Punjab

Sangrur

CC/355/2016

Dr. Ram Kumar - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

Shri Yogesh Gupta

07 Oct 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                              

                                                Complaint No.  355

                                                Instituted on:    18.04.2016

                                                Decided on:       07.10.2016

 

 

Dr. Ram Kumar, Sangrur Pet Vet Care, Dhuri Road, Sangrur.

                                                        …Complainant

                                Versus

1.     Oriental Insurance Company through B.M. Sangrur.

2.     Punjab National Bank through B.M. Gaushala Road, Sangrur.

3.     Medi Assist India TPA Pvt. Ltd. Tower D, 4^th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore-560029.

                                                        ..Opposite parties

 

For the complainant  :       Shri J.S.Sahni, Adv.

For OP No.1             :       Shri Ashish Kumar, Adv.

For OP No.2             :       Shri Ashish Grover, Adv.

For OP No.3             :       Exparte.

 

 

Quorum:   Sukhpal Singh Gill, President

                K.C.Sharma, Member

               

 

Order by : K.C.Sharma, Member.

 

1.             Dr. Ram Kumar, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant obtained a medical policy bearing number 233502/48/2016/423 from PNB Oriental Royal Mediclaim Policy schedule from the OP number 1, which is for the benefit of the complainant and his wife Renu Bala. The policy is cashless one.  It is further averred that the premium of the policy was remitted to Op number 1 through PNB because there is internal agreement. Further case of the complainant is that Renu Bala wife of the complainant took the treatment from Raffels Hospital, Panchkula w.e.f. 21.9.2015 to 28.9.2015 for knee replacement, where the hospital authorities charged Rs.2,75,000/- on account of knee replacement from the complainant. The intimation of the admission was also given to the Ops.  It is further averred that the complainant has been taking the medical policy since the year 2007. The case of the complainant is that the Ops did not pay the amount despite serving of legal notice upon the OPs, but the OPs repudiated the claim of the complainant vide letter dated 25.3.2016.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.2,75,000/- along with interest @ 12% per annum from 1.10.2015 till realisation and further claimed compensation and litigation expenses.

 

2.             In reply filed by the OP number 1, it is admitted that the complainant obtained the mediclaim policy in question for the period from 01.09.2015 to 31.08.2016 subject to the terms and conditions of the policy for Rs.5,00,000/-. It is further averred that after examining the entire record, the TPA i.e. OP number 3 assessed Rs.2,73,000/- as compensation. But, after perusal of the documents, it was found that the patient was admitted in Raffles Hospital on 21.09.2015 and diagnosed a case of OSTEO ARTHRITICS. The policy inception date is 1.9.2014 valid upto 31.8.2015 and 1.9.2015 to 31.8.2016, thus the policy was in second year and according to clause 4.2 (22) o the policy, the claim was not payable being there is a waiting period of three years.   It is further averred that if the sum insured is enhanced subsequent to the inception of the policy, the exclusions 4.1 and 4.2 will apply fresh for the enhanced portion of the sum insured for the purpose of this section. In the present case, the earlier policy issued by National Insurance Co. Ltd. alleged by the complainant for Rs.2,50,000//- only out of which wife of the complainant was insured for Rs.50,000/- only, therefore, on this ground the complainant is not entitled for any compensation.   It is stated that the claim has rightly been repudiated as the policy was in the second year. Any deficiency in service on the part of the OP has been denied.

 

3.             In reply filed by the OP number 2, legal objections are taken up on the grounds that the complaint is not maintainable, that the complainant has no cause of action to file the present complaint. On merits, it is admitted that the complainant obtained the policy in question.  The other allegations levelled in the complaint have been denied.

 

4.             Record shows that the OP number 3 did not appear despite service, as such Op number 3 was proceeded exparte.

 

5.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 copy of list of documents, Ex.C-3 copy of reimbursement claim form, Ex.C-4 copy of aadhar card, Ex.C-5 copy of request form, Ex.C-6 copy of invoice, Ex.C-7 copy of cover note, Ex.C-8 to Ex.C-17 copies of cover note, schedule and policy etc. Ex.C-18 to Ex.C-25 copies of emails, Ex.C-26 copy of application dated 4.4.2017, Ex.C-27 copy of legal notice, Ex.C-28 copy of courier receipt, Ex.C-29 copy of notice, Ex.C-30 copy of reply and closed evidence. On the other hand the learned counsel for the OP number 1 has produced Ex.OP1/1 copy of proposal form,  Ex.Op1/2 copy of policy, Ex.OP1/3 copy of circular, Ex.Op1`/4 copy of medi claim policy schedule, Ex.OP1/5 copy of claim process sheet, Ex.OP1/6 copy of medi claim policy, Ex.OP1/7 copy of letter dated 25.3.2016, Ex.OP1/8 affidavit and closed evidence.  The learned counsel for the OP number 2 has produced Ex.OP2/1 affidavit and closed evidence.

 
6              We have carefully perused the complaint, written version of the opposite parties, evidence of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

7.             The version of the complainant is that he had obtained the family mediclaim policy from OP number 1 through OP number 2 and as per the policy he had got replaced the knee of his wife, but the OP number 1 repudiated the claim on technical grounds, whereas at the time of availing the policy in question he was not supplied any terms and conditions of the policy.

 

8.             In reply the OP number 1 has submitted that the TPA had assessed the claim for Rs.2,73,000/-, but the same was not payable as there was a waiting period of three years as per the terms and conditions of the policy.

 

9.             The Op number 2 in the written reply has submitted that the complainant has to satisfy the OP number 1 as  the claim has to be settled by them. The complainant is not entitled to get any relief from the Op number 2. The OP number 3 despite notice preferred to remain exparte.

 

10.           After hearing the arguments of the learned counsel for the parties and on the perusal of documents on record, we find that the complainant was obtaining the mediclaim policies from 19.09.2009 to 18.09.2014 from National Insurance Company.  It was on 2.9.2014 that he shifted to the company of OP number 1 as he was having the account with the OP number 2 i.e. Punjab National Bank and got signed the proposal form of the policy in the office of OP number 2 as the Branch Manager of the OP number 2 has put his signatures on the proposal form document Ex.Op1/1.  So, the policy from 1.9.2014 to 31.8.2015 was issued to the complainant and the same is document Ex.C-9 on record. The said policy was renewed for a further period of one year from 1.9.2015 to 31.8.2016 and it was during the currency of this second policy, which is document Ex.C-8 that the wife of the complainant got the treatment of knee replacement from Raffels Hospital, Panchkula and remained admitted there from 21.09.2015 to 20.09.2015.

 

11.           Now, the question arises as to why the OP number 1 has not paid the claim though the OP number  3 had recommended the same for Rs.2,73,000/-.  The reason submitted by OP number 1 is that the same was not as per clause 4.2(22) of the policy.  We have gone through the document Ex.OP1/2 in which this clause has been mentioned, but the counsel for the complainant has argued that no terms and conditions were ever supplied to the complainant and the same has been specifically mentioned in the complaint.

 

12.           The learned counsel for OP number 1 has relied upon the document Ex.Op1/1 which is a proposal form of the policy in question.  The version of the OP number 1 is that the complainant had signed the proposal form document Ex.OP1/1 after understanding the conditions of the policy and has also read the prospectus.  On going through the document Ex.Op1/1 we find that the complainant has signed the proposal form in token of giving the authority to the OP number 2 to debit his account for the payment of the premium of the policy.  These signatures are in a box at a place where it has been mentioned “signatures of proposer (PNB A/C. Holder)”.  Further this form has been countersigned by the Branch Manager of OP number 2. So, it cannot be said that at the time of giving the undertaking the complainant has read the prospectus containing 17 pages which was placed on record by the Op number 1 in this own evidence.  So, how the OP number 1 can rely upon the document which was got signed by the OP number 2 when the OP number 2 has neither taken this plea in the written reply nor has mentioned in the affidavit tendered in evidence as document Ex.OP2/1.  The OP number 2 is a financial institution and as the same has been countersigned by its Branch Manager, so, it was the authority given by the complainant only for the debit of the premium of the policy as the complainant was its customer.  So, the version of the OP number 1 that the prospectus was read over by the complainant is not tenable and this has not been corroborated by the OP number 2 either in the reply or in the evidence.  The fact is that the document has been signed by the OP number 2 and it was only the OP number 2 who could have led the evidence to the effect that the prospectus containing 17 pages was read over  by the complainant. Moreover, a bare perusal of the document Ex.Op1/1 reveals that it was for the purpose of giving authority to the OP number 2 for the debit of the premium to be paid to the OP number 1 for the issuance of the policy. 

 

13.           We have gone through the written submissions of both the Ops number 1 and 2 and we find that none of the Ops have been mentioned in the reply that the terms and conditions were ever supplied to the complainant.  The OPs number 1 and 2 have neither led any evidence showing that the terms and conditions were ever supplied to the complainant.

 

14.           So, from the facts mentioned above, we find that both the Ops number 1 and 2 are deficient in service and have indulged in unfair trade practice as they have kept the complainant in dark and had not supplied the terms and conditions of the policy.  As the complainant was obtaining the medi calim policy since the year 2009 as per document Ex.C-17, the Ops number 1 and 2 could have advised him to port the policy.  Had the exclusion clause been in the knowledge of the complainant then he would have waited or one more year as knee replacement is not an emergency.  The insurance companies are in the habit of issuing policies without supplying the terms and conditions of the policy and then the innocent policy holder is compelled to knock the doors of the court for justice.

 

15.           In such like cases, reliance can be made on the citation of the Hon’ble Supreme Court of India delivered in Civil Appeal No.6895 of 1997 in the case of Modern Insulators Limited versus Oriental Insurance Company Limited. The Hon’ble supreme Court has held that “as the above terms and conditions of the standard policy wherein exclusion clause was included were neither a part of the contract of insurance nor disclosed to the appellants, respondents cannot claim the benefit of the said exclusion clause.”  In the light of above citation, we find that the OP has failed to tender any reliable and cogent evidence in support of his version that the terms and conditions were ever supplied to the complainant.

 

16.           In the light of above discussion,  we allow the complaint and direct the OP number 1 and 2, who are jointly and severally liable  to pay to the complainant a sum of Rs.2,73,000/- as assessed by the TPA i.e. OP number 3  along with interest @ 9% per annum from the date repudiation of the claim till realisation. We further order the OP number 1 and 2 to pay to the complainant a sum of Rs.20,000/- being the amount of compensation for mental tension and agony and a sum of Rs.11,000/- being the litigation expenses.

 

17.           This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                October 7, 2016.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member