DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/121/2023
Date of Institution: 20.09.2023
Date of Decision: 08.11.2024
Avtar Singh aged about 48 years son of Labh Singh, resident Manna Patti, resident of Bhaini Mehraj, Tehsil and District Barnala.
…Complainant
Versus
1. Star Health & Allied Insurance Company Limited, Branch Office, Sangrur, First Floor, Sunami Gate, above IDBI Bank, Sangrur-148001 through its Branch Manager.
2. Star Health & Allied Insurance Company Limited, Pakka College Road, above Delhi Tractor and Combines, Opp. PNB Bank, Barnala-148101, District Barnala, through its Branch Manager.
3. Star Health & Allied Insurance Company Limited Office, 1 New Tank Street, ValluvarKottam High Road, Nungambakkam, Chennai-600034 through its Managing Director.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. K.S. Sidhu Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health & Allied Insurance Company Limited, Branch Office, Sangrur, First Floor, Sunami Gate, above IDBI Bank, Sangrur-148001 through its Branch Manager & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant has taken policy of opposite parties for himself and for the whole family and opposite parties entered into compromise with complainant to provide medical bill of the complainant and his family and complainant got renewed his policy No. P/211223/01/2023/004630 on 13.3.2023. It is further alleged that the complainant had paid the premium of Rs. 21,264/- on the assurance of the opposite parties that in case of any disease or medical purpose opposite parties will pay the medical bill. It is alleged that on 15.05.2023 complainant got admitted his wife Bhupinder Kaur in Sood Nursing Home & Test Tube Baby Centre, under the supervision of Dr. Rajvansh Sood and Dr. Anuradha Sood for complication vaginal hysterectomy with cystocele repair. It is alleged that Bhupinder Kaur was operated upon and remained under indoor patient till 18.05.2023 and before admission in Sood Nursing Home Bhupinder Kaur was examined by Dr. Preet Parkash Singh Sekhon Radiologist and CT scan was conducted by the doctor. It is further alleged that Bhupinder Kaur got some medical tests from Umeed Diagnostic Lab Sangrur. It is alleged that Dr. Rajvansh of Sood Nursing Home had submitted bill of Rs. 41,222/- for the operation and medical of Bhupinder Kaur and Umeed Multispecialty Hospital had submitted bill of Rs. 2,320/- for the medical test conduct by that institute. It is further alleged that the complainant made claim from the opposite parties and submitted the record along with claim on 30.05.2023 but the opposite parties refused to pay the claim of complainant by denied reasons that claim and document was not admitted within 15 days after discharge and there is no clause in the policy issued by the opposite parties that claim be forwarded within 15 days from discharge. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to disbursed the medical claim approximate Rs. 50,000/- to the complainant alongwith interest @ 12% per annum till realization.
- To pay Rs. 1,50,000/- for compensation on account of physical pain, mental agony and harassment and Rs. 35,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainant has no cause of action to file the present complaint. The complainant has not come with clean hands etc.
4. On merits, it is admitted that the complainant has taken policy of the opposite parties for himself and for his wife and the opposite parties entered in a compromise with compliant to provide medical insurance of the complainant and his family as per terms and conditions of the policy which were sent to the complainant along with policy and the complainant got renewed his policy No. P/211223/01/2023/004630 on 13.03.2023. It is further admitted that the insured availed the Family Health Optima Insurance plan through Branch Office Covering Avtar Singh (Self), Bhupinder Kaur (Spouse) for the sum insured Rs. 10,00,000/- vide policy no. P/211223/01/2023/004630 valid from 15.03.2023 TO 14.03.2024 and the complainant had paid the premium of Rs. 21,264/- on the assurance of the opposite parties that in case of any disease or medical purpose the opposite parties will pay the medical bill, but as per terms and conditions of the policy which were sent to the complainant along with policy. It is alleged that as per the documents submitted by the complainant on 15.05.2023 the complainant got admitted his wife Bhupinder Kaur in Sood Nursing Home & test Tube baby center, under the supervision of Dr. Rjvansh Sood and Dr. Anuradha Sood for complication vaginal hysterectomy with cystocele repair. It is alleged that as per the documents submitted by the complainant Bhupinder Kaur was operated upon and remained under indoor patient till 18.05.2023. It is denied that before admitted in Sood Nursing Home & test Tube baby center, Bhupinder Kaur was examined by Dr. Preet Parkash Singh Sekhon, Radiologist and CT scan was conducted by the doctor and Bhupinder Kaur got some medical tests from Umeed Diagnostic Lab, Sangrur. It is further alleged that as per the documents submitted by the complainant, Dr. Rajvansh of Sood Nursing Home & test Tube baby center had submitted bill of Rs. 41,222/- for the operation and medical of Bhupinder Kaur and Umeed Multispecialty Hospital had submitted bill of Rs. 2,320/- for the medical test conducted by that institute. It is admitted that the complainant maid claim from the opposite parties and submitted record along with claim on 30.05.2023. It is further admitted that the opposite parties refused to honour the claim of the complainant by mentioning reasons that the claim and the documents were not admitted within 15 days after discharge as there is clause in the terms and conditions of the policy issued by the opposite parties that the claim be forwarded within 15 days from discharge. All other allegations are denied and prayed for the dismissal of complaint.
5. The complainant filed rejoinder/replication to the written version of opposite parties and denied the averments as mention in the version.
6. The complainant tendered into evidence affidavit of complainant as Ex.C-1, copy of policy as Ex.C-2, copy of bed head ticket as Ex.C-3, copy of report of city scan as Ex.C-4, copy of medical report as Ex.C-5, copy of bill as Ex.C-6, copy of emails as C-7 & C-8, affidavit of Bhupinder Kaur as Ex.C-9, Certificate U/s 65-B of Indian evidence Act as Ex.C-10, affidavit of Vineet Sharma as Ex.C-11, Pen drive as Ex.C-12 and closed the evidence.
7. The opposite parties tendered into evidence affidavit as Ex.OPs-1, copy of proposal form as Ex.OPs-2 (4 pages), copy of policy as Ex.OPs-3 (4 pages), copy of terms and conditions as Ex.OPs-4 (6 pages), copy of request of cashless as Ex.OPs-5 (4 pages), copy of prescription slip as Ex.OPs-6, copy of ultrasound report as Ex.OPs-7, copies of letters are Ex.OPs-8 to OPs-13, copy of claim form as Ex.OPs-14 (5 pages), copy of discharge summary as Ex.OPs-15 (2 pages), copy of bill as Ex.OPs-16, copy of repudiation letter as Ex.OPs-17, copy of bill assessment sheet as Ex.C-18 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that the complainant has taken policy of the opposite parties for himself and for his wife and the complainant got renewed his policy No. P/211223/01/2023/004630 on 13.03.2023. It is further admitted case of the opposite parties that the insured availed the Family Health Optima Insurance plan through Branch Office Covering Avtar Singh (Self), Bhupinder Kaur (Spouse) for the sum insured Rs. 10,00,000/- vide policy no. P/211223/01/2023/004630 valid from 15.03.2023 TO 14.03.2024 (as Ex.C-2 & Ex.O.P-3) and the complainant had paid the premium of Rs. 21,264/- on the assurance of the opposite parties that in case of any disease or medical purpose the opposite parties will pay the medical bill.
10. Ld. Counsel for the complainant argued that on 15.05.2023 complainant got admitted his wife Bhupinder Kaur in Sood Nursing Home & Test Tube Baby Centre, under the supervision of Dr. Rajvansh Sood and Dr. Anuradha Sood for complication vaginal hysterectomy with cystocele repair. It is further argued that Bhupinder Kaur was operated upon and remained under indoor patient till 18.05.2023 (as per Ex.C-3) and before admission in Sood Nursing Home Bhupinder Kaur was examined by Dr. Preet Parkash Singh Sekhon Radiologist and CT scan was conducted by the doctor. It is further argued that Bhupinder Kaur got some medical tests from Umeed Diagnostic Lab Sangrur. It is argued that Dr. Rajvansh of Sood Nursing Home had submitted bill of Rs. 41,222/- (as per Ex.C-6) for the operation and medical of Bhupinder Kaur and Umeed Multispecialty Hospital had submitted bill of Rs. 2,320/- (as per Ex.C-4) for the medical test conducted by that institute. It is further argued that the complainant made claim from the opposite parties and submitted the record along with claim on 30.05.2023 but the opposite parties refused to pay the claim of complainant by denied reasons that claim and document was not admitted within 15 days after discharge.
11. On the other hand, Ld. Counsel for the opposite parties argued that the opposite parties refused to honour the claim of the complainant by mentioning reasons that the claim and the documents were not admitted within 15 days after discharge as there is clause in the terms and conditions of the policy issued by the opposite parties that the claim be forwarded within 15 days from discharge, as such the claim of the complainant was repudiated vide letter dated 8.8.2023 Ex.O.Ps-17.
12. We have gone through the facts and evidence produced by the parties. We have also gone through the repudiation letter dated 8.8.2023 Ex.C-8 & Ex.O.Ps-17 vide which it is mentioned that;
“It is observed from the submitted medical records that the claim documents have been submitted to us after 15 days of discharge from the hospital”
Ld. Counsel for the complainant has argued that the opposite parties have not supplied the terms and conditions of the policy to the complainant alongwith policy and the copy of insurance policy and the terms and conditions of the policy are not the part of the said insurance policy. The complainant has placed on record the copy of insurance policy Ex.C-2 which is containing 4 pages and the terms and conditions are not the part of insurance policy in question. On the other hand the opposite parties have also placed on record the copy of insurance policy i.e. Ex.O.P-3 and the same is also containing 4 pages and the terms and conditions of the policy are not the part of insurance policy in question. Moreover, the opposite parties have failed to prove the fact that they have supplied the terms and conditions of the policy to the complainant alongwith policy or they have explained the same to the insured when the policy was issued or renewed. Therefore, the terms and conditions on which the opposite parties relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”.
13. So, we are of the view that at this stage the opposite parties (insurance company) cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
14. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite party.
15. The complainant to prove his claim has placed on record copy of Lab receipt Ex.C-5 and Hospital Bill Ex.C-6 from which it shows that an total amount of Rs. 43,742/- has been spent on the treatment of insured. However, the complainant in his complaint has claimed an amount of Rs. 50,000/- on account of medical claim. So, we are of the view that the complainant is entitled to the amount of Rs. 43,742/-.
16. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 43,742/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
8th Day of November, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
