Punjab

Faridkot

CC/19/184

Shanker Goel - Complainant(s)

Versus

Reliance General INSURANCE co LTD - Opp.Party(s)

N.K Maheshwari

10 Feb 2020

ORDER

  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

          C.C. No. :                       184 of 2019

Date of Institution:  01.08.2019

Date of Decision :   10.02.2020

 Shanker Goyal aged about 45 years s/o Sh Banarsi Dass Sadawartia r/o Ward No.13,  Kocher Street, Near Jain Mandir, Jaitu, Tehsil Jaitu, District Faridkot.

                                                      ...Complainant

Versus

 

1. Reliance General Insurance Company Ltd. Reliance Centre, 19, Walchand Hirachand Marg, Ballard Estate, Mumbai-400001, through its Managing Director /Director/ Manager/Authorized Person.
2. Reliance General Insurance Co. Ltd. 1^st and 2^nd Floor, SCO-36/37, New Leela Bhawan, Patiala through Branch Manager /Authorized Person.
3. Smt Kusum Sharma, Agency Name & Code : Kusum Sharma & 20A09110, Agent Contact No. 98148-04202 through its Branch Office: Reliance General Insurance Co. Ltd. 1^st and 2^nd Floor, SCO-36/37, New Leela Bhawan, Patiala.

....OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

 

Quorum:      Sh. Ajit Aggarwal, President,

                   Smt Param Pal Kaur, Member.

 

Present:       Sh Neeraj Maheshwary, Ld Counsel for complainant,

                   Sh Manohar Lal Chugh, Ld Counsel for OPs.

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 ORDER

(Ajit Aggarwal, President)

                                         Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OP seeking directions to OP to make payment of insurance claim amount of Rs.2,55,552/- with interest and for further directing OPs to pay Rs 50,000/- as compensation for harassment, inconvenience, mental agony and litigation expenses of Rs 10,000/-.

2                                     Briefly stated, the case of the complainant is that Ops approached complainant for Health Insurance Policy and represented that policy in question is meant for medical treatment of insured in case of need and also explained about fast services of Company for settlement of claim. Detail of transparency in the working of Ops was given to complainant and on assurance of Ops, complainant purchased the General Insurance Policy for family for Rs.3,00,000/- for benefit in future five years ago and paid the premium as per terms and conditions of policy. After due enquiry and investigation of everything, Ops gave cover note of policy to complainant and again assured of beneficial features of the Policy. Complainant has been making regular payment of premium and is still under cover of insurance policy. In October, 2011, complainant felt some problem and after diagnose from PGI Chandigarh, it was found that he was suffering from Blood Cancer and since then, he has been regularly taking treatment and huge amount is being spent by him on his regular check ups and treatment. Intimation about this fact was given to OPs both telephonically as

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well as by written letter. Company officials conducted all kinds of enquiry and complainant also supplied all documents as required by them. Though complainant has fulfilled all formalities and also requested OPs many times to make payment of his genuine insurance claim, but all in vain. Ld counsel for complainant brought before the Forum that to get his insurance claim for treatment upto year 2012, he filed complaint before this Forum, which was decided in his favour on 21.02.2013 and ld Forum ordered OPs to pay Rs.1,65,621/- with interest to complainant. He again filed complaint before this Forum for obtaining insurance claim for the period from 5.02.2013 to 31.10.2015, which was also allowed in his favour on 16.01.2017 and ld Forum ordered OPs to pay Rs.2,33,540/- with interest to complainant, which was paid by OPs on 27.03.2018. It is further submitted that policy of complainant is for Rs.3 lacs and is valid till date as he has been availing the policy continuously and he is still under insurance cover and is entitled to claim for expenses spent by him on his treatment, but Ops have flatly refused to make payment of his genuine claim. Despite repeated requests, OPs have denied to make reimbursement of expenses spent by complainant on his treatment though he is still under insurance cover. Ld counsel for complainant has submitted that OPs may be directed to make payment of genuine insurance claim of complainant for Rs.2,55,552/- for treatment for the period from 4.06.2016 to 27.04.2019. Request for accepting the present complaint alongwith compensation and litigation expenses is made by complainant. Hence, the present complaint.

 

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3                                               The counsel for complainant was heard with regard to admission of the complaint and vide order dated 05.08.2019, complaint was admitted and notice was ordered to be issued to the opposite party.

 4                                                       On receipt of the notice, OPs filed written statement taking legal objections that complaint is not the consumer of OPs and complainant neither approached them to settle his claim nor informed about the treatment taken by him. Complainant has not referred any medical bill on account of which he has sought the claim from answering Ops. Moreover, they have already made payment of Rs.1,65,621/-to complainant as per award dated 21.02.2013 passed by this Forum. It is further averred that compliance of order dated 16.01.2017 passed by this Forum has also been made by them vide instrument no.382967 dated 6.04.2017. It is further averred that complainant has not abided by the terms and conditions of the policy and is therefore not entitled to any relief as mere diagnose of any disease does not give any right for seeking amount as claim. Present complaint involves complex questions of law and facts requiring huge evidence, which can not be tried in this Forum and is liable to be dismissed. It is further averred that this Forum has no jurisdiction to hear and try the present complaint and even complaint filed by complainant is time barred and is not maintainable in this Forum. However, on merits, ld counsel for OPs has denied all the allegations of complainant being wrong and incorrect. As per  OPs, complainant never spent Rs.2,55,552/-on his treatment. He is bound by the terms and conditions of the Policy. It is also denied that they

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ever assured regarding giving of any cashless treatment to him and it is also wrong that every kind of treatment is covered under the Policy. It is further denied that complainant has been regularly paying premium for the said policy and even complainant never informed OPs about his disease and treatment taken by him either telephonically or in writing and thus Ops are not bound to make payment of claim sought by complainant to him. Allegations regarding mis-representation or humiliation of complainant by Ops have been refuted at all. All the other allegations leveled by complainant are also denied being wrong and incorrect and it is further reiterated that there is no deficiency in service or unfair trade practice on the part of OPs. The allegations with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

6                                               Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1, and documents Ex C-2 to C-28 and then, closed his evidence.

7                                              In order to rebut the evidence of the complainant, ld counsel for OPs tendered in evidence affidavit of Suryadeep Singh Thakur as Ex OP-1 and then, closed the evidence on behalf of OPs

8                                        Ld Counsel for complainant vehementally argued that on assurance of Ops complainant purchased Health Insurance Policy for betterment in future. Ops gave detail of all features of insurance policy and assured complainant that there is hidden feature of expenses of

cc no.-184 of 2019

policy and complainant need not worry about medical expenses in case of any need and also gave assurance that OPs/ Insurance Company is very fast and renowned for providing best services. As per terms and conditions of said policy, complainant paid premium and after due enquiry and investigation of everything, Ops issued cover note of policy to complainant and again assured of beneficial features of the Policy. Complainant has been making regular payment of premium and is still under cover of insurance policy. In October, 2011, complainant felt some problem and after diagnose from PGI Chandigarh, it was found that he was suffering from Blood Cancer and since then, he has been regularly taking treatment and huge amount is being spent by him on his regular check ups and treatment. Due intimation about this fact was given to OPs. Complainant supplied all documents as required by OPs. Though complainant fulfilled all formalities and also requested OPs many times to make payment of his genuine insurance claim, but all in vain and even OPs humiliated and ill treated him. Counsel for complainant brought before the Forum that to get his insurance claim for treatment upto year 2012, he filed complaint before this Forum, which was decided in his favour on 21.02.2013 and in compliance thereof, OPs paid Rs.1,65,621/- to complainant. It is further submitted that policy of complainant is for Rs.3 lacs and is valid till date and he is still under insurance cover and is entitled to claim for expenses spent by him on his treatment, but Ops have flatly refused to make payment of his genuine claim. He again filed complaint for obtaining insurance claim for the period from 5.02.2013 to 31.10.2015, which was also allowed and ld Forum ordered OPs to pay Rs.2,33,540/- with interest to complainant, which was paid by OPs on

cc no.-184 of 2019

27.03.2018. It is further submitted that policy of complainant is for Rs.3 lacs and is valid till date as he has been availing the policy continuously. He is still under insurance cover and is entitled for reimbursement of expenses incurred by him on his treatment, but Ops have flatly refused to make payment of his genuine claim. Despite repeated requests, OPs have denied to make reimbursement of expenses spent by him on his treatment though he is still under insurance cover. Counsel for complainant has prayed for direction to OPs to make payment of genuine insurance claim of complainant for Rs.2,55,552/-for treatment for the period from 4.06.2016 to 27.04.2019. He has stressed on documents Ex C-1 to 28.

9                                       To controvert the arguments of complainant, ld counsel for OPs averred that complaint is not their consumer and he neither approached them to settle his claim nor informed about the treatment taken by him. Complainant has not referred any medical bill on account of which he has sought the claim from answering Ops. Moreover, they have already made payment of Rs.1,65,621/-to complainant in compliance of award dated 21.02.2013 passed by this Forum and even order dated 16.01.2017 passed by this Forum has also been duly complied by them on 6.04.2017. Complainant has not abided by the terms and conditions of the policy and therefore is not entitled to any relief as mere diagnose of any disease does not give any right for seeking claim. Complaint involves complex questions of law and facts requiring huge evidence, which cannot be tried in this Forum and is liable to be dismissed and even present complainant is time barred and is not maintainable in this Forum. Ld counsel for OPs has denied all the allegations

cc no.-184 of 2019

of complainant being wrong and incorrect and asserted that they never assured complainant that payment of Rs. 3 lacs on medical treatment would be given to him, rather he is bound by terms and conditions of the Policy. It is also denied that they ever assured regarding giving of any cashless  treatment to him and it is also wrong that every kind of treatment is covered under the Policy. It is further averred that complainant is not entitled for claim sought by him. All the other allegations have been refuted at all and it is further reiterated that there is no deficiency in service or unfair trade practice on the part of OPs. Ld Counsel for OPs has prayed for dismissal of complaint.

10                                                      We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

11                                                      After scrutinizing the record placed on file and careful perusal of pleadings and arguments, it is observed that the case of complainant is that he purchased Mediclaim Insurance Policy from OPs and he is still under insurance cover. During the subsistence of policy, complainant suffered from Blood Cancer and he has to spend huge amount on his treatment. Earlier also the Ops rejected his claim and then paid Rs.1,65,621/-to complainant in compliance of award dated 21.02.2013 passed by this Forum. They also rejected his claim for Rs.2,33,540/-, which  was thereafter cleared by them in compliance of order dated 16.01.2017 passed by this Forum. This time again they have repudiated the claim of complainant without any reason though it is admitted fact that complainant is

cc no.-184 of 2019

their consumer and he is under insurance cover. It is general tendency of Ops to take premiums and then at the time of making claim payment they keep finding reasons to escape their liability of fulfilling their promise. To controvert the plea of Ops that every kind of disease is not covered under this policy, ld counsel for complainant has placed reliance on the citation titled as United India Insurance Co. Ltd & Anr Vs S. M.S. Tele Communications & Anr 2009 (4) Consumer Law Today 145 wherein Hon’ble National Consumer Disputes Redressal Commission, New Delhi held that Consumer Protection Act, 1986 Section 2 (1) (g) - Insurance Act, 1938, Section 114 (A)- Insurance Regulatory and Development Authority (Protection of Policy Holders’ Interest) Regulations, 2002, Regulation 3 – Insurance claim – Exclusion clause – Held that being aware of the existence of the policy is one thing and being aware of the contents and meaning of clauses of the policy is another – Not the case of the petitioner-Insurance Company that the contents and the meaning of the policy were made known to the complainant as the policy was taken by the Bank – Insurance Company had explained the meaning of all the exclusion clauses to the Bank – Findings of the Fora below that exclusion clause not binding on the respondent-complainant upheld. He argued that Ops did not disclose any terms and conditions of exclusion clause at the time of purchase of policy to complainant. Moreover, the disease suffered by complainant is not of such nature which have any pre existing history or symptoms which can be known to a person beforehand. So, the Insurance Company can not deny the claim of complainant even on this ground.

cc no.-184 of 2019

  12                                              We have carefully gone through the file and from the above discussion, we come to the conclusion that the OPs are finding ways and means to escape their liability of providing assured help to insurer. Moreover, complainant suffered from this disease after the purchase of policy. Therefore, in these circumstances, we are fully convinced with the arguments and case law produced by the complainant and complainant succeeds in proving his case. The act of OPs in repudiating the genuine claim of complainant amounts to deficiency in service and trade mal practice. Present complaint is hereby allowed. OPs are ordered to pay the Mediclaim worth Rs.2,55,552/- to complainant alongwith interest at the rate of 7% per anum from the date of filing the present complaint till final realization. Ops are further directed to pay Rs.5,000/-as consolidated compensation for harassment and mental agony as well as for litigation expenses to complainant. Compliance of this order be made within one month from the date of receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 10.02.2020                 

 (Param Pal Kaur)                  (Ajit Aggarwal)

  Member                               President