PER:

Charanjit Singh, President.

1        The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.

2        The complainant is the holder of Medi Classic Insurance Policy (individual) bearing Cover Note No. P/211111/01/2016/006127 for a period of one year w.e.f. 26.2.2016 to midnight, having been purchased by her from the opposite party for valuable consideration, against the premium of Rs. 5,736/- which was duly paid by her to the opposite party and the insurance cover note was duly issued by the opposite party to her without supplying any terms and conditions of such policy which are also required to be supplied by them. This policy is for the sum insured of Rs. 2 Lacs with commutative bonus of Rs. 30,000/-. The complainant has been purchasing such insurance policy from the opposite party since the year 2011 onwards till date. The previous policies for the year 2011-12, 2012-13 and 2013-14 were for the sum assured of Rs. 1 Lac and policy for the year 2014-15 was for Rs. 1.5 Lac with Rs. 20,000/- as bonus and the policy for the year 2015-16 was Rs. 1.5 Lac with commutative bonus of Rs. 27,500/- and the complainant has been regularly paying the premium amounts to the opposite party. The policy in question relating to the present subject matter bears No. P/211111/01/2015/004592 for the period from 26.2.2015 to 25.2.2016 against the premium of Rs. 5,051/- which was duly issued by the opposite party in her name against the premium received by them. During the subsistence of the said policy in question for the period 26.2.2015 to 25.2.2016, the complainant suffered spine pain caused to her legs and she got herself treated from Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi where she remained admitted against Regn. No. 1955118, date of admission 4.10.2016, date of discharge 7.10.2016 with the diagnosis 14-15 Bilateral Canal Stenosis with L4-L5 prolapsed Intervertebral Disc. As she was suffering from lower backache and pain in both lower limbs. The said hospital authorities were informed about the health insurance policy obtained by her from the opposite party and requisite documents were supplied by them. Accordingly, the opposite party was also informed by the said hospital authorities about the treatment of the complainant. For the treatment of the complainant in the said Hospital, the total amount of Rs. 2,14,893/- was spent out of which Rs. One Lac was paid by the opposite party to the said hospital authorities and the balance amount of Rs. 1,44,893/- was paid by the complainant to the hospital authorities out of her pocket, the liability of the opposite party is for total sum of Rs. 1,77,500/- out of which they have paid only Rs. One Lac  to the hospital authority. Thus, there is liability of balance amount of Rs. 77,500/- against the opposite party towards the complainant. After her treatment and discharge from the said hospital, the complainant alongwith her husband approached the opposite party and requested them to make payment of balance sum of Rs. 77,500/- to her which she had paid to the hospital authorities but they put off the matter on one pretext or the other inspite of repeated visits, demands and requests by her from time to time. Ultimately, few days ago, they flatly refused to make any payment to the complainant without issuing any repudiation letter. This shows the malafide intention of the opposite party to grab the said amount whereas they are legally bound to pay the same which is covered under the policy in question. The complainant is legally entitled to claim this amount alongwith interest on it. The complainant has prayed that the present complaint be accepted and the following reliefs may be granted to the complainant against the opposite party.

(i)      The opposite party may be directed to make payment of Rs. 77,500/-  being the balance amount of policy in question alongwith interest on it @18% p.a. to the complainant.

(ii)     The opposite parties be directed to pay compensation of Rs. 10,000/- to the complainant for suffering mental pain, agony, harassment, inconvenience on account of deficiency in service on their part.

(iii)    The costs of proceedings to the tune of Rs. 5,000/-.

3        After formal admission of the complaint, notice was issued to Opposite Party and opposite party appeared through counsel and filed written version and contested the complaint by inter-alia pleadings that the present complaint is not legally maintainable. The complainant has not come to this commission with clean hands and suppressed the true and material facts from this commission. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has got no cause of action to file the present complaint. The complainant obtained the policy as mediclassic insurance policy (individual) from the opposite party vide policy No. P211111/01/2010/000441 for sum insured Rs. 1,00,000/- valid from 23.2.2010 to 22.2.2011 which were revised vide policy No. P/211111/01/2011/001907 for sum insured Rs. 1,00,000/- valid from 23.2.2011 to 22.2.2012, policy No. P/211111/01/2012/002885 for sum insured Rs. 1,00,000/- valid from 23.2.2012 to 22.2.2013, the policy No. P/211111/01/2013/003341 for sum insured Rs. 1,00,000/- valid from 23.2.2013 to 22.2.2014, then policy No. P/211111/01/2015/003699 for sum insured Rs. 1,50,000/- valid from 25.2.2014 to 24.2.2015 revised  vide policy No. P/211111/01/2016 for sum insured Rs. 2,00,000/- valid from 26.2.2016 to 25.2.2017. The complainant admitted in Indian Spinal Injury Centre on 20.9.2016 for the treatment of lower back pain and raised pre-authorization request for cashless treatment in perusal of the claim records and the company approved Rs. 90,000/- on 8.9.2016 towards cashless treatment. As the authorization was not utilized, the company withdrawn the same vide their letter dated 4.10.2016. However, the complainant was again admitted in Sir Ganga Ram Hospital on 4.10.2016 for the treatment of Bilateral Canal Stenosis and raised pre authorization request for cashless treatment. On receipt of pre authorization request, it is observed that The Pre Authorisation Forms vide claim No. CLI/2017/211111/0201109 stated that the insured and the complaints of low back pain since 2½ years. Thus the insured is symptomatic since 2½ years where the sum insured was Rs. 1,00,000/-. As per condition 8, if the policy is to be renewed or ported from other Indian Insurance company for enhanced sum insured, then the waiting period as applicable to a fresh policy will apply to additional sum insured as if a separate policy has been issued for difference. In other words, the enhanced sum insured will not be available for an illness, disease, injury already contracted under the proceeding policy periods. As the insured has the said complaint since 2½ years. The sum insured was restricted to Rs. 1,00,000/- and the same was paid on 25.10.2016. Thus this is the maximum amount payable as per the terms and condition of the policy. As such on account of the aforesaid reasons and terms and conditions of the policy and due to the fact that the claim of the complainant for enhanced amount was not payable as during earlier insurance policy terms, the complainant availed the no claim bonus and did not opt to get her treatment done whereas she was having symptomatic since 2½ years and as such, the complainant was not entitled for the said claim and the said pre authorization was withdrawn and rejected and in this regard, the complainant was duly informed vide letter dated 4.10.2016 as the complainant is not entitled for any more, than the amount which is already paid by the company to the hospital and her claim has been rightly repudiated. Hence the repudiation of claim is genuine and valid one and claim is not at all payable.   The complainant was duly supplied the terms and conditions of the policy and insurance policy document and she was fully aware of each and everything since she obtained policy for 5/6 years regularly.  The opposite party has denied the other contents of the complaint and prayed that the present complaint may be dismissed.

4        To prove the case, Ld. counsel for the complainant has tendered in evidence affidavit of complainant Ex. C-1 alongwith documents i.e. copy of claim policy schedule Ex. C-2, copy of the insurance policy Ex. C-3, C-4, copy of discharge summary Ex. C-5, copy of hospital bill Ex. C-6, copy of policy from 23.2.2010 to 22.2.2011 Ex. C-7, Copy of policy from 23.2.2011 to 22.2.2012 Ex. C-8, copy of policy from 23.2.2012 to 22.2.2013 Ex. C-9, copy of policy from 23.2.2013 to 22.2.2014 Ex. C-10, copy of policy from 26.2.2017 to 22.2.2018 Ex. C-11, copy of proposal form dated 23.2.2010 Ex. C-12 and closed the evidence.  On the other hands, Ld. counsel for the opposite party tendered in evidence affidavit of P.C. Triphathy, Zonal Manager Ex. OP1, copy of the resolution Ex. C-2, copy of power of attorney in favour of V.Jagannathan Ex. OP3, copy of power of attorney in favour of P.C. Tripathy Ex. OP4, copy of  terms and conditions of policy Ex. OP5, copy of proposal form Ex. OP6, copy of policy schedule 2010-11 Ex. OP7, copy of policy schedule 2010-11 Ex. OP8, copy of policy schedule 2011-12 Ex. OP9, copy of the policy schedule 2013-14 Ex. OP10, copy of policy schedule 2014-15 Ex. OP11, copy of policy schedule 2015-16 Ex. OP12, copy of policy schedule 2016-17 Ex. OP13, copy of pre authorization request form Ex. OP14, copy of OPD card Ex. OP15, copy of authorization for cashless treatment of insured patient Ex. OP16, copy of withdrawal of authorization letter Ex. OP17, copy of the query on pre authorization Ex. OP18, copy of authorization for encashment of amount Ex. OP19, copy of the request letter by Ashok Bhandari Ex. OP20, copy of bill assessment sheet Ex. OP21 and closed the evidence.

5        We have heard the Ld. counsel for the complainant and opposite party and have gone through the record on the file.

6        Ld. counsel for the complainant contended that the complainant is the holder of Medi Classic Insurance Policy (individual) bearing Cover Note No. P/211111/01/2016/006127 for a period of one year w.e.f. 26.2.2016 to midnight, having been purchased by her from the opposite party for valuable consideration, against the premium of Rs. 5,736/- which was duly paid by her to the opposite party and the insurance cover note was duly issued by the opposite party to her without supplying any terms and conditions of such policy which are also required to be supplied by them. He further contended that this policy is for the sum insured of Rs. 2 Lacs with commutative bonus of Rs. 30,000/-. The complainant has been purchasing such insurance policy from the opposite party since the year 2011 onwards till date. The previous polices for the year 2011-12, 2012-13 and 2013-14 were for the sum assured of Rs. 1 Lac and policy for the year 2014-15 was for Rs. 1.5 Lac with Rs. 20,000/- as bonus and the policy for the year 2015-16 was Rs. 1.5 Lac with commutative bonus of Rs. 27,500/-. He further contended that the policy in question relating to the present subject matter bears No. P/211111/01/2015/004592 for the period from 26.2.2015 to 25.2.2016 against the premium of Rs. 5,051/- which was duly issued by the opposite party in her name against the premium received by them. During the subsistence of the said policy in question for the period 26.2.2015 to 25.2.2016, the complainant suffered spine pain caused to her legs and she got herself treated from Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi where she remained admitted from 4.10.2016 to 7.10.2016. She was suffering from lower backache and pain in both lower limb. An amount of  Rs. 2,14,893/- was spent on treatment but out of which Rs. One Lac was paid by the opposite party to the said hospital authorities and the balance amount of Rs. 1,44,893/- was paid by the complainant to the hospital authorities. The liability of the opposite party is for total sum of Rs. 1,77,500/- out of which they have paid only Rs. One Lac  to the hospital authority. There is liability of balance amount of Rs. 77,500/- against the opposite party towards the complainant. The husband of complainant requested the opposite party to make payment of balance sum of Rs. 77,500/- to her which she had paid to the hospital authorities but they flatly refused to make any payment to the complainant without issuing any repudiation letter. The complainant is legally entitled to claim this amount alongwith interest on it. The complainant has prayed that the present complaint be allowed.

7        On the other hands, Ld. counsel for the opposite party contended that the complainant obtained the policy as mediclassic insurance policy (individual) from the opposite party vide policy No. P211111/01/2010/000441 for sum insured Rs. 1,00,000/- valid from 23.2.2010 to 22.2.2011 which were revised vide policy No. P/211111/01/2011/001907 for sum insured Rs. 1,00,000/- valid from 23.2.2011 to 22.2.2012, policy No. P/211111/01/2012/002885 for sum insured Rs. 1,00,000/- valid from 23.2.2012 to 22.2.2013, the policy No. P/211111/01/2013/003341 for sum insured Rs. 1,00,000/- valid from 23.2.2013 to 22.2.2014, then policy No. P/211111/01/2015/003699 for sum insured Rs. 1,50,000/- valid from 25.2.2014 to 24.2.2015 revised  vide policy No. P/211111/01/2016 for sum insured Rs. 2,00,000/- valid from 26.2.2016 to 25.2.2017. He further contended that the complainant admitted in Indian Spinal Injury Centre on 20.9.2016 for the treatment of lower back pain and raised pre-authorization request for cashless treatment in perusal of the claim records and the company approved Rs. 90,000/- on 8.9.2016 towards cashless treatment. As the authorization was not utilized, the company withdrawn the same vide their letter dated 4.10.2016. However, the complainant was again admitted in Sir Ganga Ram Hospital on 4.10.2016 for the treatment of Bilateral Canal Stenosis and raised pre authorization request for cashless treatment. On receipt of pre authorization request, it is observed that The Pre Authorisation Forms vide claim No. CLI/2017/211111/0201109 stated that the insured and the complaints of low back pain since 2½ years. Thus the insured is symptomatic since 2½ years where the sum insured was Rs. 1,00,000/-. As per condition 8, If the policy is to be renewed or ported from other Indian Insurance company for enhanced sum insured, then the waiting period as applicable to a fresh policy will apply to additional sum insured as if a separate policy has been issued for difference. In other words, the enhanced sum insured will not be available for an illness, disease, injury already contracted under the proceeding policy periods. As the insured has the said complaint since 2½ years. The sum insured was restricted to Rs. 1,00,000/- and the same was paid on 25.10.2016. This is the maximum amount payable as per the terms and condition of the policy. As such on account t of the aforesaid reasons and terms and conditions of the policy and due to the fact that the claim of the complainant for enhanced amount was not payable as during earlier insurance policy terms, the complainant availed the no claim bonus and did not opt to get her treatment done whereas she was having symptomatic since 2½ years.  The complainant was not entitled for the said claim and the said pre authorization was withdrawn and rejected and in this regard, the complainant was duly informed vide letter dated 4.10.2016. The complainant is not entitled for any more, than the amount which is already paid by the company to the hospital and her claim has been rightly repudiated. He further contended that the complainant was duly supplied the terms and conditions of the policy and insurance policy document and she was fully aware of each and everything since she obtained policy for 5/6 years regularly and prayed that the present complaint may be dismissed.

8        In the present case, insurance is not in dispute. It is also not disputed that the complainant remained admitted in Sir Ganga Ram Hospital, New Delhi. After admitting the insurance and admission of the complainant in the hospital, the opposite party has given the claim to the complainant to the tune of Rs. 1,00,000/-. In the present case, the complainant has spent Rs. 2,14,893/-. The complainant has claimed that out of that amount the complainant is entitled to Rs. 1,77,500/-, but the opposite party has made the payment of Rs. 1,00,000/- only. The opposite party has refused to pay Rs. 77,500/- on the ground that the complainant is entitled to Rs.1,00,000/- only.  It is admitted by the opposite party that the complainant is getting the policy from the opposite party continuously since the year 2011. The opposite party has placed on record insurance policy Ex. OP-12 in which sum assured is written as Rs. 1,50,000/- and Rs. 27,500/- is written as bonus. The opposite party has denied the payment of Rs. 77,500/- only on the ground that as per condition 8, if the policy is to be renewed or ported from other Indian Insurance Company for enhanced sum insured, then the waiting period as applicable to a fresh policy will apply to additional sum insured as if a separate policy has been issued for difference. The case of the complainant is that the terms and conditions of the policy have not been supplied to the complainant. On the other hands, the opposite party has not placed on record any document to show that the terms and conditions have been supplied to the complainant and the opposite party has also not pleaded in the written version that what was the mode for supplying the terms and conditions of the policy to the complainant. Ld. counsel for the complainant has also contended that the opposite party has not explained the terms and conditions of the policy in question to the complainant and same are not supplied or explained to her at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, 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 DharmendraGoel 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.UshaYadav& 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.

9        The opposite party has failed to prove that the terms and conditions were ever supplied to the complainant. The opposite party has placed on record one document Ex. OP-5 i.e. terms and conditions of the policy. But the opposite party has miserably failed to prove that terms and conditions were supplied to the complainant. The terms and conditions which are not communicated to the complainant are not binding upon the complainant. 

10      In view of the above discussion, the present complaint is allowed and the opposite party is directed to make the payment of Rs. 77,500/-  . Complainant is also entitled to Rs. 5,000/- (Rs. Five Thousand only) as compensation on account of harassment and mental agony and Rs 3,500/- (Rupees Three Thousand Five Hundred only) as litigation expenses. Opposite Party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.

Announced in Open Commission

06.09.2022