Punjab

Sangrur

CC/492/2021

Nem Kumar - Complainant(s)

Versus

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

Sh. Satnam Saini

05 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                        Complaint No. 492

 Instituted on:   15.04.2021

                                                                        Decided on:     05.10.2023

Nem Kumar son of Sh. Pushap Dant, R/O House No.62, W.No.4B, MK Road, Dhuri, Tehsil Dhuri, District Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             Star Health and Allied Insurance Co. Ltd. through its M.D. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.

2.             Star Health and Allied Insurance Co. Ltd through its Branch Manager, 1^st Floor, Sunami Gate, Above IDBI Bank, Sangrur 148001.

                                                        ..Opposite parties.

 

For the complainant  :       Shri Satnam Saini, Adv. with

                                          Complainant.

For Opp.parties                :       Shri Rohit Jain, Adv.

 

Quorum                                          

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                        Kanwaljeet Singh, Member

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that he obtained one mediclaim insurance policy from  OPs bearing policy number P/211223/01/2020/001758 for the period from 14.3.2020 to 13.3.2021  by paying the requisite premium of Rs.15,287/- and the insured value was to the tune of  Rs.5,00,000/-. The grievance of the complainant is that during the subsistence of the insurance policy, he suddenly fell ill and availed medical treatment from Subhash Nursing Home, Dhuri from 29.8.2020 onwards and incurred expenditure to the tune of Rs.1,70,776/-. Thereafter the complainant submitted mediclaim of Rs.1,70,776/- to the OPs for reimbursement alongwith other required documents as sought for by them. The case of the complainant is that OPs paid only an amount of Rs.1,01,706/- to the complainant on 9.12.2020 and withheld the remaining amount of Rs.69,070/-. Further case of complainant is that he got served the legal notice upon the OPs then the OPs paid more amount of Rs.21,470/- to the complainant on 11.01.2021, but still an amount of Rs.47,600/- is due against the OPs, which has been kept by them without assigning any reason thereof.  The complainant though served second legal notice on 13.01.2021 but nothing was done by the OPs. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the remaining claim amount of Rs.47,600/- alongwith with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by OPs, preliminary objections are taken up on the grounds that the complainant has got no locus standi to file the present complaint, that the complaint is not maintainable and that the complainant has not come to this Commission with clean hands. On merits, it is admitted that the complainant was insured under the policy in question and the policy terms and conditions were provided to the complainant at the time of insurance of the complainant. It is stated further that the complainant submitted the mediclaim bill of Rs.1,70,776/- for reimbursement and an amount of Rs.1,01,706/- was initially paid to the complainant on 9.12.2020 and further an amount of Rs.21,470/- was paid to the complainant on 11.01.2021, but the remaining allegations levelled in the complaint have been denied. The complainant has accepted the total amount of Rs.1,23,176/- in full and final settlement and nothing remains due. It is stated further that the amount of Rs.47,600/- has been deducted on various counts like hospitalization expenses, day care/OPD investigations and treatment charges, oxygen charges etc. The other allegations levelled in the complaint have been denied. Lastly, the Ops have prayed that the complaint be dismissed with special costs.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-61 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OP/1 affidavit alongwith Annexure R-1 to R-18 and closed evidence.

4.             We have gone through the pleadings put in by  the parties along with their supporting documents with their valuable assistance. 

5.             It is an admitted fact between the parties that the complainant was insured with the OPs under the medical insurance policy. The contention of the complainant that during the subsistence of the insurance policy the complainant fell ill and took treatment from Dr. Subhash Jindal of Subhash Nursing Home, Dhuri from 29.8.2020 onwards and spent total  amount of Rs.1,70,776/-, but the OPs paid only an amount of Rs.1,23,176/- to the complainant, whereas the balance amount of Rs.47,600/- was withheld by the OPs, which is said to be illegal on the part of the OPs.  Further to support his contention, the complainant has produced Ex.C-1 copy of insurance policy.  Ex.C-2 is the copy of claim form, Ex.C-3 to Ex.C-8 are copies of legal notice and postal receipts, Ex.C-11 to Ex.C-57 are the copies of various receipts and bills for medicine, clinical tests showing the amount paid by the complainant and a bare perusal of the file clearly reveals that the OPs paid only an amount of Rs.1,23,176/- whereas an amount of Rs.47,600/- was withheld by the OPs.  The complainant has also drawn our attention towards the certificate dated 20.10.2020 Ex.C-56 wherein it has been clearly mentioned that the complainant remained admitted in the hospital i.e. Subhash Nursing Home for 11 days as his oxygen level was not stable.  In the certificate it has also been mentioned how the complainant was treated.  On the other hand, the stand of the OPs is that the deductions in the payment has only been made as per the policy terms and conditions. The OPs in the written reply has submitted that the amount of Rs.47,600/- has been deducted on various counts like hospitalization expenses, day care/OPD investigations and treatment charges, oxygen charges etc. But, we are unable to go with this contention of the learned counsel for the opposite parties as a bare perusal of it clearly reveals that all these expenses are the part of the treatment of the complainant.  The OPs have deducted an amount of Rs.47,600/- out of the total bill of Rs.1,70,776/- without any basis. We may mention that the OPs have miserably failed to prove on record that the terms and conditions of the policy were ever known/explained to the complainant or copy of the same was ever supplied to the complainant. The OPs have produced nothing on record to support this contention of the OPs.  It is settled law that the OPs cannot take benefit of the terms and conditions of the policy in the absence of supply of the same to the insured.  The learned counsel for the complainant has cited Ashok Sharma versus National Insurance Company Limited 2016(2) CLT 143 (NC) wherein it has been held when condition relied upon by the insurance company for repudiation of claim was never brought to the knowledge of the insured, the obligation of good faith applies to both the parties to the contract and it is not only the duty of the insured but also the duty of the insurance company and its agent to disclose all material facts in their knowledge to the insured. The insurance company was not justified in repudiating the insurance claim on the basis of said condition. The Hon’ble National Commission has also relied upon on the judgment of the Hon’ble Supreme Court of India titled as Modern Insulators Ltd versus Oriental Insurance Company Limited 2000(2) SCC 734 (SC).   Similar is the position in the present case and the law laid down above by the Hon’ble Supreme Court is also applicable in the present case. As such, we find that the OPs are liable to pay to the complainant an amount of Rs.47,600/- so deducted from the original claim of the complainant.

6.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

7.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the remaining claim amount of Rs.47,600/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 15.04.2021 till realisation. Further OPs are directed to pay to the complainant an amount of Rs.3500/- as compensation for mental tension, agony and harassment and further an amount of Rs.3500/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

 

8.             The complaint could not be decided within the statutory time period due to heavy pendency of cases.

9.             Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.      

                        Pronounced.

                        October 5, 2023.