA i.e. opposite party No. 2 sent repudiation letter dated 24.5.2015 informing the complainant that after examining the claim from the associated documents of Kishan Kumar, he was admitted in hospital for the treatment taken on OPD basis. Under these circumstances the said TPA informed that as per exclusion clause No. 4 under its sub clauses 4.7 according to which any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc. unless arising from disease or injury and which required hospitlisation for treatment, the company shall not be liable to make any expenses whatsoever incurred in this regard on OPD basis. It has been clearly agreed in the standard policy that if there is admission in the hospital for more than 24 Hours, only then expenses incurred on the said treatment are payable. As there was no hospitlisation more than 24 hours, therefore, the claim has been rightly repudiated by the TPA under exclusion clause 4.7 as referred above. However, the complainant has not given reference of the said repudiation issued by opposite party No. 2 to him which clearly shows that the complainant has not approached this commission with clean hands and has concealed the material facts. In this regard it is worthwhile to mention that even the said repudiation was challenged by the complainant and he made request to reconsider the same by opposite party No. 1 and the matter was again referred to opposite party No. 2 who vide their letter again confirmed that ‘We have received claim file for reconsideration as per request of the insured. But the claim is not payable as Dental treatment is taken OPD basis, whereas dental treatment are payable if it requires hosptalisation for more than 24 hours but not paid for OPD treatments. Even otherwise the claim was intimated very late and no documents were supplied but the same were supplied after long period which clearly shows that the complainant has failed to fulfill the obligations put on him to give information immediately and also to supply requisite documents. The complainant has stated in the complaint that he has given information to Mr. Ashok Chatrath but hesitation date of intimation nor any receipt showing the delivery of said intimation in writing with documents has been produced on the court file. Hence, the complainant cannot avail any benefit of the alleged verbal intimation even if it is proved to be given  to Mr. Ashok Chatrath. Moreover, as per procedure of the company, the intimation regarding any loss or damage or injuries is to be given to the office of the insurance co. in writing alongwith documents because the agent is not the employee of the company and after issuing insurance policy, his roles comes to an end and subsequently, he is not authorized to receive any claim intimation or documents from the party. Hence, this plea taken by the complainant also not legally maintainable to condone the delay or late submission of documents. As the claim has been repudiated on merits well in time, therefore, there is no deficiency in service on the part of the opposite party. Hence the relief of compensation as well as interest and costs cannot be allowed because basically there is no such provision to allow such reliefs nor there is any agreed clause to accept any such liability on the basis of contract of insurance on the basis of which present complaint has been filed. The present complaint is bad for non joinder of necessary parties and causes of action. In this case as the complainant has taken the treatment from Dhan Dhan Baba Deep Singh Multispecialty Hospital as well as Dr. Avinash C. Prabhakar.. however, the said hospital authorities as well as the treating doctor have not been impleaded as party to the present complaint intentionally because the complainant is fully aware that if the said hospital authorities and concerned doctor file any written version, the same will go against the complainant and the complaint filed by him shall stands smashed. Moreover. Mr. Ashok Chatrath has not been impleaded as party to the case whom the complainant alleged to have submitted any information and documents. The complainant has given reference of policy dated 14.5.2013 which came to end on 13.5.2014 whereas in the present case alleged date of accident is stated as 22.3.2015 which does not fall under the aforesaid policy. Hence the complainant be directed to produce relevant policy with terms and conditions in original i.e. for the period 2014-15. The opposite party  No. 1 has denied the other contents of the complaint and prayed for dismissal of the same.

4        Notice was issued to the opposite party No. 2, but the opposite party No. 2 did not appear despite service, therefore, the opposite party No. 2 was proceeded against exparte.

5        To prove the case, complainant has tendered in evidence his affidavit Ex. CW1/A alongwith documents i.e. copy of insurance policy EX. C-2, copy of insurance policy cards Ex. C-2 to Ex. C-4, copy of the doctor slip Ex. C-5, copy of receipt dated 31.3.2015 Ex. C-6 and closed the evidence. On the other hands, Ld. counsel for the opposite party no. 1 has placed on record affidavit of Sh. R.K. Sharma Divisional Manager Ex. OP/1, affidavit of Dr. Kamal Krishan, Medical Officer, E Meditec TPA Pvt. Ltd. Ex. OP/2, Prescription of Dhan Dhan Baba Deep Singh Ji Hospital Dated 14.3.2015 pertaining to the complainant Ex. OP/3, Certificate of Dr. Avinash C Prabhakar conforming that patient was referred to his Clinic by Dhan Dhan Baba Deep Singh Ji Hospital after giving first aid to him Ex. OP/4, Certificate of Dr. Avnash C. Prabhakar confirming that there no need was felt for X-ray examination Ex. OP/5, Claim form submitted by the complainant confirming he went to Dhan Dhan Baba Deep Singh Hospital on 14.3.2015 and was discharge on the same day Ex. OP/6, Detail of expenses charged by Dr. Avnash C Prabhakar confirming that no room rent etc. was charged Ex. OP/7, Repudiation letter dated 24.8.2015 written by the E-Meditek TPA to the complainant Ex. OP/8, Letter reg return of the file to reconsider the request of the complainant by TPA sent by opposite party Ex. OP/9, Final decision of the TPA confirming that the decision conveyed earlier is reasserted as correct on Ex. OP/10, final repudiation letter sent by the co to the complainant Ex. OP/11, Attested copy of the Postal receipt of repudiation letter dated 9.9.2015 Ex. OP/12 and certified copy of the insurance policy alongwith terms and conditions Ex. OP/13 and closed the evidence on behalf of opposite party No. 1.

6        We have heard the Ld. counsel for the complainant and opposite party No. 1 and have gone through the record on the file. In the present complaint , the complainant kishan Kumar purchased the insurance policy from the OP No 1, issued on 14/05/2013 and same has been renewed from time to time against the payment of requisite premium . On dated 22/03/2015 the complainant met with an accident and he obtained first aid treatment from Dhan Dhan Baba Deep Singh Multi-specialty Hospital , Amritsar and spent 2000/- . Further the complainant obtained treatment from Dr. Avinash C Prabhakar ,BDS where the complainant went on dated 25/03/2015 and obtained medical treatment and the complainant further spent 12000/-. Later ,the complainant lodged his claim through agent Ashok Chatrath and supplied all the requisite documents to the OPs but OPs have failed to pay the claim of the complainant. OP No. 1 stated in their written version that the complainant has only supplied copy of insurance policy starting from 14 May 2013 with ending 13 May 2014 whereas the alleged occurrence in the complaint has been stated on dated 22 March 2015 which does not fall in the aforesaid policy. Specific request was made to the complainant that relevant policy of the year 2014- 2015 should be supplied but the same was not supplied so far . Further, the complaint has not produced any certificate dated 22 March 2015 nor any bill of ₹2000 has been placed on the record for which the complainant obtained first aid treatment from Dhan Dhan Baba Deep Singh multi specialist hospital. Further complainant obtained treatment from Dr. Avinash on dated 23.03.2016 and spent Rs. 12000/- but the entire treatment was OPD treatment.  As per terms and conditions Clause No. 4 under its sub clauses 4.7 according to which :-

“Any dental treatment or surgery which is corrective, cosmetic or off aesthetic procedure ,Filling of cavity,root canal including wear and tear etc.  unless arising from disease or injury and which required hospitalization for treatment, the company shall not be liable to make any expenses whatsoever incurred in this regard on opd basis”

It has been clearly agreed in the standard policy that if there is admission in the hospital for more than 24 hours only then expenses incurred on the said treatment are payable as there was no hospitalization more than 24 hours therefore, the claim has been rightly  repudiated  by TPA under exclusion clause number 4 .7. (Ex Op 13-terms and conditions). On dated 24.08.2015 , OP No. 2 sent repudiation letter informing the complainant, that he was admitted in the hospital for the treatment taken on OPD basis and it’s not covered under terms and conditions.(Ex OP/8). Lateron ,the opposite party received claim file for reconsideration as per request of the insured and TPA stated that the claim is not payable as dental treatment is taken on OPD basis whereas dental treatment are payable if it requires hospitalization for more than 24 hours but not paid for OPD treatment. (Ex OP/11 -final repudiation letter). In view of the above discussion and documents placed on record, we are of the considered view that, as per Consumer Protection Act,1986 section 2 (1)(g) – It is well settled principle of law that the parties are bound by the terms and conditions of the insurance policy and none of the parties can seek any relief beyond those terms and conditions. The Hon'ble State Commission has relied upon the ruling of the five judge bench of the Apex Court in General Assurance Society Ltd. Vs. Chandmull Jain and Anr. AIR 1966 Supreme Court 1644. It has been further held by the Hon'ble Apex Court in case M/s Suraj Mal Ram Niwas Oil Mills (P) Ltd Vs. United India Insurance Co.Ltd & Anr that in a contract of insurance the rights and obligations are governed by the terms of the contract. Terms of contract of insurance have to be strictly construed. No exception can be made on the ground of equity- in construing the terms of a contract of insurance, the words used therein must be given paramount importance and it is not open for the court to add, delete or substitute any word. In this case also contract of insurance between the parties is based on terms and conditions of the policy and must be followed in letter and spirit . Opposite party deducted the amount from the claim amount of the complainant as per terms and conditions of the policy which was the base of the contract of insurance between the parties.

 7       As per complainant evidence, he provided copy of cashless card of the insurance policy (Ex C2 to C4) , which prove he was entitled For the insurance claim policy. But failed to provide any receipt from where he took first aid treatment i.e. Dhan Dhan Baba Deep Singh Multi Specialist hospital Amritsar. Thereafter , the complainant provided the doctor slip (Ex C-5) dated 31.03.2015 where regarding hospitalization for more than 24 hours was not mentioned only expenses charged were there but no room rent etc are there  but it was just OPD treatment by Dr. Avinash C Parbhakar. Further, OP No 1 placed on record the Affidavit of Dr. Kamal Krishan ,MO E-meditak ,TPA. who stated that the claim form and associated documents of the insured Krishna Kumar were received by the TPA for payment . However on scrutiny of the same it was observed that he was admitted in Dhan Dhan Baba Deep Singh Ji Hospital but treatment taken on OPD basis (Ex OP/3 ). Therefore, we regret to inform that the claim is being denied on account of terms and conditions. OP No. 1 provided the document on record (Ex OP/6) claim Form submitted by the complainant confirming he went to Dhan Dhan Baba Deep Singh Ji Hospital on 14.03.2015 and was discharged on the same day, which itself prove the treatment was taken on OPD basis . Moreover , (Ex OP/5) certificate of Dr . Avinash C Parbhakar confirming that there was no need felt for X Ray examination .Op No 1 also provided attested copy of postal receipt of repudiation letter dated 09.09.2015 (Ex Op /12) which proves claim is still not pending but repudiated by the O.Ps. Thus, in view of the above discussion there is no deficiency in service and unfair trade practice on the part of OPs and the complainant himself failed to provide sufficient evidence as per the terms and conditions of the policy.

8        In view of the above discussion, the complaint is without merit and the same is hereby dismissed with no order as to cost. Copy of order be supplied by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.

Announced in Open Commission

20.09.2022