Chandigarh

StateCommission

A/154/2017

R K Luther - Complainant(s)

Versus

Star Health & Allied Insurance Co. Ltd. - Opp.Party(s)

Gaurav Mohunta, Adv.

31 Oct 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

UNION TERRITORY, CHANDIGARH

 

Appeal No.	154 of 2017
Date of Institution	01.06.2017
Date of Decision	31.10.2017

 

R.K.Luther, aged about 79 years, son of Shri Mulakh Raj Luther, resident of House No.24, Sector-6, Panchkula.

                ....Appellant/Complainant

Versus

Star Health & Allied Insurance Co. Limited, 130-131, 4^th Floor, Sector 34-A, Chandigarh.

                              ....Respondent/Opposite Party

Appeal under Section 15 of the Consumer Protection Act, 1986.

BEFORE:   SH. DEV RAJ, PRESIDING MEMBER.

                SMT. PADMA PANDEY, MEMBER.

 

Argued by:  Sh. Gaurav Mohunta, Advocate for the appellant.

                     Sh. Gaurav Bhardwaj, Advocate for Respondent.

                                         

                  

PER PADMA PANDEY, MEMBER

              This appeal is directed against an order dated 17.04.2017, rendered by District Consumer Disputes Redressal Forum-II, UT, Chandigarh (hereinafter to be called as the District Forum only), vide which, it dismissed the complaint, filed by the appellant/complainant.

2.    The facts in brief, are that, the complainant purchased a Senior Citizen Red Carpet Health Insurance Policy No.P/161113/01/2016/003788 dated 18.02.2016 from the Opposite Party, in continuation of policy w.e.f. 08.02.2008, and has been paying premium regularly since then, but policy cover, terms and conditions were not sent to him by the Opposite Party. It was stated that the present policy was valid w.e.f 18.02.2016 to 17.02.2017 for insurance of Rs.7,50,000/-. It was stated that at the time of taking insurance, it was told to the complainant that if he does not claim any amount for 2 years, from the date of issuance of the policy, then all medical expenses after that will be paid by the Opposite Party. It was further stated that the complainant got treatment of Cataract of his both eyes, with the prior understanding with Opposite Party, that he will get full reimbursement for the expenses incurred, on the treatment. The complainant incurred Rs.2,32,800/-, on his treatment. It was further stated that, later on, the Opposite Party only agreed to pay Rs.23,000/- for one eye only.  It was further stated that the Opposite Party was deficient in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed.
3. The Opposite Party in its reply stated that the complainant was well aware that the expenses payable in respect to the cataract surgery are limited to Rs.23,000/- only, in one policy year. It was stated that a chart has been provided on page 2 of the terms and conditions with regard to payable expenses, in respect of various ailments. It was further stated that the complainant got operated his left eye and he was paid Rs.23,000/-, but the complainant then again filed a claim for right eye and the same was declined, because the limit for the cataract had already been exhausted. It was further stated that the complainant is getting the policy since 2008 and every time he was supplied with terms and conditions of the policy. It was further stated that even with the present policy the terms and conditions were supplied as it is categorically mentioned on the policy, that the insurance under this policy is subject to conditions, clauses and exclusion etc. attached. It was further stated that there is no deficiency in service on their part, and the answering Opposite Party had prayed for dismissal of the complaint.
4.          The complainant filed replication, wherein he reiterated all the averments contained in the complaint and repudiated those as contained in the written statement of the Opposite Parties. 
5.    The Parties, led evidence, in support of their case.
6.    After hearing the Counsel for the Complainant and Opposite Party, and, on going through the evidence, and record of the case, District Forum, dismissed the complaint. 
7.        Feeling aggrieved, the instant appeal, has been filed by the appellant/complainant.
8.        We have heard the Counsel for the parties, and, have gone through the evidence, and record of the case, carefully.
9.        After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the parties, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be accepted, for the reasons to be recorded hereinafter.
10.          As is evident, the complainant/appellant purchased a Senior Citizen Red Carpet Health Insurance Policy vide No.P/161113/01/2016/003788 dated 18.02.2016 in continuation of the policy w.e.f. 08.02.2008 and was paying the annual premium of Rs.24,045/- regularly since the date of purchase i.e. 08.02.2008. It is worth mentioning that except the policy cover, no terms and conditions were ever sent to the appellant by the respondent. The present policy was valid from 18.02.2016 to 17.02.2017 and the sum insured was Rs.7,50,000/-. The respondent claimed that the complete policy including terms and conditions were sent to the appellant through courier service named “On Dot” on 21.03.2016, the policy was said to have been handed over to some Ankur who is neither a friend, relative, worker, employee or domestic help of the appellant and the appellant was not knowing the said person. Thus, it is quite apparent that the appellant was neither served with the policy documents and was never aware about the terms and conditions to the effect that there is a cap for treatment of cataract of Rs.23,000/- only and that too for treatment of one eye only in a year, despite the fact that the agent of the company selling the policy had informed the appellant that “if no health insurance claim was taken for 2 years, then full payment for treatment would be reimbursed by the company-respondent”. It is abundantly clear that the policy holder was duped in the hands of the respondent, in as much as that they did not give time to the appellant, to read the policy conditions and made him sign on the dotted lines of the contract/policy. The appellant was advised by the Grewal Eye Institute on 29.07.2016 for the treatment of Cataract by “Robolazr” technique, which is the first to be started in Tri-city and that too only by ‘Grewal Eye Institute’ and the condition of both the eyes of the appellant wanted treatment for removal of cataract. It was not that the appellant preferred to undertake the cataract removal through the said technique, but he was advised by the doctors, to opt for the same and to get his problem removed. The appellant undertook the said treatment with Grewal Eye Institute for removal of cataract of both the eyes, at the cost of Rs.2,32,800/- on the understanding given by the agent of the respondent company, that in the absence of any medical claim for the last 7 years, during which he paid policy premium in the sum of Rs.1.5 lac, the respondent company would compensate the full amount of medical treatment, but the complainant was shocked to know that only Rs.23,000/- was paid towards cataract removal of one eye leaving behind such a big gap which was met by the appellant from his own pocket. The respondent company in all its fairness, should have at least reimbursed another sum of Rs.23,000/- towards the cataract operation of the other eye, which they have miserably failed to do so, which had put the appellant into great difficulty and financial loss. Though, the appellant is entitled to claim the entire amount of expenses incurred by him, it would have been in the fitness of things if the company had reimbursed of Rs.23,000/- towards cataract operation of the second eye, which in all fairness, would meet the ends of justice. The respondent was therefore, deficient in rendering service and indulged into unfair trade practice by duping a 79 years old senior citizen. Accordingly, we are of the considered opinion that the present appeal is liable to be partly allowed and appellant deserves to be compensated for deficiency on the part of respondent.
11.          No other point, was urged, by the Counsel for the parties.
12.         In view of the above discussion, it is held that the order passed by the District Forum, being not based on the correct appreciation of evidence, and law, on the point, suffers from illegality and perversity, warranting the interference of this Commission. The order dated 17.04.2017 passed by the learned District Forum, is set aside.
13.          For the reasons recorded above, the appeal is partly accepted, with no order as to costs. The respondent is directed to pay a sum of Rs.23,000/- and Rs.10,000/- towards compensation.
14.         Certified copies of this order, be sent to the parties, free of charge.
15.          The file be consigned to Record Room, after completion.

Pronounced.

31.10.2017

                                                                                          Sd/-

                                                           [DEV RAJ]

PRESIDING MEMBER

                                                       

 

                                                                         Sd/-

 [PADMA PANDEY]

                                                                      MEMBER

GP

 

 

STATE COMMISSION

(Appeal No.154 of 2017)

(R.K. Luther Vs. Star Health & Allied Insurance Co. Ltd.)

 

Argued by:

Sh. Gaurav Mohunta, Advocate for the appellant.

Sh. Gaurav Bhardwaj, Advocate for Respondent.

 

Dated the 31^st day of October, 2017

 

ORDER

 

              Vide our detailed order of the even date, recorded separately, this appeal filed by the appellant/complainant, has been partly accepted, and the order passed by the District Forum, is set aside.

 

      

              Sd/-                                              Sd/-

(DEV RAJ) PRESIDING MEMBER	(PADMA PANDEY)                     MEMBER

 

Gp