Before the District Consumer Disputes Redressal Forum, Rohtak.

                                                          Complaint No. : 55.

                                                          Instituted on     : 05.02.2014.

                                                          Decided on       : 24.05.2016.

Rajesh Kumar s/o Sh. Jai Lal R/o Village-Kheri Khummar Teh. & Distt. Jhajjar.

                                                          ………..Complainant.

                             Vs.

Reliance Life Insurance Company, Appu Ghar Complex, Rohtak through its Branch Manager.

                                                          ……….Opposite party.

          COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.

BEFORE:  SH.JOGINDER KUMAR JAKHAR, PRESIDENT.

                   MS. KOMAL KHANNA, MEMBER.

                   SH. VED PAL, MEMBER.

Present:       Sh. P.K.Jangra Advocate for the complainant.

                   Sh. Gulshan Chawla, Advocate for the opposite party.

                                      ORDER

SH. JOGINDER KUMAR JAKHAR, PRESIDENT :

1.                          The present complaint has been filed by the complainant with the averments that he has obtained a health policy from the opposite party vide policy no.18029259 commencing from 18.10.2010 vide Card No.RLC4U001183. It is averred that at the time of obtaining the policy, the complainant was medically examined by the paneled doctor for the opposite party and he was found fit in all respects. It is averred that under the above said policy the opposite party is liable to bear the expenses of treatment of the insured person in case she/he is suffered from any disease. It is averred that unfortunately in April 2013 the complainant suffered with ailment of stomach pain, fever, headache, typhoid, vomiting and jaundice and he was got admitted in Deep Hospital, Jhajjar on 02.04.2013 and was discharged on 08.04.2013. It is averred that the complainant paid Rs.35379/- to the hospital for the treatment and after discharging from the hospital applied for obtaining the insurance claim with the opposite party and also submitted the relevant documents.  But his claim was not settled despite his repeated requests and complainant served a legal notice dated 10.06.2013 upon the opposite party which was replied vide letter dated 25.06.2013 in which they have shown less amount of claim but even after that the opposite party has failed to pay the said amount to the complainant.  Complainant again served a legal notice but the same was not replied. As such it is prayed that opposite party may kindly be directed to pay an amount of Rs.35379/- as claim amount and a sum of Rs.50000/- as compensation on account of mental agony and harassment alongwith compensation and litigation expenses to the complainant.

2.                          On notice, opposite party appeared and filed its written reply submitting therein that the contents regarding admission of the complainant with Deep Hospital Jhajjar for a span of 02.04.2013 to 08.04.2013 is correct as per documents provided by the complainant. The contents regarding complainant having paid an amount of Rs.35379/- is matter of record. It is averred that in the present case claim of the complainant was repudiated vide letter dated 18.05.2013 on the ground that the ailment for which hospitalization took place can be treated on an OPD basis & does not warrant hospitalization. Hence the claim is not payable.   It is averred that complainant is not entitled to the relief prayed for. Opposite party prayed for dismissal of the complaint with cost.

3.                          Both the parties led evidence in support of their case.

4.                          Complainant in his evidence tendered his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C12 and has closed his evidence. On the other hand,  ld. counsel for the opposite party in his evidence has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R3 and closed his evidence.

5.                          We have heard ld. counsel for the parties and have gone through the material aspects of the case very carefully.

6.                          In the present case it is not disputed that the complainant was insured with the opposite party vide policy no. 18029259 which is proved from the premium receipt Ex.C1. It is also not disputed that he was hospitalized in Deep Hospital Jhajjar for a span of 02.04.2013 to 08.04.2013  and that he had filed a claim with the opposite party vide claim form Ex.C3  for a sum of Rs.35379/- on account of hospitalisation expenses and also served a legal notice Ex.C5 upon the opposite party and in reply to the same vide letter Ex.C6 opposite party agreed to pay an amount of Rs.18824/- but lateron the same was repudiated by the opposite party vide its letter Ex.R3 on the ground that : “The ailment for which hospitalization took place can be treated on an OPD basis & does not warrant hospitalization”. In order to prove its contention opposite party has placed on record terms and conditions of the policy vide document Ex.R1. 

7.                          After going through the file and hearing the parties it is observed that the opposite party vide its letter Ex.C6 dated 25.06.2013 has admitted the liability of Rs.18824/- but lateron the same was repudiated by the opposite party on the ground that the ailment for which hospitalization took place can be treated on an OPD basis & does not warrant hospitalization and has also placed reliance upon the condition no.1.1.24 of the policy whereby it is mentioned that “Medically necessary “ treatment is defined as any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which is required for the medical management of the illness or injury suffered by the insured must not exceed the level of care necessary to provide safe, adequate and appropriate medicare in scope, duration or intensity, it must have been prescribed by a Medical Practitioner and must confirm to the profession standards widely accepted in international medical practitioner by the medical community in India. In this regard it is observed that as per the claim form Ex.C3, Annexure A  is filled by the attending physician i.e. Dr.Manoj Kumar, M.D. whereby the reason for hospitalization and diagnosis is also mentioned. Hence it is not proved on file that the hospitalization was not necessary and that the alleged treatment taken by the complainant was not prescribed by the medical practitioner.  On the other hand, as per letter Ex.C6 opposite party has admitted the liability of Rs.18824/-. In this regard reliance has been placed upon the law cited in 2012(4)LJR 101 titled as Ved Parkash Vs. Faqir Chand, whereby Hon’ble High Court of Punjab & Haryana has held that: “As per Evidence Act, 1872, Section 21, Civil Procedure Code, 1908, Order 12 Rule 6-Evidentiary value of admission-it is settled proposition of law that admission by the party is the best evidence against it”.  Moreover it is not proved on file that the alleged terms and conditions were part of the policy and were delivered to the complainant. In this regard we have placed reliance upon 2013(1)CLT 589 titled as New India Asurance Co. Ltd. Vs. Pabbati Sridevi & Others whereby Hon’ble National Commission has held that: “Terms and conditions therein, not communicated to the insured-Whether can be used by Insurance Company-No-Held that the terms and conditions were never issued to the insured-Policy is in the nature of standard, printed documents. There is nothing to show that its contents were part of the policy document issued to the insured-Terms and conditions in insurance policy cannot be rely upon by insurance company”, as per 2015(1)CLT591 titled as Star Health and Allied Vs. Asha & Others, whereby it is held that: “Insurance policy-Exclusion clause-Not explained to insured when cover not was issued-Insurance company cannot derive any benefit from exclusion clause” and as per 2009(3)CLT 184 titled ICICI Lombard General Insurance Co. Ltd. Vs. Gurmeet and another, Hon’ble Punjab State Commission, Chandigarh has held that: “No evidence to prove if the document was either signed by the complainant-insured or if it was an enclosure of the insurance policy or if it was duly communicated to respondent no.1-The insurance Company cannot avail the benefits of these terms and conditions contained in the document”. In view of the aforesaid law which are fully applicable on the facts and circumstances of the case it is observed that the repudiation of claim by the opposite party is illegal and unjustified and the complainant is entitled for the claim amount as admitted by the opposite party vide its letter Ex.C6 to the tune of Rs.18824/-.

8.                               In view of the facts and circumstances of the case, it is directed that opposite party shall pay the claim amount of                 Rs.18824/-(Rupees eighteen thousand eight hundred twenty four only) along with interest @ 9% p.a. from the date of filing the present complaint i.e. 05.02.2014 till its realization and shall also pay a sum of Rs.3500/-(Rupees three thousand five hundred only) as litigation expenses to the complainant maximum within one month from the date of decision failing which the awarded amount shall carry further interest @ 12% p.a. from the date of decision.  Complaint is allowed accordingly.

9.                          Copy of this order be supplied to both the parties free of costs.

10.                        File be consigned to the record room after due compliance.

Announced in open court:

24.05.2016.

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                                                          Joginder Kumar Jakhar, President

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                                                          Komal Khanna, Member.

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                                                          Ved Pal, Member.