BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JIND.
Complaint Case No. : 119 of 2020
Date of Institution : 18.02.2020
Date of Decision : 27.10.2022
Dr. Manoj Kumar Garg S/o Sh.Amarnath Garg R/o Garg Hospital, Gohana Road, Jind Tehsil and District Jind.
.….Complainant
Versus
1. Oriental Insurance Company Limited, HUDA Shopping Centre LIC Building, Jind Tehsil and District Jind through Branch Manager (e-mail:261402@orientalinsurance.co.in.).
2. M/s Park Mediclaim TPA Ltd., 702 Vikrant Towers, Rajendera Place, Delhi -110008 (e-mail:park@parkmediclaim.co.in).
……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.261402/48/2018/116 effective from 04.05.2017 to 03.05.2018 from Op No.1 by paying a premium of Rs.17,913/- for a risk coverage of Rs.6.00 lacs for complainant and his wife Dr. Deepika Garg and his dependant daughter Neha. Prior to the said policy, complainant had earlier also purchased a policy no.261402/48/2017/172 from OP No.1 for the same risk cover and of same persons and OP No.1 appointed Op No.2 as TPA as per policy document. Complainant has averred that his wife suddenly suffered high grade fever and was admitted as in-door patient at Garg Heart and Child Care Centre, Gohana Road, Jind on 16.03.2018 and was discharged on 23.03.2018 and was advised rest for five days. Complainant incurred a sum of Rs.26,387/- on the treatment and submitted claim with the OPs annexing all the relevant documents but the OPs lingered on the matter under one pretext or the other on the grounds that ‘It is a matter of common knowledge that the hospital extends discount to the known people, doctors and other influential people’ In this case, the patient is not only wife of attending consultant but a doctor also. As such, it is not possible that complainant Dr. Manoj Garg would not have given discount and charged his own wife Dr. Deepika’ However, the OP disbursed only a sum of Rs.5240/- in the bank account of complainant and the remaining amount of Rs.21,147/- was not disbursed. Complainant has submitted that the act & conduct of OPs amounts to deficiency in service as well as unfair trade practice on the part of OPs. Hence, the present complaint has been preferred by complainant seeking directions to Ops to pay a sum of Rs.21,147/- alongwith interest @2% per month w.e.f. June 2018 till realization, 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 etc. on the part of OP insurance company. On merits, OP No.1 insurance company submitted that on receiving the claim of complainant of Rs.26,387/- including Rs.17,500/- as Room rent and Rs.1400/- as professional fee was sent to TPA (OP NO.2) who after making necessary deductions allowed a sum of Rs.5240/- which was paid to the complainant. OP No.1 has further urged that the complainant himself is a doctor and is running his own hospital and it is a matter of common knowledge that hospitals extends discount to the known people, doctors and other influential people whereas in the present case, patient is not only the wife of the attending consultant but is a doctor also. As such, it is not possible that Dr. Manoj Kumar would not have given discount and charged his own wife, Dr. Deepika. As such, the claim of insured person was considered under the terms of the policy and settled accordingly by disbursing a sum of Rs.5240/-. OP No.1 has further submitted that there is no deficiency in service on its part and prayed for dismissal of complaint with costs.
3. To prove the factum of complaint, learned counsel for complainant tendered into evidence affidavit of complainant as Annexure CW1/A alongwith documents as Annexures C-1 to Annexures C-5 and closed the evidence whereas on the other hand, learned counsel for OP no.1 tendered into evidence affidavit of one Sh. R.K. Chhabra, Sr. Divisional Manager as Annexure OPW1/A alongwith documents as Annexures OP1/1 to Annexures OP1/11 and closed the evidence on behalf of OP No.1.
4. We have heard learned counsel for complainant and learned counsel for OP No.1 and evaluated the documents/evidence placed on file on behalf of both the parties.
5. Learned counsel for complainant has argued that during the health insurance policy period, wife of complainant suffered high grade fever and remained admitted in Garg Heart and Child Care Centre, Jind w.e.f. 16.03.2018 to 23.03.2018 and was advised rest for five days. On the treatment, a sum of Rs.26,837/- were spent but the OP insurance company paid only a sum of Rs.5240/- against the amount incurred by complainant. Counsel for complainant further contended that OPs avoided to disburse the remaining claim amount 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 Punjab & Haryana High Court in CWP No.26178 of 2016 titled as National Insurance Co.Ltd. Vs. Sandeep & others reported in 2017 (1) RCR (Civil) Page 621 wherein it has been held that “Insurance companies give lucrative offers to attract customers-However, the moment any insured puts even the most genuine claim, seldom said claim would be accepted by any insurance company.”
On the other side, learned counsel for Op No.1 has argued that on receipt of claim of the insured/patient Dr. Deepika, OP company considered the same within purview of the terms of policy and Rs.5240/- paid in the bank account of complainant. Counsel for OP No.1 further urged that the complainant himself is a doctor and it is a matter of common knowledge that hospitals extends discount to the known people, doctors and other influential people. In the present case, patient is not only the wife of the attending consultant but also a doctor. As such, it is not possible that Dr. Manoj Kumar would not have given discount and charged his own wife. Dr. Deepika. Counsel for OP No.1 has further urged that as such, there is no deficiency in service on the part of OP insurance company and prayed for dismissal of complaint with costs.
6. At the very outset, it is not in dispute that the complainant alongwith his wife & daughter were insured under the policy in question for a period from 04.05.2017 to 03.05.2018. Grievance of complainant is that an amount of Rs.26,837/- so incurred by complainant on the treatment of his wife during the policy period had not been reimbursed by the OP insurance company. However, it is admitted on record that the OP insurance company has settled the claim of complainant at a sum of Rs.5,240/- as per letter dated 12.06.2018 (Annexure C-5) issued by OP No.2 TPA (Third Party Administrator) of OP-Insurance Company with the reasoning of disallowing the claim of Rs.21,147/- that ‘It is a matter of common knowledge that the hospitals extends discount to the known people, doctors and other influential people. In this case, the patient is not only the wife of the attending consultant but a doctor also. As such, it is not possible that Dr. Manoj Garg would not have given discount and charged his own wife Dr. Deepika.’ But we are not inclined to accept the contention of the OP insurance company’s TPA i.e. OP No.2 appointed by Insurance Company that complainant would have extended concession to his wife Dr. Deepika Garg while paying the hospital bills. On the other hand, OPs have not raised any objection in respect to the disease of insured Dr. Deepika Garg or on the treatment method applied by the hospital concerned. The treating hospital has given any concession or not, is not the business of OP insurance company. Therefore, in the present circumstances, the case law (supra) referred by the complainant strengthens the roots of the present case and are fully applicable to the facts of the case in hand.
7. In view of the foregoing discussion, we have come to the conclusion that the OP No.1 insurance company has arbitrarily and illegally withheld the remaining claim of complainant whereas he is squarely entitled for the same. Further the act & conduct of Op insurance company is a glaring deficiency in services and OP insurance company is liable to reimburse the amount so withheld, to the complainant with interest & penalty. 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.21,147/- (Rs.Twenty one thousand one hundred fourty seven 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 & his wife.
- Also to pay Rs.5500/- (Rs. Five thousand five hundred only) as litigation expenses including Advocate’s fee 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 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
Complaint Case No. : 119 of 2020
Present: Sh. O.P. Bansal, learned counsel for complainant.
Sh. Satish Bhardwaj, Adv. counsel for OP No.1.
OP No.2 exparte vide order dated 18.03.2021.
Arguments concluded. Vide our separate order of even date, the present complaint is allowed. File after due compliance be consigned to record room.
Dated: Member Member President
DCDRC, Jind.
nowadays it has become tendency of mediclaim insurance company to receive premium and to issue mediclaim policy but when the claim is made by the policy holder, the insurance company pays no heed and either repudiates the claim on flimsy grounds or takes no action and which is unfair trade practice to defraud the public at large and because of which most of the citizen fear from
