DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

BATHINDA

C.C. No. 254 of 20-07-2015

Decided on : 29-11-2016

Ashish Singla aged about 40 years S/o Ved Parkash R/o #4247, Gurdwara Singh Sabha Street, Bathinda.

…...Complainant

Versus

Oriental Insurance Company Limited through its DM/authorised person 4501, Bank Street Bathinda.

Medi Assist India TPA Pvt. Ltd., through its Managing Director 47/1 Sri Krishna Arcade, Ist Main, 9th Cross, Saranki Industrial Layout, J P Nagar, 3rd Phase, Bangalore.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986.

Quorum :

Sh. M.P.Singh. Pahwa, President

Sh. Jarnail Singh, Member

Present :

For the complainant : Sh. Sanjay Goyal, Advocate.

For the opposite parties : Sh. M L Bansal, Advocate.

O R D E R

M. P. Singh Pahwa, President

Ashish Singla, complainant (here-in-after referred to as 'complainant') has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act') against Oriental Insurance Company Limited and another (here-in-after referred to as 'opposite parties).

Briefly stated, the case of the complainant is that he purchased one Medi-claim policy from the opposite parties. It was family insurance plan in which he alongwith his wife Rachna Singla, son Raghva Singla and daughter Mannat Singla were insured for Rs. 5,00,000/-. He paid Rs. 6830/- to the oposite parties and policy No. 233200/48/2014/2234 valid from 11-11-2013 to 10-11-2014 of the complainant was issued. Thereafter again policy No. 233200/48/2015/2283 was issued and complainant and his family members were insured. It was assured that in case of any medical treatment, full amount shall be reimbursed to him.

It is alleged that only cover note was issued to the complainant. Neither any policy nor any terms and conditions were ever supplied to him. The complainant was also never informed that there shall be any rider/exclusion of claim in case claim is lodged. Unfortunately, wife of complainant Rachna Singla had Leiomyoma of uterus. She was admitted with Usha Mission Hospital, Bathinda. She remained admitted in the hospital from 4-3-2015 to 9-3-2015. She has undergone surgery/treatment of Fibroad Uterus. Total amount of Rs. 39,003/- was spent for treatment. The complainant submitted all the original documents alongwith all other formalities with opposite parties for reimbursement of the amount as on 28-3-2015.

It is alleged that opposite parties illegally and again law and facts vide letter dated 21-5-2015 repudiated the claim by mentioning that said treatment was not covered for first two years of insurance and that there was a clause in the terms and condtions of policy.

It is reiterated that no such terms and conditions were ever supplied to complainant nor made part of cover note and no policy till date was ever supplied to complainant. As such, terms and conditions, if any, is not binding upon the complainant. Moreover, insurance is a contract like any other contract. Since no such terms and conditions were ever agreed or made known to complainant , as such, repudiation of claim is false and wrong.

It is also pleaded that opposite parties have failed to make payment of medical claim of complainant and rejected the same.

On this backdrop of facts, the complainant has alleged deficiency in service and unfair trade practice on the part of the opposite parties. He has claimed Rs. 20,000/- as compensation for mental tension; Rs. 11,000/- as litigation expenses and Rs. 39,000/- alongwith interest @ 12% p.a. spent on treatment of his wife. Hence, this complaint.

Upon notice, the opposite parties appeared through their respective counsel and contested the complaint by filing separate written reply. In written reply, the opposite party No. 1 raised legal objections that complainant has no locus standi and cause of action to file the complaint. That complaint is not maintainable; That complainant is estopped from filing the complaint. That this Forum has no jurisdiction to try and decide the complaint. That the complainant has not approached this Forum with clean hands. He has concealed material facts and as such not entitled to any relief .

It is unfolded that it has been specifically mentioned under clause 4.2(ix) that during the period of insurance cover, the expenses on treatment of Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of uterus for specififed period of two years are not payable if contracted and/or manifested during the currency of the policy. It is further mentioned under Clause 4.2 (xiv) that during the period of insurance cover, the expenses on treatment of surgery of genitor urinary system excluding malignancy for specified period of two years are not payable if contracted and/or manifested during the currency of policy. In view of aforementioned conditions, complainant is not entitled to any relief.

It is also pleaded that Hon'ble National Commission in its deicision dated 19-5-2010 rendered in Revision Petition No. 469 of 2006 has also held that complainant is expected to have ascertained the terms of the policy before signing the proposal form specifically when it was a case of obtaining a medi-claim policy. The complainant cannot allege that he has not received any policy. The complaint is liable to be dismissed. That complainant has filed complaint on the basis of totally false, baseless and concocted facts. As such, it is liable to be dismissed with special costs.

On merits, it is not denied that complainant purchased one medi-claim policy and has mentioned that it is a matter of record. It is admitted that complainant also purchased one policy for the period from 11-11-2014 to 10-11-2015 as detailed by complainant but further mentioned that no such assurance of reimbursement of alleged medical treatment was given by the opposite parties. It is denied that only cover note was issued to complainant. It is also mentioned that complainant has intentionally denied receipt of poicy. He was well aware of the terms and conditions of the policy and only thereafter opted to purchase the same. It is also mentioned that as per terms and conditions of the policy, no claim is payable to the complainant. It is also reiterated that claim has been rejected as per terms terms of the policy and it is legal and valid. After controverting all other averments, opposite party No. 1 prayed for dismissal of complaint.

The opposite party No. 2 in its separate written reply raised legal objections regarding locus standi, cause of action, maintainability of complaint, estoppel, jurisdiction and concealment of material facts. In further legal objections, the opposite party No. 2 has reiterated the stand of opposite party No 1.

On mertis, the opposite party No. 2 has also adopted the version of opposite party No. 1 and prayed for dismissal of complaint.

Parties were afforded opportunity to produce evidence. In support of his claim, complainant has tendered into evidence his affidavit dated 20-7-2015 (Ex. C-1), photocopy of repudiation letter (Ex. C-2) and photocopy of policy schedule (Ex. C-3 & Ex. C-4).

In order to rebut this evidence, opposite parties have tendered into evidence photocopy of policy schedule (Ex. OP-1/1), photocopy of prospectus (Ex. OP-1/2), photocopy of claim file (Ex OP-1/3), affidavit dated 23-1-2016 of R L Baleem (Ex. OP-1.4) and photocopy of proposal form (Ex. OP-1/5).

We have heard learned counsel for the parties and gone through the record.

Learned counsel for complainant has reiterated his stand as set up in the complaint and as detailed above. It is further submitted by learned counsel for the complainant that material facts are not in dispute. It is not disputed that complainant previously obtained insurance policy of opposite party No. 1 which was effective from 11-10-2013 to 10-10-2014 and he got it renewed w.e.f. 11-10-2014 to 10-10-2015. The premium receipts Ex. C-3 & Ex. C-4 also prove this fact. The wife of the complainant was covered in this policy. This fact also stands proved from both the premium receipts. Rachna Singla wife of the complainant got treatment from Usha Mission Hospsital, Bathinda and complainant spent a sum of Rs. 39,003/- for this treatment. The complainant submitted bills after completing all the formalities. This claim of the complainant has been rejected vide letter dated 21-5-2015 (Ex. C-2). As per this letter and written version of the opposite parties, the claim has been rejected mainly for the reason that this treatment was excluded for a period of two years as per terms and condition of the policy. The categorical stand of the complainant is that he was not supplied with any policy document. He was also not made aware of any terms and conditions. The opposite parties have not produced any record to prove that policy document was despatched to the complainant and he has received the same. No record has been produced to prove this fact. Moreover, the insurance is a contract. Contract can be entered into with the consent of both the parties. No document has been produced to prove that complainant agreed to the terms and conditions and signed any document. From all angles, exclusion clause, if any, is not applicable on the complainant. As such repudiation of claim by the opposite parties is not sustainable. Order of repudiation be rejected being illegal. Complainant be awarded relief claimed by him.

To suport his submissions, learned counsel for the complainant has cited :-

(i) 2010 (1) CPJ 189 case titled New India Assurance Company Limited and Anr. Vs. Arun Kumar Mangal wherein it was observed that alleged terms and condtiions of policy were not communicated to the insured. Repudiation of claim was not justified.

(ii) 2000 (2) R.C.R. (Civil) case titled M/s. Modern Insulators Ltd., Vs. Oriental Insurance Co. Ltd.,

(iii) 2016(1) CPJ 26 (Punj.) case titled Oriental Insurance Company Limited & Ors., Vs. Narinder Kumar Mittal & Ors.

(iv)2016(1) CPJ 347 (NC) case titled SBI Life Insurance Co. Ltd., Vs. Kamaljeet Kaur & Anr.

- to support above submissions.

On the other hand, learned counsel for opposite parties has submitted that complainant has concealed material facts from this Forum. The claim is based on the policy obtained by the complainant. He has not produced on record copy of policy document. The opposite parties have produced complete policy document (Ex. OP-1/2) which shows that as per Clause 4.2 (ix) the treatment for Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of uterus is excluded for the period of two years. The complainant has claimed that he obtained policy firstly w.e.f. From 11-10-2013 and secondly w.e.f. 11-10-2014. The period of two years was to complete on 10-11-2015. The wife of the complainant has taken treatment w.e.f. from 4-3-2015 i.e. within a period of two years. Therefore, this claim falls under exclusion clause and is not payable.

It is further submitted by learned counsel for the opposite parties that main contention of the complainant is that he was not supplied with the terms and conditions or the policy document. The complainant himself has brought on record premium receipts Ex. C-3 & Ex. C-4. It is categorically mentioned in these documents that insurance under this policy is subject to conditions. It is also mentioned that for terms and condition of the policy, insured can visit website of the opposite parties. The policy document Ex. OP-1/2 reveals that this policy is available to account holders/employees of Punjab National Bank and the policy was to be issued in the name of Punjab National Bank with the schedule of account holders/employes. Therefore, the opposite parties were not required to supply the policy to each and every account holder/employee. The account holder/employee were to visit site of the opposite parties for terms and condition. The opposite parties have also placed on record copy of proposal form (Ex. OP-1/5), The complainant has also agreed to accept the policy subject to terms, exceptions and conditions prescribed therein. This fact also shows that before filling up proposal form, the complainant has examined the terms, exceptions and conditions. Therefore at this stage, the complainant cannot plead that he was not supplied with terms and conditions.

It is further submitted by learned counsel for the opposite parties that insurance policy is not a statutory policy. It is contractual policy. The complainant is supposed to examine terms and conditions before entering into contract. The complainant has firstly obtained policy w.e.f. 11-10-2013 and secondly w.e.f. 11-10-2014. As per premium receipts, terms and conditions for both the years were same. In case the complainant has not received policy documents for the policy effective from 11-10-2013, he was not expected to opt for the policy for subsequent year. He was also expected to insist for supply of terms and conditions if he was not aware about the terms and conditions. All these facts show that complainant was fully aware about the terms and conditions of the policy. Therefore, complainant cannot impugned order of repudiation.

To support above submissions, learned counsel for the opposite parties has cited :-

(i) Revision Petition No. 469 of 2006 decided on 19-5-2010 case titled United India Insurance Co. Ltd., Vs. Subhash Chandra wherein contention of the complainant with regard to delayed receipt of the policy document was disbelieved by observing that that respondent-complainant being literate person expected to have ascertained the terms of the policy before signing proposal form, specially when it was a case of obtaining medi-claim policy.

(ii) Revision Petition No. 717 of 2013 decided on 30-1-2015 case titled New India Assurance Co. Ltd., and another Vs. Nanak Singla and others

We have carefully gone through the record, case law cited by learned counsel for the parties and have considered the rival contentions.

Undisputed facts are that complainant obtaianed medi-claim policy of the opposite parties firstly w.e.f. 11-10-2013 and secondly w.e.f. 11-10-2014. Rachna Singla, wife of complainant was also covered under this policy. Rachna Singla obtained treatment w.e.f. 4-3-2015 to 9-3-2015. The complainant lodged claim of Rs. 39,003/- with the opposite parties which was repudiated vide letter dated 21-5-2015. Copy of this letter is brought on record as Ex. C-2 which proves that claim has been repudiated under execlusion clause by observing that that during the period of two years the expenses on treatment of Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of uterus were not payable.

The main contention of complainant to impugne this decision is that the opposite parties have not supplied policy document or terms and conditions. Therefore the entire controversy revolves around the fact whether the opposite parties were required to supply policy document/terms and conditions to complainant individually and whether the complainant was aware about the terms and conditions or not.

The complainant has himself placed on record copies of premium receipts Ex. C-4 & Ex. C-5, of course, to prove that he has purchased the policy w.e.f. 11-10-2013 and then from 11-10-2014 covering family members of complainant also but this document also proves that insurance policy is subject to terms and conditions clause. It is also mentioned in this receipts “For terms and conditions of the policy, kindly visit website of the opposite parties”. Address of the website is also mentioned on these receipts. The opposite parties have also placed on record copy of proposal form submitted by the complainant. This document also contains declaration by proposer. As per this declaration, the proposer (complainant in this case) has accepted the policy subject to terms, exceptions and conditions prescribed therein. All these documents prove that complainant was aware that policy was subject to terms, exceptions and conditions. The complainant has firstly obtained the policy w.e.f 11-10-2013. In case he was not made aware about terms and conditions, then he was not expected to opt for the policy in subsequent year. Moreover, there is nothing to show that complainant ever agitated regarding non supply of terms and conditions. The opposite parties have also placed on record copy of policy document (Ex.OP-1/2). Salient Features of the policy includes that policy is to be issued in the name of Punjab National Bank. This is also meant for account holders/employees of Punjab National Bank. Therefore, this dcument also shows that opposite parties were not required to individually supply policy document to each and every employee/account holder of Punjab National Bank who have opted for this policy.

The following observations of the Hon'ble National Commission, in the case United India Insurance Company Limited Vs. Subhash Chandra are also relevant for the decision of controversy :-

“Insofar as the contention of the learned counsel for the respondent-complainant with regard to delayed receipt of the policy document is concerned, the respondent-complainant being a literate person it was expected of him to have ascertained the terms of the policy before signing the proposal form, specially when it was a case of obtaining a mediclaim policy.”

These observations are also fully applicable to the facts of the case in hand.

From the above discussions, net conclusion is that the contention of the complaiant that he was not supplied with the terms and conditions is not acceptable. This contention of the complainant stands repelled and the result is that the complainant is bound by the terms and conditions contained in the policy document. The policy document reveals that treatment for “Hysterectomy for menorrhagia or fibronmyoma or myomectomy or prolapse of uterus is not payable within two years. Therefore, there is no illegality in the order of repudiation calling interference of this Forum.

In the result, this complaint fails and is hereby dismissed with no order as to costs.

The complaint could not be decided within the statutory period due to heavy pendency of cases.

Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

Announced :

29-11-2016

(M.P.Singh Pahwa )

President

(Jarnail Singh )

Member