DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA
RBT/Consumer Complaint No.344of 2018
Date of institution: 24.05.2018
Date of Decision: 28.04.2022
Geeta Jain wife of Sh. Anil Kumar Jain
Anil Kumar Jain son of Shri Bimal Kumar Jain, Both residents of C-145, Rishi Nagar, Ludhiana
….Complainants
Versus
The Reliance General Insurance Company Limited, Branch Office, 7th floor, Surya Tower, 108, The Mall, Ludhiana
……..Opposite Parties
Complaint under Consumer Protection Act
Quorum: Shri Ranjit Singh, President.
Mrs. Ranvir Kaur, Member
Present: Sh. Rajeev Kumar Goyal, Advocate, for complainant
Sh. G.S. Kalyan, Advocate, for OP
Order dictated by :- Shri Ranjit Singh, President
Order
The present order of ours will dispose of the above complaint filed under Consumer Protection Act, received by way of transfer from District Consumer Disputes Redressal Commission, Ludhiana by the complainant against the Opposite Party on the ground that the complainant No.1 had obtained Hospitalization benefit policy/Medical Insurance from the Opposite party without any break from 2.3.2015. The Opposite Party has been receiving premium from complainant No.2, who is the proposer/husband of complainant No.1 every year and has been issuing cover note in this regard every year. Earlier the sum insured was Rs.2,00,000/- which was increased to Rs.3,00,000/- starting from 22.3.2017 to 21.3.2018. The complainants paid a sum of Rs.13,570/- as premium to the opposite party and the cover note was issued by the opposite party for the period from 22.3.2017 to 21.3.2018. It is further averred that on 21.6.2017, the complainant No.1 admitted in Paras Hospital, Gurgaon, Haryana as she was suffering from Water discharge from left nostril since 1/-1/2 months. Various tests including procedure of Endoscopic trans nasal exploration of anterior skull base and repair of crebri form plate and left lateral wall of sphenhold sinus by fat fascia bind glue done under GA on 22.6.2017 by Dr. Amit Srivastava and Dr.Radhamadhav Sahu of complainant No.1 in the said hospital also and she was managed conservatively. The complainants informed the opposite party about the medical treatment of complainant No.1. The complainants submitted the medical claim forum and the medical claim amounting to Rs.2,40,153/- incurred on the medical treatment of the complainant No.1. The said medical claim was received by the opposite party and the OP only passed and paid the amount of Rs.2,00,000/- only and did not pay the balance amount of Rs.40,153/- without any reason. The complainant No.1 wrote a letter dated 21.7.2017 to the opposite party whereby given the detail of the amount incurred on her medical treatment, also informed that the present illness is not related to the previous surgery done in the month of February 2015 in Apollo Hospital, Delhi and that time the claim of Rs.1,50,000/- was passed. The complainant No.1 also submitted the certificate dated 23.6.2017 issued by Paras Hospitals, Gurgaon that the present illness is not related to the previous surgery/illness and also requested to pay the balance amount of Rs.40,153/-. The said letter dated 21.7.2017 was received by OP and paid a sum of Rs.4000/- only in the bank account of the complainant No.2 in the month of August 2017 but did not pay the entire balance amount of Rs.40,153/- to the complainants. The aforesaid act of the opposite parties amounts to deficiency in service, unfair trade practice and it has caused mental as well as physical agony and also caused inconvenience to the complainant. Vide instant complaint, the complainant has sought the following reliefs:-
- To pay a sum of Rs.36953/- as balance amount of genuine claim lodged by the complainants being the medical treatment of the complainant No.1 under the policy
- To pay compensation of Rs.50,000/- along with interest @ 12% per annum as further damages
2. Upon notice, the learned counsel for the OPs appeared and filed written reply taking preliminary objection; that the present complaint is not maintainable; that the complainant has no cause of action to file the present complaint; that the answering Op had explained entire features/terms and conditions of the said health insurance plan to the complainant and the complainant out of his own free will and violation agreed to terms and conditions of the policy; that there is no deficiency in service on the part of the Ops; that the present complaint is false, frivolous and vexatious. On merits, it is stated that the Ops has already paid the claim amount to the complainant in accordance with the policy, terms and conditions and exclusion and no further amount is due at the end of insurance company. The complainant is trying to take unnecessary benefit from public fund without any credible reason. The complainant opted health wise policy from insurance company by choosing sum insured of Rs.2 Lakhs for the period from 22.3.2015 to 21.3.2016 which was again renewed from 22.3.2016 to 21.3.2017 for same sum insured of Rs.2 Lakhs. But suddenly in the third year of policy, the complainant took the portability option by switching previous policy (health wise) into new policy of Health Gain with a request to enhance sum insured from 2 Lakhs to 3 Lakh. The complainant was explained about terms and conditions of portability benefit which was also agreed by the complainant at the time of policy inception. Thus, alleging no deficiency on the part of the answering O.P.
3. In support of this claim the complainant has tendered various documents and on the other hand, the opposite parties have also tendered certain documents in support of his version.
4. We have heard learned counsel for the parties at considerable length and have also examined the record of the case.
5. The learned counsel for the complainants has argued that the complainant had taken treatment from Paras Hospital, Gurgaon, Haryana and the complainants informed the opposite party about the medical treatment of complainant No.1. The complainants submitted the medical claim forum and the medical claim amounting to Rs.2,40,153/- incurred on the medical treatment of complainant No.1. The medical claim was received by the opposite party and opposite party only passed and paid the amount of Rs.2,00,000/- only and did not pay the balance amount of Rs.40,153/- without any reason. Lastly prayed to allow the present complaint.
6. The learned counsel for the OP has also argued that the OP has already paid the full claim amount to the complainant as per policy terms and condition and exclusion and no further amount is due at the end of insurance company. The complainant is trying to take unnecessary benefit from public fund without any credible reason. Lastly prayed to dismiss the complaint.
7. It is important to mention here that for the policy bearing No. 2001272828000301 dated 16.3.2017 starting from 22.3.2017 to 21.3.2018 for the sum insured Rs.3,00,000/- and the complainant paid premium of Rs.13,750/- for the above said policy but when the complainant lodged the claim as per policy sum insured, the OP paid the claim amount as per previous policy. We have perused the star document Ex.C1, which is placed on record by the complainant in support of their complaint, which is clearly mentioned that Insured with the company since 02.03.2015 and base sum insured Rs.3,00,000/-.
8. It is pertinent to mention here that when the insurance company mentioned in the cover note of the insurance policy that sum insured is of Rs.3,00,000/- then how can refuse to pay the claim as per Ex.C1. In the absence of any cogent, reliance or confidence inspiring evidence from the side of the OP, we are of the view that the complainants are entitled for claim as per policy cover note Ex.C1. So, the OP is directed to pay the remaining amount of Rs.36,953/- along with interest @ 8% per annum from the date of repudiate the claim. The OP is further directed to pay Rs.20,000/- as compensation and Rs.11000/- as litigation expenses to the complainants. The OP is also directed to comply with the aforesaid order within a period of 30 days from the date of receiving the certified copy of this order. Copy of the said order be sent to the parties as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the record room.
- (RANJIT SINGH)
(RANVIR KAUR)
MEMBER
CC No.344of 2018
Vide our separate detailed order of today, the complaint stands allowed. Free certified copies of this order be sent to the parties, as per rules. The files be sent back to the District Commission Ludhiana, for consigning the same to the record room.
April,28 2022
(Ranjit Singh)
(Ranvir Kaur)
