Punjab

Faridkot

CC/16/61

Jasvir Singh - Complainant(s)

Versus

Tata AIG General Insurance Company Limited - Opp.Party(s)

Atul Gupta

10 Oct 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      61

Date of Institution:  25.02.2016

Date of Decision :   10.10.2016

 

Jasvir Singh s/o Sh Hemraj, Handloom Street, Surgapuri, Kotkapura, Tehsil Kotkapura, District Faridkot.

...Complainant

Versus

Tata AIG General Insurance Company Limited through Chief/General Manager, A-501, 5^th Floor, Building No. 4, Infinity I.T. Park, Dindoshi, Malad (E) Mumbai-400097.

.....Opposite Party

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

                Sh P Singla, Member.

 

Present: Sh Atul Gupta, Ld Counsel for complainant,

              Sh Neeraj Maheshwary, Ld Counsel for OP,

         

(Ajit Aggarwal, President)

                               Present complaint is filed under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of insurance claim of Rs.55,000/-and for further directing OPs to pay Rs.20,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.10,000/-.

2                                Briefly stated, the case of the complainant is that complainant purchased a Medical Healthcare Policy from OP through online and as per terms and conditions of Policy, the OPs was to pay the amount of Rs.5000/-per day as ‘In-Hospital Indemnity for Sickness’, whenever and wherever the complainant would be sick and admitted as patient in any hospital. It is further submitted that complainant was admitted in hospital on 4.09.2015 and he remained there for 11 days and was discharged on 15.09.2015. After getting discharged from the hospital complainant made many requests to OP to make payment of insurance claim of Rs.55000/-  as they are liable to pay Rs.55,000/- as ‘In Hospital Indemnity for Sickness’. On receipt of documents from complainant, OP sent a letter dated 6.11.2015 to complainant, which was duly replied by complainant vide letter dated 4.12.2015 through e-mail. Complainant made many requests to OP but all in vain. Thereafter, complainant issued legal notice dated 15.12.2015 but that also bore no fruit. All this amounts to deficiency in service and trade mal practice. Complainant has prayed for directions to OP to make payment of insurance claim alongwith compensation and litigation expenses. Hence, the present complaint.

3                           The counsel for complainant was heard with regard to admission of the complaint and vide order dated 3.03.2016, complaint was admitted and notice was ordered to be issued to the opposite party.

4                      OP filed written statement taking preliminary objections that complainant has filed the present complaint only to injure the goodwill and reputation of OP and it is false, frivolous and vexatious. Complicated questions of law and facts are involved in this case, which cannot be decided in summary proceedings and therefore, complaint is not maintainable in this Forum. Complainant has concealed the material fact and documents from this Forum and OPs and he is not entitled for relief sought. Moreover, complainant has not complied with the terms and conditions of the Policy and therefore, he can not take the benefit of his own wrong. However, on merits, OP has denied all the allegations levelled by complainant being wrong and incorrect and asserted that there is no deficiency in service on the part of answering OP. However, it is admitted that complainant purchased the policy in question and asserted that complainant was admitted to Punjab Health System Corporation from 4.09.2015 to 15.09.2015 and was diagnosed with PUO with Enteric Fever  and from the documents on record, it was observed that hospitalization was not required for such a long duration and keeping in view the matter, case of complainant was referred to an independent Medical Expert, who opined that enteric fever report is mildly  positive patient with no complications and does not require admission and moreover, indoor case papers were scanty and no details were available after 8.09.2015 till the date of discharge. There was nothing on record like fever chart, daily notes and therefore, show cause  vide letter dated 6.11.2015 was issued to complainant explaining that hospitalization was not justified, but reply  thereof received from complainant was not satisfactory and thus, claim of complainant can not be proceeded with. Complainant is not entitled to any relief as sought by him and claim decision was communicated to him. Complainant resubmitted his claim for payment, but there were no new facts on record  and then reply was sent to complainant reiterating their earlier stand vide letter dated 8.12.2015. All the other allegations levelled by complainant are denied being wrong and incorrect and it is reiterated that there is no deficiency in service or unfair trade practice on the part of answering OP. The allegations with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-10 and then, closed his evidence.

6                             In order to rebut the evidence of the complainant, OP tendered in evidence affidavit of Mohd. Azhar Wasi as Ex OP-1/A and documents Ex OP-1 to 5, and then, closed the same.

7                                          Ld Counsel for complainant vehementally argued complainant purchased a Medical Healthcare Policy from OP through online and as per terms and conditions of Policy, the OPs was to pay the amount of Rs.5000/-per day as ‘In-Hospital Indemnity for Sickness’, whenever and wherever the complainant would be sick and admitted as patient in any hospital. It is further submitted that complainant was admitted in hospital on 4.09.2015 and he remained there for 11 days and was discharged on 15.09.2015 and after discharge from the hospital, complainant made many requests to OP to make payment of insurance claim of Rs.55000/-  as they are liable to pay the same as ‘In Hospital Indemnity for Sickness’. On receipt of documents from complainant, OP sent a letter dated 6.11.2015 to complainant, which was duly replied by complainant vide letter dated 4.12.2015 through e-mail. Complainant made many requests to OP but all in vain. Complainant also issued legal notice dated 15.12.2015 to OP, but that also bore no fruit. All this amounts to deficiency in service and trade mal practice. Complainant has prayed for accepting the present complaint. Ld counsel for complainant has stressed on documents Ex C-1 to 10.

8                                To controvert the allegations of ld counsel for complainant, ld counsel for OPs asserted that present complaint is filed only to injure the goodwill and reputation of OP and to extract money from them. It is false, frivolous and vexatious. Complicated questions of law and facts are involved in this case, which cannot be decided in summary proceedings and therefore, complaint is not maintainable in this Forum. Complainant has concealed the material fact and documents from this Forum and OP and he is not entitled for relief sought. Moreover, complainant has not complied with the terms and conditions of the Policy and therefore, he cannot take the benefit of his own wrong. OP has denied all the allegations levelled by complainant being wrong and incorrect and asserted that there is no deficiency in service on the part of answering OP.  Ld counsel for OP argued before the Forum that complainant purchased the policy in question and he was admitted to Punjab Health System Corporation from 4.09.2015, he remained there for 11 days and was discharged on 15.09.2015. Complainant was diagnosed with PUO with Enteric Fever and from the documents on record, it was observed that hospitalization was not necessary for such a long duration and keeping in view the matter, case of complainant was referred to an independent Medical Expert, who opined that enteric fever report is mildly positive patient with no complications and does not require admission and moreover, indoor case papers were scanty and no details were available after 8.09.2015 till the date of discharge. It is further argued that there was nothing on record like fever chart, daily notes and therefore, show cause vide letter dated 6.11.2015 was issued to complainant explaining that hospitalization was not justified, but reply thereof received from complainant was not satisfactory and thus, claim of complainant cannot be proceeded with. Complainant is not entitled to any relief as sought by him and claim decision was communicated to him. Complainant resubmitted his claim for payment, but as there were no new facts on record  and then reply was sent to complainant reiterating their earlier stand vide letter dated 8.12.2015.All the other allegations have been denied being wrong and incorrect and prayer for dismissal of complaint is made.       

 9                                  We have heard the ld counsel for complainant as well as OPs and have duly gone through the record available on the file.

10                              The case of the complainant is that he purchased  Medical Healthcare Policy from OP through online and as per terms and conditions of Policy, the OPs was to pay the amount of Rs.5000/-per day as ‘In-Hospital Indemnity for Sickness’, whenever and wherever the complainant would be sick and admitted as patient in any hospital. Complainant was admitted in hospital on 4.09.2015 and he remained there for 11 days and was discharged on 15.09.2015. After getting discharged from the hospital, he made many requests to OP to make payment of insurance claim of Rs.55000/- as they are liable to pay Rs.55,000/- as ‘In Hospital Indemnity for Sickness’, but OP did not make payment of claim, rather issued a letter dated 6.11.2015 to complainant, which was duly replied by complainant vide letter dated 4.12.2015 through e-mail. Complainant made many requests to OP but all in vain. Even legal notice dated 15.12.2015 issued by complainant bore no fruit. All this amounts to deficiency in service and has caused harassment to complainant. In reply OP admitted that complainant purchased the policy in question from OP and he was admitted to Punjab Health System Corporation from 4.09.2015, he remained there for 11 days and was discharged on 15.09.2015. Complainant was diagnosed with PUO with Enteric Fever and from the documents on record, it was observed that hospitalization was not necessary for such a long duration and therefore, case of complainant was referred to an independent Medical Expert, who opined that enteric fever report is mildly positive patient with no complications and does not require admission and moreover, indoor case papers were scanty and no details were available after 8.09.2015 till the date of discharge. It is further argued that there was nothing on record like fever chart, daily notes and therefore, show cause vide letter dated 6.11.2015 was issued to complainant explaining that hospitalization was not justified, but reply thereof received from complainant was not satisfactory and thus, claim of complainant cannot be proceeded with. Complainant is not entitled to any relief as sought by him and claim decision was communicated to him. Complainant resubmitted his claim, but as there were no new facts on record and then reply was sent to complainant reiterating their earlier stand vide letter dated 8.12.2015. All the other allegations have been denied and prayer for dismissal of complaint is made.       

11                        We have thoroughly gone through the file, evidence on record and arguments addressed by the parties. It is admitted case of the parties that complainant purchased Medical Health Care Policy from OPs. It is further admitted that complainant remained hospitalized from 4.09.2015 to 15.09.2015 and submitted his claim for the payment of insurance claim to OPs. In order to prove that complainant remained in hospital for his treatment, he has produced his medical record and discharge summary as Ex C-3, Attending Physician’s Statement ExC-4from which it is proved that complainant remained hospitalized from 4.09.2015 to 15.09.2015. Only plea of Ops is that after receiving the claim from complainant, it was referred to their expert for opinion, who opined that for the treatment             of disease of complainant, it does not require hospitalization and further no detail of treatment is available on the indoor case papers and hospitalization of complainant was not justified. So, his claim was rejected. There is no doubt that attending and treating doctor is the best judge to decide whether the patient requires hospitalization for his treatment or not. The alleged expert who gave opinion only from the documents i.e too who is appointed by the Insurance Company and paid by them cannot decide whether any patient requires hospitalization or not for his treatment. It is general tendency that a person reports in favour of the party, who engages him and paid him. So, we cannot rely upon the opinion of alleged expert appointed by Insurance Company.  It is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. On this point, Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Ors 2008 (3) RCR (Civil) Page 111 has held that it seems that 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.5,000/-for luxury litigation.

12                                    In view of above discussion, we are of considered opinion that Ops have wrongly and illegally repudiated the claim of complainant which amounts to deficiency in service and trade mal practice. Hence, present complaint in hand is hereby allowed with direction to OPs to pay Rs.55,000/- as insurance claim to complainant alongwith interest at the rate of 9 % per anum from 6.11.2015 when they repudiated the claim of complainant till final realization. OPs are further directed to pay Rs.3000/-to complainant as  litigation expenses. Compliance of this order be made within one month of receipt of the copy of the order, failing which complainant shall be entitled to proceed under section 25 and 27 of the Consumer Protection Act. Copy of the order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 10.10.2016                 

  Member                                        President

                                         (P Singla)                          (Ajit Aggarwal)