DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                        Complaint No. 30

 Instituted on:   27.01.2020

                                                                        Decided on:     01.12.2022   

Nand Kishore son of Bhagat Ram, Resident of Main Bazar, Ward No.4, Longowal-148106, Distt. Sangrur.         

                                                          …. Complainant.     

                                                 Versus

1.     Religare Health Insurance Limited, Ist Floor, Above Kamal Medicose, Nabha Gate, Sangrur-148001 through its Branch Manager/authorized signatory.

2.     Religare Health Insurance Limited, through its Authorised Representative Regd. Office 5th Floor,19 Chawla House, Nehru Place, New Delhi-110019.

3.     Religare Health Insurance Limited, through its Authorized Representative Corp. Office Vipul Tech Square, Tower C, 3^rd Floor, Golf Course Road, Sector 43, Gurugram 122009 (Haryana).

….Opposite parties. 

QUORUM                                       

JOT NARANJAN SINGH GILL: PRESIDENT

SARITA GARG                         : MEMEBR

KANWALJEET SINGH             : MEMBER

For the complainant    : Shri K.C.Sharma Adv.              

For the Ops               : Shri Jatinder Verma, Adv.

ORDER BY

JOT NARANJAN SINGH GILL, PRESIDENT.

1. The brief facts of the case are that the present complaint has been filed by complainant and he availed the services from Ops by getting insured himself of Rs. 5,00,000/- of mediclaim insurance policy number 12335552 renewed on 06.04.2019 for the period of 06.04.2019 to 05.04.2020. The complainant paid the premium amount of Rs. 15,391/- to the Ops. Ops covered all the diseases of the complainant and assured that the expenses upto Rs. 5,00,000/- will be payable for the treatment of all the diseases. On 18.11.2019 complainant suddenly fell ill and was taken to DMC, Ludhiana for treatment, where he remain admitted from 18.11.2019 to 21.11.2019 and spent an amount of Rs.1,77,884/- on his treatment. The Ops paid only a sum of Rs. 1,03,372/-. The remaining amount of Rs. 74,512/- was paid by the complainant to the concerned hospital. Complainant after discharge from the hospital requested for the claim to the Ops for reimbursement of Rs.74,512/-, but the Ops disallowed the rightful claim of the complainant. The insurance policy terms and conditions neither explained nor provided to the complainant. The complainant prayed that Ops may kindly be directed to pay remaining claim amount of Rs.74,512/- along with interest @12% per annum from the date of repudiation of the claim. Further the Ops be directed to pay a sum of Rs. 20,000/- as compensation for mental tension and harassment and Rs.15,000/- as litigation expenses.
2. Upon notice Ops appeared and filed reply and taking preliminary objections that the present complaint is not maintainable. The Ops already paid the payable amount under claim as per policy terms and conditions. On merits, the Ops admitted that they issued policy group care (PNB) policy number 11561922 w.e.f. 06.04.2018 to 05.04.2019 for a sum insured of Rs.5,00,000/- subject to the terms and conditions covering the complainant and his spouse. The said policy was later renewed from 06.04.2019 to 05.04.2020. The detail of the policy along with policy certificate was duly sent to the proposer. The complainant approached the Ops through DMC, Ludhiana with respect to his pre-auth form, the complainant was provisionally diagnosed with HTN, unstable Angina. Query letters dated 18.11.2019,19.11.2019, 20.11.2019 were also send to the hospital and was asked to provide the documents by the Ops. Query Reply was received from the hospital and cashless request was approved on 2.11.2019 for the total amount of Rs. 1,03,322/- by the Company. Non medical expenses of Rs. 687/- was deducted. Co-payment of 20% would be applicable in case of treatment for heart related ailments. Therefore, Rs. 25,842/- was deducted by Company. Proportionate charges of Rs.47,981/- was deducted by the Company. Discount of Rs.23,390/- was also deducted, provided by the hospital. Complainant has not claim this amount, because the said amount of Rs.23,390/- has already been given concession by the hospital. Proportionate charges deductions were levied on various counts as per clause 4.5(a)(II) of the policy terms and conditions. It is stated further that the complainant is not entitle for any further amount beyond the terms and conditions of the policy. OPs have already paid entire amount under the policy to the complainant. Thus, the Ops have prayed that the complaint filed by complainant may kindly be dismissed with costs.
3. Complainant has tendered into evidence Ex.C-1 affidavit of the complainant and documents Ex.C-2 to Ex.C-6 and closed the evidence. Similarly, Ops tendered into evidence documents Ex.Ops.1 to Ex.Ops.17 and Ex.Ops.18 affidavit and closed the evidence.
4. We have heard the learned counsels of both the parties and gone through the record file carefully with the valuable assistance of the learned counsels for the parties.
5. During arguments the contentions of both the learned counsels are similar to their respective pleadings. So, no need to reiterate the same to avoid repetition. Further, no doubt it is admitted fact that policy number 12335552 was valid from 06.04.2019 to 05.04.2020 and complainant paid  premium of Rs.15,391/-. Complainant admitted in hospital on 18.11.2019 and discharge on 21.11.2019. The Ops sanctioned an amount of Rs.1,03,372/-. As per Ex.C-4 claim amount was Rs.2,01,274/-. As per Ex.C-5 dt. 18.11.2019 complainant deposited a sum of Rs.5,000/- and as per Ex.C-6 dated 21.11.2019 complainant again deposited a sum of Rs.69,512/- , total Rs.74,512/-. Ops have deducted Rs.687/- stating non medical expenses. Further, Ops have deducted Rs.25,842/- on the pretext  of co-payments. Ops deducted Rs.47,981/- as proportionate charges. During arguments the learned counsel for the complainant pressed on this issue that the Ops did not provide the policy terms and conditions regarding the deduction of amount.
6. To support the case, the learned counsel for the complainant has cited M/s. Modern Insulators Ltd. Versus Oriental Insurance Co. Civil Appeal No.6895 of 1997 dated 22.02.2000,  wherein it has been held by the Hon'ble Supreme Court of India that the exclusion clause was neither a part of the contract of insurance nor disclosed about the clause to appellant, respondent cannot claim benefit of exclusion clause.  Similar is the position in the present case, as such, we are of the considered opinion that the OP insurance company cannot take the benefit of the exclusion clause as discussed above.
7.  It is crystal clear that the Ops are miserably failed to prove this fact that they had provided policy papers to the complainant. Moreover, no cogent evidence has been produced by the OPs regarding the receiving of terms and conditions of the policy by the complainant. No postal receipt has been  placed on the record by the Ops regarding the policy documents were supplied to the complainant.
8. This Commission, considered that the complainant was insured for an amount of Rs.5,00,000/-. It is admitted fact that the Ops paid a sum of Rs.1,03,372/- to the complainant. Keeping in view the facts and circumstances of the case, we find that the Ops are liable to pay the remaining amount of Rs.74,512/- to  the complainant. Resultantly, we partly allow this complaint and Ops are directed to pay a sum of Rs.74,512/-. We further direct Ops to pay to the complainant an amount of Rs.5500/- as consolidated amount of compensation and litigation expenses. This order be complied with within a period of 60 days from the date of receipt of this order.
9.  The complaint could not be decided within the         statutory time period due to heavy pendency of cases.
10. Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance. 

                                Announced.

                                December 1, 2022.

( Kanwaljeet Singh)    (Sarita Garg)  (Jot Naranjan Singh Gill)

    Member                         Member                   President