Punjab

Faridkot

CC/19/166

Mukesh Singla - Complainant(s)

Versus

Star Health and Allied Insurance Company LImited - Opp.Party(s)

Amit Kumar Mittal

17 Feb 2020

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C.C. No. :                 166 of 2019

Date of Institution:    08.07.2019

Date of Decision :      17.02.2020

 

 

1. Mukesh Singla aged about 40 years son of Gian Chand Singla.
2. Kamni Singla aged about 39 years wife of Mukesh Singla.

Both residents of House No.3, Balbir Hospital Complex, Opposite Bus Stand, Faridkot, Tehsil and District Faridkot.

...Complainant

Versus

 

Star Health  and Allied Insurance Company Ltd, Registered and Corporate Office 1, New Tank Street, Valluvar Kotam High Road, Nungambakkam, Chennai-600034.

Second Address:

15 Balaji Complex, Whites Lane, First Floor, Royapettah, Chennai-600014.

.....OP

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Param Pal Kaur, Member.

 

Present:  Sh  Amit Mittal, Ld Counsel for complainant,

               Sh Neeraj Maheshwary, Ld Counsel for OP.

 

ORDER

(Ajit Aggarwal, President)

                                      

cc no.-166 of 2019

                                                Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OP seeking directions to make payment of insurance claim of Rs.1,59,849/-and for further directing OPs to pay Rs.2,00,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.55,000/-.

2                                               Briefly stated, the case of the complainant is that complainant purchased a Family Health Optima Insurance Policy from OP. OP issued Policy bearing no. P/700004/01/2020/000219 valid for the period from 8.04.2017 to 7.04.2018, 8.04.2018 to 7.04.2019 and from 8.04.2019 to  7. 04. 2020. Policy in question covered complainant, his wife Kamni Singl and his daughters Sukriti Singla and Kritika Singla. Policy in question was purchased from Faridkot through online process and payment of premiums was paid from the accounts of complainants. At the time of purchase, none of their family member was suffering from any ailment. It is submitted that on 07.04.2019, wife of complainant got health problem and all of sudden due to swear pain, she was got admitted in Dayanand Medical College and Hospital, Ludhiana in late hours and on next day i.e 8.04.2019, on advise of doctor, surgical operation was conducted upon her and complainant spent Rs.1,59,849/-on her treatment. Thereafter, complainant gave due intimation regarding illness of his wife to OP and also lodged claim for reimbursement of expenses incurred by complainant

cc no.-166 of 2019

no.1 on treatment of complainant  no.2, but OP repudiated the same without disclosing any reason. Complainants made several requests to OP to clear their genuine claim, but OP did not pay any heed to hear their genuine requests. Act of OP in repudiating the genuine claim of complainants amounts to deficiency in service and trade mal practice and it has caused harassment and mental agony for which they have prayed for directions to OPs to pay Rs.2,00,000/-as compensation alongwith Rs.55,000/- as cost of litigation besides the main relief of medical insurance claim. Hence, the present complaint.

3                                                        The counsel for complainant was heard with regard to admission of the complaint and vide order dated 10.07.2019, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                                                        On receipt of the notice, OP filed written statement taking preliminary objections that intricate questions of law and facts are involved in present complaint that require voluminous evidence which is not permissible in the summary proceedings of the present complaint. He has not come to the Forum with clean hands and has concealed the material facts from this Forum and thus, he is not entitled for relief sought by him. Complainant has no locus standi to file the present complaint. It is averred that insurance under the policy is subject to terms and conditions, causes, warranties, exclusions etc. However, it is admitted that complainants availed policy in question for

cc no.-166 of 2019

the period from 8.04.2017 to 7.04.2018 and from 8.04.2018 to 7.04.2019 and it is also admitted that complainant raised preauthorization request for cashless treatment of Adenomyosis and expenses for this disease are not payable during first two years of continuous operation of insurance cover. As per waiting clause3 ii.c. of Insurance Policy in question, expenses for all treatments (conservative, interventional, laproscopic and open) related to all Diseases of Cervix, Uterus, Fallopian Tubes, Ovaries (other than due to cancel) uterine bleeding, peliv inflammatory diseases and benign diseases of the breast” shall not be payable during the first two years of continuous operation of insurance cover. Complaint filed by complainant is not maintainable and is liable to be dismissed. however, on merits, Opposite party has denied all the allegations of complainant being wrong and incorrect and reiterated that there is no deficiency in service on their part and prayed for dismissal of complaint with costs. It is reiterated that     claim would be covered only after two years of continuous coverable and before two years, Insurance Company is not liable for any relief sought by complainant. It is reiterated that there is no deficiency in service on the part of OP.  All the other allegations and the allegation with regard to relief sought too are denied being wrong and incorrect and prayer for dismissal of complaint with costs is made.

5                                                      Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his

 

cc no.-166 of 2019

affidavit Ex.C-1 and documents Ex C-2 to C-57 and then, closed his evidence.

6                                                In order to rebut the evidence of the complainant, counsel for OP tendered in evidence affidavit of Rajiv Jain Ex OP-10 and documents Ex OP-1 to Ex OP-9 and closed the same on behalf of OP.

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

8                                                      Ld Counsel for complainant vehementally argued that complainant purchased a Health Insurance Policy, which was valid from 8.04.2017 to 7.04.2018, 8.04.2018 to 7.04.2019 and from 8.04.2019 to 7. 04. 2020 and it covered complainant, his wife and his two daughters and at the time of purchase, none of their family member was suffering from any ailment. Due to swear pain, wife of complainant was got admitted in Dayanand Medical College and Hospital, Ludhiana in late hours and on 8.04.2019, surgical operation was conducted upon her. Amount of Rs.1,59,849/- was spent on her treatment. Thereafter, complainant gave due intimation regarding illness of his wife to OP and also lodged claim with OP for reimbursement of expenses incurred by complainant no.1 on treatment of complainant  no.2, but OP repudiated the same without disclosing any reason. Complainants made

cc no.-166 of 2019

several requests to OP to clear their genuine claim, but all in vain. Act of OP in repudiating the genuine claim of complainants amounts to deficiency in service. To prove his pleadings complainant has placed on record copy of bills that prove that vide bills Ex C-3 to Ex C-57, complainant paid Rs.1,59,849/-to hospital authorities. He has prayed for accepting the present complaint and stressed on documents produced by him.

9                                              To controvert the allegations of complainant, ld counsel for OP argued that there is no deficiency in service on their part and stressed mainly on the point that cashless treatment of Adenomyosis and expenses for this disease are not payable during first two years of continuous operation of insurance cover. As per waiting clause3 ii.c. of Insurance Policy in question, expenses for all treatments (conservative, interventional, laproscopic and open) related to all Diseases of Cervix, Uterus, Fallopian Tubes, Ovaries (other than due to cancel) uterine bleeding, pelvic inflammatory diseases and benign diseases of the breast” shall not be payable during the first two years of continuous operation of insurance cover. Moreover, it is totally denied by OP that complainants have lodged any claim with them. It is reiterated that there is no deficiency in service on their part and prayer for dismissal of complaint.

10                                                      From the careful perusal of the record and after going through the evidence and documents available, it is

cc no.-166 of 2019

observed that case of the complainant is that he purchased mediclaim insurance policy in question from OP and as per policy, being insured he was entitled for cashless treatment for himself and other insured family members. On 07.04.2019, due to swear pain, wife of complainant was got admitted in Dayanand Medical College and Hospital, Ludhiana and on 8.04.2019, operation was conducted upon her and he paid Rs.1,59,849/-for her treatment. Grievance of the complainant is that as per terms and conditions of the policy, complainant was entitled for cashless treatment and all the expenses on account of treatment of wife of complainant were to be borne by the Insurance Company/OP, but despite repeated requests, they have not made reimbursement of this amount, which amounts to deficiency in service. He has prayed for accepting the complaint. In reply, OP stressed mainly on the point that cashless treatment of Adenomyosis and expenses for this disease are not payable during first two years of continuous operation of insurance cover. As per waiting clause3 ii.c. of Insurance Policy in question, expenses for all treatments (conservative, interventional, laproscopic and open) related to all Diseases of Cervix, Uterus, Fallopian Tubes, Ovaries (other than due to cancel) uterine bleeding, pelvic inflammatory diseases and benign diseases of the breast” shall not be payable during the first two years of continuous operation of insurance cover. There is no deficiency in service on their part and prayed for dismissal of complaint.

 

cc no.-166 of 2019

11                                                          There is no dispute regarding insurance of complainant and his family members with OP. Ops have themselves admitted that his wife was insured with them as per Family Medicare Policy. There is no denial that complainant spent Rs.1,59,849/- from his own pocket though he was entitled for cashless treatment. It is also admitted that complainants availed policy in question for the period from 8.04.2017 to 7.04.2018 and from 8.04.2018 to 7.04.2019 and it is also admitted that he raised preauthorization request for cashless treatment of Adenomyosis, but as per OPs, expenses for this disease are not payable during first two years of  policy.  Ld Counsel for complainant argued that the OP cannot repudiate the claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them 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 generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find

cc no.-166 of 2019

ways and means to decline the claims. The 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 the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power. Therefore, repudiation of genuine claim by OP on the ground that disease of complainant no.2 is not covered under insurance cover during the first two years of insurance policy, is inappropriate and it amounts to deficiency in service and trade mal practice on the part of OP. OP cannot deny the amount in dispute to complainant on the ground that her disease was not covered under insurance cover during first two years of policy.

12                                             From the above discussion, we are of considered opinion that Opposite Party has wrongly and illegally

cc no.-166 of 2019

repudiated the claim of complainant on false grounds of terms and conditions, which amounts to deficiency in service on their part. From the documents produced by the complainant it is proved that he spent Rs.1,59,849/-for treatment of his wife from his own pocket which are not paid by OP despite the fact taht wife of complainant was entitled for cashless treatment under policy in question being insured. The OP have failed to place on record any documentary evidence to contradict the pleadings of complainant. Hence, present complaint is hereby accepted and OPs are directed to pay Rs.1,59,849/-to complainant alongwith interest at the rate of 9% from the date of filing the present complaint till final realization. OP is further directed to pay Rs.5,000/- to complainant as consolidated compensation for harassment and mental agony suffered by him and for litigation expenses. Compliance of this order be made within prescribed period of 30 days of receipt of the copy of this order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 17.02.2020

 

(Param Pal Kaur)              (Ajit Aggarwal)

                                       Member                          President