BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 468 of 2017
Date of Institution:19.7.2017
Date of Decision:28.1.2019
Mr. Kashmir Singh S/o Sh. Makhan Singh R/o Nanak Pura, Tehsil Ajnala District Amritsar
Complainant
Versus
- Religare Health Insurance Company India Limited through its Chairman/Managing Director/Principle Officer through its Branch Office at District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager SCO 28 Taneja Tiower B-Block
- Religare Health Insurance Co.Ltd. GYS Global Plot No. A3 A4 A5 Sector 125, Noida UP through Authorized signatory
Opposite Parties
Complaint under section 12 & 13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh.Inderjit Lakhra,Advocate
For the opposite parties : Sh. R.P.Singh,Advocate
Coram:
Sh.Charanjit Singh, President
Mr.Anoop Sharma, Member
Ms. Rachna Arora, Member
Order dictated by:
Sh.Charanjit Singh, President
1. Sh.Kashmir Singh, complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that the complainant got health Benefit mediclaim Insurance for himself and family vide policy No. 10465940. Unfortunately complainant got dog bite and wounded and was to be hospitalized at Sardar Harcharan Singh Ajnala Memorial Hospital, Ajnala from 16.3.2017 to 18.3.2017 . The treatment cost of the said hospitalization came to Rs. 39,740/-. Opposite party was immediately informed as the said policy was issued on cashless basis and the sum insured is for Rs. 3 lacs. Opposite party instead of making payment repudiated the genuine claim of the complainant vide letter dated 12.6.2017 on the ground that complainant was not required hospitalization. The act of the opposite party in repudiating the claim of the complainant on frivolous grounds is an act of deficiency in service, malpractice, unfair trade practice and has caused lot of mental pain, agony and harassment to the complainant. Vide instant complaint, complainant has sought for the following reliefs:-
(a) Opposite party be directed to pay the amount of Rs. 39,740/- alongwith interest @ 12% from 18.3.2017 till realization ;
(b) Compensation to the tune of Rs. 50000/- alongwith adequate litigation expenses may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version in which it was admitted that a policy bearing No. 10465940 providing insurance coverage to the complainant, spouse, daughter and son was issued on 3.12.2015 and renewed subsequently to 3.12.2016. The said policy issuance and its subsequently renewal were subject to policy terms and conditions governing the policy. In this case claim of the complainant has been repudiated on the ground dog bite vaccination charges are not payable as per the policy terms and conditions. Also the hospitalization is not warranted and OPD treatment is not covered under the policy. Therefore, as per terms and conditions of the policy, under clause 4.2(i) the claim was not payable as the complainant was admitted primarily for evaluation/diagnostic purpose and vaccination purpose, which is a permanent exclusion in the referred policy. No final discharge summary has been produced by the treating doctor or complainant. Only a noting of doctor showing the date of admission and date of discharge has been supplied to the opposite party in which no date or room number has been mentioned, merely DOD has been mentioned as 18.3.2017. Moreover the complainant has produced two different treatment charts dated 16.3.2017. As per first treatment chart, only treatment for 16.3.2017 has been mentioned and the consultant are mentioned a “Dr.Gurlal and Dr.Rana Ranjit” However, the second treatment chart mentions about the treatment of 16.3.2017 and 17.3.2017 in a different handwriting from the first treatment chart . This is not possible, since treatment chart and indoor case paper are made only once during the treatment . Also the treatment chart dated 18.3.2017 is not maintained by the treating hospital authority. Hence, it is clear that actually the treatment was given only on 16.3.2017, however, OPD treatment has been converted into IPD treatment . Hence, this shows that complainant has tried to manage the documents to show the admission in the hospital, whereas no admission was required for the treatment taken therefore, present complaint is liable to be dismissed. While denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case Sh.Inderjit Lakhra,Adv.counsel for the complainant tendered into evidence affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-16 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.R.P. Singh,Adv.counsel for the opposite party tendered into evidence affidavit of Sh.Arvind Singhm Naruka, Manager Legal Ex.OP1,2/A alongwith documents Ex.OP1,2/1 to Ex.OP1,2/12 and closed the evidence on behalf of the opposite party.
5. We have heard the Ld.counsel for the parties and have carefully gone through the record o the file.
6. Ld.counsel for the complainant has vehemently contended that the complainant got health Benefit mediclaim Insurance for himself and family vide policy No. 10465940, copy of policy certificate is Ex.C-3 on record. It has further been contended that unfortunately complainant got dog bite and wounded and was to be hospitalized at Sardar Harcharan Singh Ajnala Memorial Hospital, Ajnala from 16.3.2017 to 18.3.2017, copy of certificate issued by hospital account for Ex.C-6 & Ex.C-7 on record. The treatment cost of the said hospitalization came to Rs. 39,740/- and in this regard complainant has placed on record copies of medicines bills Ex.C-8 for Rs. 2740/- and Ex.C-9 for purchase of vaccination of Rs. 31000/- as well as hospital bill of Rs. 6000/- in which admission fee, room charges as well as doctor visit charges were duly mentioned. Opposite party was immediately informed as the said policy was issued on cashless basis and the sum insured is for Rs. 3 lacs. Opposite party instead of making payment repudiated the genuine claim of the complainant vide letter dated 12.6.2017 on the ground that complainant was not required hospitalization. The act of the opposite party in repudiating the claim of the complainant on frivolous grounds is an act of deficiency in service, malpractice and unfair trade practice.
7. On the other hand Ld.counsel for the opposite party has vehemently contended that claim of the complainant has been repudiated on the ground that dog bite vaccination charges are not payable as per the policy terms and conditions. Also the hospitalization is not warranted and OPD treatment is not covered under the policy. Therefore, as per terms and conditions of the policy, under clause 4.2(i) the claim was not payable as the complainant was admitted primarily for evaluation/diagnostic purpose and vaccination purpose, which is a permanent exclusion in the referred policy. But however, we are not agreed with this plea of the opposite party as the complainant has duly proved on record that he got admitted himself in Harcharan Singh Ajnala Memorial Hospital and in this regard has placed on record relevant documents i.e. hospital bill Ex.C-11 as well as medicine bills Ex.C-8 and Ex.C-9 . The plea of the opposite party that vaccination charges are not payable as per the policy terms and conditions is without any basis as these charges are not excluded under any terms and conditions. The opposite party has failed to prove on record that complainant has procured the treatment record as onus was upon the opposite party to prove that fact to successfully absolve it from the liability. There is nothing on record produced by the Opposite Party to prove that there was absolutely no need for the complainant to be treated as indoor patient in that hospital. No opinion of any doctor or medical expert has been adduced on record to counter the treatment record produced by the complainant. As such, in our considered opinion, the repudiation of claim vide letter Ex.C-16 is not sustainable at law. The opposite party is deficient in service. Moreover it is usually seen that insurance companies show green pastures to the insured persons at the time of selling the insurance policy and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.
The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
8. From the aforesaid discussion, it emerges that the rightful claim of the complainant has been wrongly repudiated by the Opposite Parties without any rhyme or reason and the complainant is entitled to the claim amount of Rs. 39,740/- alongwith interest @ 9% per annum from the date of filing the complaint until full and final recovery. The costs of the complaint are assessed at Rs.5,000/-. Compliance of this order be made by Opposite Parties within 30 days from the date of receipt of copy of this order, failing which complainant shall be entitled to get the order executed through the indulgence of this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
