BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JIND.
Complaint Case No. : 120 of 2020
Date of Institution : 18.02.2020
Date of Decision : 27.10.2022
Amarnath Garg S/o Matu Ram R/o H.No.312 Scheme No.5 Gandhi Nagar, Jind Tehsil and District Jind.
.….Complainant
Versus
- Oriental Insurance Company Limited, HUDA Shopping Centre LIC Building, Jind Tehsil and District Jind through Branch Manager (e-mail:261402@orientalinsurance.co.in.).
- M/s Raksha Health Insurance, 15/5 Mathura Road, Faridabad District Faridabad-121003 through its Branch Manager (e-mail:crcm@rakshatpa.com.).
……Opposite Parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
CORAM: SH. A.K. SARDANA, PRESIDENT.
SMT. NEERU AGARWAL, MEMBER.
SH. G.D. GOYAL, MEMBER.
Present: Sh. O.P. Bansal, Adv. counsel for complainant.
Sh. Satish Bhardwaj, Adv. counsel for OP No.1.
OP No.2 exparte vide order dated 18.03.2021.
ORDER:
Shorn off unnecessary details, complainant has preferred the present complaint with the averments that he purchased a mediclaim policy no.261402/48/2018/765 effective from 07.09.2017 to 06.09.2018 from Op No.1 by paying a premium of Rs.7173/- for a risk coverage of Rs.5.00 lacs for himself and his wife Smt. Satyawati. Prior to the said policy, complainant had earlier also purchased a policy no.261200/48/2017/1537 from OP No.1 for the same risk cover and of same persons. Complainant has averred that his wife suddenly suffered acute lower back pain and for diagnose, investigation conducted at Delhi in a private hospital but she was not cured and did not get relief in the pain. So, she was admitted on 06.12.2017 in Garg Heart and Child Care Centre, Gohana Road, Jind and was discharged on 16.12.2017 and a sum of Rs.62,545/- were incurred in the treatment. Hence, complainant submitted claim with the OPs by annexing all the relevant documents but the OPs lingered on the matter under one pretext or the other and ultimately when no response was received from their side, complainant preferred the present complaint with the averments that the act & conduct of Ops amounts to deficiency in service and requested for issuing a directions to Ops to pay a sum of Rs.62,545/- alongwith interest @2% per month w.e.f. March 2018 till realization alongwith Rs.1.00 lac as damages and Rs.20,000/- as cost of litigation etc.
2. Notice of complaint was issued to the Ops. Op No.2 did not bother to appear and was proceeded against exparte vide order date 18.03.2021 whereas OP No.1 appeared through counsel and tendered reply raising preliminary objections w.r.t. neither cause of action nor locus standi rather suppression of material facts and no any deficiency in service on the part of OP insurance company etc. On merits, OP No.1 has admitted that complainant had purchased the policy in question by accepting all the terms and conditions of the policy. Patient Satyawati, wife of complainant was admitted PIVD L2/L3, L4/L5, patient managed with spinal block and other supportive treatment. OP No.1 has further urged that as per policy terms and conditions, PED covered after three years and spine related treatment covered after 2 years. Patient Satyawati is the mother of Dr. Manoj Garg who runs his own hospital under the name and style of Garg Heart & Child Care Centre, Gohana Road, Jind and complainant has already taken his claim vide claim No.55622181900911 against the said policy for an amount of Rs.30,810/- towards medical expenses incurred for the treatment of Enteric fever at the Garg Hospital, Jind during the current Policy Period and another claim of his wife was also settled vide claim no.556221718296507 against the policy issued by the OP for an amount of Rs.23530/- towards medical expenses incurred for the treatment of Dengue fever with high grade fever Dengue antigen positive at the said hospital during the current Policy Period. As such, the claim of insured person Satyawati was again considered under the terms of the policy and is not payable in this case and thus there is no deficiency in service on the part of OP insurance company and prayed for dismissal of complaint with costs.
3. To prove the contention of complainant, learned counsel for complainant tendered into evidence affidavit of complainant as Annexure CW1/A alongwith documents as Annexures C-1 to Annexures C-10 and closed his evidence whereas on the other side, learned counsel for OP no.1 tendered into evidence affidavit of Sh. R.K. Chhabra, Sr. Divisional Manager as Annexure OPW1/A alongwith documents as Annexures Op1/1 to Annexures OP1/8 and closed the evidence on behalf of Op No.1.
4. We have heard learned counsels for complainant as well as OP No.1 insurance company and evaluated the documents/evidence placed on file by both the parties.
5. Learned counsel for complainant has argued that during the health insurance policy period, wife of complainant remained admitted in Garg Heart and Child Care Centre, Jind from 06.12.2017 to 16.12.2017 on account of acute lower back pain and on the treatment, a sum of Rs.62,545/- were spent but the OP insurance company did not released the amount so incurred by complainant despite submitting the claim alongwith all necessary formalities. Counsel for complainant further urged that OPs avoided the claim submitted in this case on the very ground that claim of complainant is not covered as per terms & conditions of policy being pre-existing disease though the wife of complainant was not having any pre-existing disease (PED) while purchasing the mediclaim Policy Period from OP No.1 as clear from contents of Insurance policy (Annexure C-1) placed on court file by complainant. In this way, OP No.1 has failed to settle the claim till date which amounts to deficiency in service on the part of OPs. To support his version, Ld. counsel for complainant placed reliance on the case law rendered by Hon’ble Andhra Pradesh State Consumer Disputes Redressal Commission, Hyderabad in First Appeal no.1000/2013 titled as Branch Manager LIC of India & others Vs. Pasupuleti Bhagya Laxmi & others decided on 24.08.2014 and reported in 2014(4) CLT Pg. 115 wherein General Observations have been rendered by the Hon’ble Bench that “we have been observing that in a number of cases, the insurance companies are issuing policies basing on the statements made by the proposer in utmost good faith but when it comes to settlement of claims, they start examining the matter under the microscope. In a majority of policies issued by the insurance companies they were routed through their agents. The agents in their anxiety to get their commission and the insurance company in order to do more and more business see that the policies are issued the moment they received the premium amount. Even the insurance companies are not aware as to who is the proposer, what is his /her status or health condition etc.. Here, the intention is very clear that first they induce the people to purchase the policies and later they start litigation. Even in the instant case also, the proposal was made through agent. On Ex.B1 we find the rubber stamps of the agent and specified person code and license Nos. on the first and last pages of the proposal. A close scrutiny of the proposal form would reveal even the columns were filled up by the agent and simply obtained the signatures of proposer on ‘x’marks. It is manifest that the proposal was routed through the agent of the LIC. If we may say so, the agents are playing fraud on LIC as well as gullible consumers with false assurances. When the policy was issued by the insurance company with utmost good faith, the same yardstick has to be applied while settling the claims also. The LIC ought to have made thorough enquiry, investigation or necessary medical health check—ups before issuance of policy irrespective of the amount involved. Without doing so, when they have issued the policy, now they cannot turn round and contend that they need not pay any amount as there was suppression of material information with regard to his health”. Besides it, the counsel for complainant also placed reliance on another case law delivered by Hon’ble National Consumer Disputes Redressal Commission, New Delhi titled as New India Assurance Co. Ltd. Vs. B.Y. Srikanta reported in Vol. IV (2015) CPJ 380 (NC) wherein it has been held that “Insurance company has not produced any evidence to show that Parkinson disease is a pre-existing disease and the same was not disclosed in the proposal form by the complainant-Repudiation not justified.”
On the other side, learned counsel for Op No.1 has argued that on receipt of claim of the insured patient Satyawati, OP company considered the same within the purview of terms of the policy and found that complainant has already received an amount of Rs.30810/- for treatment of Enteric fever of himself and Rs.23530/- for the treatment of Dengue fever for his wife during the policy period from 07.09.2017 to 06.09.2018. As such, now no claim is payable to the complainant being a case of (PED) Pre-existing disease and as per policy terms and conditions, PED covered after 3 years and spine related treatment covered after 2 years and vehemently argued for dismissal of complaint with heavy costs.
6. At the very outset, it is not in dispute that the complainant and his wife were insured under the policy in question for the period from 07.09.2017 to 06.09.2018. Grievance of complainant is that an amount of Rs.62,545/- so incurred by complainant on the treatment of his wife for her medical treatment during the policy period had not been reimbursed by the OP insurance company. On the contrary, the contentions of OP insurance company is that patient Satyawati was admitted PIVD L2/L3, L4/L5, patient managed with spinal block and other supportive treatment and PED covered after 3 years and spine related treatment covered after 2 years and thus this claim is not payable to the complainant though as per pleadings of OP insurance company during the said policy period, medical treatment amount has already been reimbursed to the complainant earlier 2 times.
To substantiate his version, OP insurance company has placed on record claim rejection letter dated 19. Jan 2018 (Annexure OP1/1) issued by OP No.2 TPA to OP No.1 read with Happy Family Floater Policy-Prospectus (Annexure OP1/8) wherein it has been specifically mentioned in clause 3.17-PRE EXISTING DISEASE “Means- any condition, ailment or injury or related condition(s) for which the insured person(s) had signs or symptoms, and /or was diagnosed, and /or received medical advice /treatment within 48 months prior to the first policy issued by the insurer” but there is no any mentioning of PED in the case of complainant as clear from the contents of insurance policy (Annexure C-1) and apart from it, OP has also not placed any document on the court file wherefrom it is proved that complainant or his wife was having any pre-existing disease prior to purchase of the mediclaim policy or they concealed the same while getting the policy in question. Further, on perusal of clause 4.2 read with clause 4.3 of policy prospectus (Annexure OP1/8), it nowhere transpires that the complainant spine related treatment falls within the parameters of this clause. So, the recommendation of Op No.2 TPA to OP No.1 w.r.t. claim of complainant as NON-TENABLE is neither legal nor justified in the eyes of law.
7. In view of the foregoing discussion, we have come to the conclusion that OP No.1 insurance company has illegally & arbitrarily repudiated the claim of complainant and the observations as mentioned in the case laws cited (supra) are fully applicable to the facts of the case of complainant. Further the act & conduct of Op insurance company is admittedly deficient in providing proper services to the complainant and therefore, Op No.1 is liable to reimburse the amount of mediclaim to the complainant. Accordingly, the complaint is allowed with a direction to OP No.1 insurance company to comply with the following directions within thirty days from the date of communication of this order:-
- To pay a sum of Rs.62,545/- (Rs.Sixty two thousand five hundred fourty five only) to complainant alongwith simple interest @ 9% per annum from the date of institution of complaint to till date.
- To pay a sum of Rs.5500/- (Rs. Five thousand five hundred only) as compensation on account of mental agony and harassment suffered by complainant and his wife.
- Also to pay Rs.5500/- (Rs. five thousand five hundred only) as litigation expenses including the counsel fee’s etc.
Further the directions issued above at (i) to (iii) must be complied with by the Op No.1 within the stipulated period failing which the all the awarded amounts shall further attract simple interest @ 12% per annum for the period of default. Copies of this order be supplied to the parties concerned, as per rules. File be consigned to the record room after due compliance.
Announced on: (A.K. SARDANA) PRESIDENT
(Neeru Agarwal)
Member
(G.D. Goyal) Member
