DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/25/2023
Date of Institution: 01.03.2023
Date of Decision: 24.10.2024
Madan Gopal son of Sh. Dev Raj resident of Kothi No. 94, Om City, Handiaya Road, Barnala, Tehsil and District Barnala, Punjab.
…Complainant
Versus
1. Punjab National Bank, branch Pakho Kalan, District Barnala through its Branch Manager.
2. Star Health and Allied Insurance Company Limited Branch/issuing Office : 2nd Floor, Above Delhi Tractor and Combines, Opposite PNB Bank, College Road, Barnala-148101, Punjab through its Branch Manager/Authorized Signatory.
3. Star Health and Allied Insurance Company Limited Registered and Corporate Office No. 1, new Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai 600034 Ph: 044-28288800 through its Managing Director/Chairman/Branch Manager/Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Ms. Sarabjit Kaur Adv counsel for complainant.
Sh. A.K. Jindal Adv counsel for opposite party No. 1.
Sh. Rohit Jain Adv counsel for opposite parties No. 2 & 3.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Punjab National Bank, branch Pakho Kalan, District Barnala through its Branch Manager & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant is the customer of Punjab National Bank having saving bank account with the opposite party No. 1. It is alleged that in the month of December, 2020 the complainant visited the bank where the representative of opposite party No. 1 allured the complainant of their Medical insurance policy by telling the complainant their best insurance policy and services. As such, the complainant got issued an Insurance Policy from the opposite parties in the name of himself, his wife Rano Devi and his son Pardeep Kumar (Dependent child) bearing Master Policy No P/900000/01/2022/000030, Policy Certificate No P/211229 01/2021/000597 for the period from 29.12.2020 to 28.12.2021 for the Floater Basic Sum Insured of Rs. 2,00,000 and thereafter got renewed the same for next year and was issued Policy Certificate No. P211229/01/2022/001201 for the period from 29.12.2021 to 28.12.2022 for the Floater Basic Sum Insured of Rs 2,00,000/- and paid an amount of Rs. 6,668/- as annual premium. It is further alleged that on 29.08.2022, Rano Devi, the spouse of the complainant fell ill and she was admitted to Kular Hospitals, Pvt. Ltd. GT Road, Bija, Near Khanna, Ludhiana and she had taken the treatment and was discharged on 02.09.2022 on which an amount of Rs. 3,65,000/- were spent. It is further alleged that the complainant duly informed the opposite parties regarding the admission of his spouse Rano Devi in the said hospital for cashless claim, but the cashless treatment was not provided by the opposite parties to the complainant and as such, the complainant had to arrange money for the treatment of his wife with great difficulty and he got treated his wife from said hospital by spending Rs. 3,65,000/- on her treatment. Thereafter, the complainant contacted the opposite parties and requested them for the reimbursement of amount of Rs. 3,65,000/- spent on the treatment of his wife and the opposite parties asked the complainant to submit the requisite documents with the opposite parties and as such, the complainant submitted all the requisite documents with them as demanded by the opposite parties and the opposite parties assured the complainant that the amount of Rs. 3,65,000/- spent by the complainant on the treatment of his wife shall be reimbursed to the complainant within few days. It is further alleged that after waiting for some days, the complainant again visited opposite party No.1 and requested to reimburse the amount spent by the complainant on the treatment of his wife but the opposite parties again asked the complainant to submit the requisite documents, whereas the complainant had already submitted all the requisite documents with them. The opposite parties linger on the matter on one pretext or the other and till now they have not redress the grievance of the complainant and had not reimbursed the amount to the complainant. Thereafter, the complainant got served a legal notice dated 27.01.2023 upon the opposite parties to pay the claim amount, but to no avail. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to make the payment of Rs. 3,65,000/- alongwith interest @ 12% per annum from the date of filing the claim till realization.
- To pay Rs. 1,00,000/- towards mental tension and harassment.
- Further, to pay Rs. 15,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written reply by taking legal objections interalia on the grounds that the opposite party No. 1 is not in the business of insurance nor under law can it carry on the business of insurance and is only doing the business of Banking and the actual insurance policy issued by the opposite party No. 2 and 3, therefore no cause of action arose against the opposite party No. 1 and the OP No. 1 is not liable to pay any amount to the complainant. The present complaint is frivolous, vexatious and liable to be dismissed under Section 36 of the C.P. Act. The present complaint is wholly mis-conceived, groundless and unsustainable in law and is liable to be dismissed. The complainant has got no locus-stand or cause of action to file the present complaint against the answering opposite party etc.
4. On merits, it is submitted that the complainant himself purchased the said insurance policy from opposite party No. 2 and 3 and on the request of the complainant, the premium amount has been paid to them on 22-12-2020 and again on 24.12.2021. It is admitted that the complainant maintains his saving account with the opposite party No. 1 being the customer. All other allegations of the complaint are denied and prayed for the dismissal of complaint with cost.
5. The opposite parties No. 2 & 3 filed separate written version by taking preliminary objections on the ground that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainant has no cause of action to file the present complaint. The complainant has not come with clean hands etc.
4. On merits, it is admitted that the insured availed the Star Group Health Insurance Policy - Gold (For Bank Customers) through Branch Office Covering Madan Gopal- Self, Rano Devi- Spouse, Pardeep Kumar- Dependent Child for the sum insured Rs. 2,00,000/- vide policy No P/211229/01/2022/001201 valid from 29.12.2021 to 28.12.2022, P/211229/01/2021/000597 valid from 29.12.2020 to 28.12.2021. It is further alleged that the terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover, it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is submitted that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed in the Proposal Form. It is further admitted that the insured Mrs. Rano Devi was admitted on 27.08.2022 at Kular Hospitals Pvt Ltd., and sought for Pre Authorization Request for Cashless treatment and the same was denied vide letter dated 26.08.2022 stating that Chronicity cannot be ruled out in cashless level and requested the insured to submit documents for reimbursement of medical expenses. Subsequently, the insured has submitted the claim records towards reimbursement of medical expenses of Rs. 3,73,700/-. It is further alleged that on scrutiny of claim documents, it was observed from the consultation report dated 03.03.2022, the insured was prescribed with Tablet Ecospirin. Hence, the insured was requested to furnish the letter from treating doctor stating the indication of ecosporin. It is noted that insured have not furnished the required documents and details and in the absence of the above documents/details, the opposite parties are not able to further process the claim. It is further alleged that as per specific conditions No. 13 of the above policy, the insured person has to submit all the required documents and details called for by them. Hence, claim was rejected and conveyed to insured vide letter dated 4.12.2022. All other allegations are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for the complainant on 30.11.2023 has suffered the statement that I do not want to file any rejoinder.
6. The complainant tendered into evidence affidavit of complainant Ex.C-1, copy of insurance policies Ex.C-2 and Ex.C-3, copy of treatment bills Ex.C-4 to Ex.C-22, copy of legal notice dated 27.1.2023 and postal receipts Ex.C-23 to Ex.C-28 and closed the evidence.
7. The opposite party No. 1 tendered into evidence affidavit of Hari Mohan Ex.O.P1/1, copy of statement of account Ex.O.P1/2 (containing 9 pages) and closed the evidence.
8. The opposite parties tendered into evidence copy of proposal form as Ex.OP2.3/1 (containing 2 pages), copy of policy as Ex.OP2.3/2 (containing 9 pages), copy of terms and conditions are Ex.OP2.3/3 (containing 12 pages), copy of request letter Ex.OP2.3/4 (containing 6 pages), copy of letters Ex.OP2.3/5 & Ex.OP2.3/6, copy of claim form Ex.OP2.3/7 (containing 4 pages), copy of discharge summary as Ex.OP2.3/8 (containing 5 pages), copy of Final bill Ex.OP2.3/9, copies of letters Ex.OP2.3/10 & Ex.OP2.3/11, copy of repudiation letter Ex.OP2.3/12 (containing 3 pages), copy of bill assessment sheet Ex.OP2.3/13 (containing 2 pages), affidavit of Sumit Kumar Sharma Ex.OP2.3/14 and closed the evidence.
9. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by opposite party No. 1.
10. It is admitted case of the opposite parties No. 2 & 3 that the insured availed the Star Group Health Insurance Policy - Gold (For Bank Customers) through Branch Office Covering Madan Gopal- Self, Rano Devi- Spouse, Pardeep Kumar- Dependent Child for the sum insured Rs. 02,00,000/- vide policy No P/211229/01/2022/001201 valid from 29.12.2021 to 28.12.2022, P/211229/01/2021/000597 valid from 29.12.2020 to 28.12.2021 (as per Ex.C-2, & Ex.C-3). It is also not disputed between the parties that the insured Rano Devi was admitted to Kular Hospitals Pvt. Ltd. GT Road, Bija, Near Khanna, Ludhiana on 29.08.2022 and was discharged on 2.9.2022 (as per Discharge Summary Ex.O.P2.3/8).
11. Ld. Counsel for the complainant argued that on 29.08.2022, Rano Devi, the spouse of the complainant fell ill and she was admitted to Kular Hospitals, Pvt. Ltd. GT Road, Bija, Near Khanna, Ludhiana and she had taken the treatment and was discharged on 02.09.2022 on which an amount of Rs.3,65,000/- were spent. It is further argued that the complainant duly informed the opposite parties regarding the admission of his spouse Rano Devi in the said hospital for cashless claim, but the cashless treatment was not provided by the opposite parties to the complainant and the complainant got treated his wife from said hospital by spending Rs.3,65,000/- on her treatment. It is further argued that the complainant contacted the opposite parties and requested them for the reimbursement of amount of Rs. 3,65,000/- spent on the treatment of his wife and the opposite parties asked the complainant to submit the requisite documents with the opposite parties and the complainant submitted all the requisite documents with them and the opposite parties assured the complainant that the amount of Rs 3,65,000/- shall be reimbursed to the complainant within few days. It is further argued that after waiting for some days the complainant again visited opposite parties and requested to reimburse the amount spent by the complainant on the treatment of his wife but the opposite parties again asked the complainant to submit the requisite documents, whereas the complainant had already submitted all the requisite documents with them. It is further argued that the complainant got served a legal notice dated 27.01.2023 (Ex.C-23) upon the opposite parties to pay the claim amount, but to no avail.
12. Ld. Counsel for the opposite party No. 1 argued that the opposite party No. 1 is not in the business of insurance nor under law can it carry on the business of insurance and is only doing the business of Banking and the actual insurance policy issued by the opposite party No. 2 and 3, therefore no cause of action arose against the opposite party No. 1 and the OP No. 1 is not liable to pay any amount to the complainant. It is further argued that the complainant himself purchased the said insurance policy from opposite party No. 2 and 3 and on the request of the complainant, the premium amount has been paid to them on 22-12-2020 and again on 24.12.2021 (as per Ex.O.P1/2).
13. Ld. Counsel for the opposite parties No. 2 & 3 argued that the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover, it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is further argued that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed in the Proposal Form. It is further argued that the same was denied vide letter dated 26.08.2022 stating that Chronicity cannot be ruled out in cashless level and requested the insured to submit documents for reimbursement of medical expenses and subsequently the insured has submitted the claim records towards reimbursement of medical expenses of Rs. 3,73,700/-. It is further argued that on scrutiny of claim documents, it was observed from the consultation report dated 03.03.2022, that the insured was prescribed with Tablet Ecospirin, hence the insured was requested to furnish the letter from treating doctor stating the indication of ecosporin but the insured has not furnished the required documents and details and in the absence of the above documents/details, the opposite parties are not able to further process the claim. It is further argued that as per specific conditions No. 13 of the above policy, the insured person has to submit all the required documents and details called for by them, hence claim was rejected and conveyed to insured vide letter dated 4.12.2022 (Ex.O.P2.3/12).
14. The case of the opposite parties is that despite the above said letters (i.e. Ex.O.P2.3/10 & Ex.O.P2.3/11) sent by the opposite parties to the complainant for requirement of additional documents/information as mentioned in the said letters but the complainant has failed to submit the required documents, as such the opposite parties have repudiated the claim of the complainant vide letter dated 4.12.2022 (Ex.O.P2.3/12). On this, the Ld. Counsel for complainant argued that after the discharge of the patient the complainant submitted all the required documents alongwith medical record to the opposite parties as demanded by them for the reimbursement of treatment. Moreover, from the perusal of the file it shows that all the documents are already on the Court file and we are of the view that if the opposite parties required the same to settle the claim of the complainant, then they could have procure the same from the Court file but at this stage they cannot escaped from their liabilities by taking these types of unreasonable and unjustified grounds. Ld. Counsel for the complainant has argued that the opposite party No. 2 & 3 (insurance company) have not supplied the terms and conditions of the policy to the complainant alongwith policy and the copy of insurance policy is Ex.C-2 and the terms and conditions of the policy are not the part of the said insurance policy. On the other hand the opposite party No. 2 & 3 have also placed on record Ex.O.P2.3/2 and the same is not containing terms and conditions of the policy. Moreover, the opposite parties No. 2 & 3 have failed to prove the fact that they have supplied the terms and conditions of the policy to the complainant alongwith policy or they have explained the same to the insured when the policy was issued or renewed. Therefore, the terms and conditions on which the opposite parties relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”. So, we are of the view that at this stage the opposite parties (insurance company) cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
15. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties (insurance company) on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties (insurance company).
16. The complainant to prove his claim has placed on record Hospital Main Bill Ex.C-4 and the same is also placed on record by the opposite parties No. 2 & 3 i.e. Ex.O.P2.3/9 from which it shows that an amount of Rs. 3,65,000/- has been spent on the treatment of insured at Kular Hospitals Pvt. Ltd. GT Road, Bija, Near Khanna, Ludhiana. However, on the perusal of the insurance policy Ex.C-2 & Ex.O.Ps 2.3/2 vide which Floater Basic Sum Insured mentioned as Rs. 2,00,000/-. The complainant paid the premium for sum assured of Rs. 2,00,000/-. Moreover, in the Para No. 2 of the complaint the complainant mentioned that Floater Basic Sum Insured is Rs. 2,00,000/-. So, we are of the view that the complainant is entitled to the Floater Basic Sum Insured i.e. Rs. 2,00,000/- as mentioned in the insurance policy in question.
17. In view of the above discussion, the present complaint is partly allowed against the opposite parties No. 2 & 3 and the opposite parties No. 2 & 3 are directed to pay an amount of Rs. 2,00,000/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties No. 2 & 3 are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
24th Day of October, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
