Punjab

Moga

CC/17/24

Shikha Garg - Complainant(s)

Versus

The Branch Manager, United India Insurance Corporation of India - Opp.Party(s)

Sh. Radhe Mohan Garg

23 Aug 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                      CC No. 24 of 2017

                                                                                      Instituted on: 02.03.2017

                                                                                      Decided on: 23.08.2017

 

Smt. Shikha Garg w/o Sh. Brij Mohan Garg r/o H.No.689, St. No.6, Vedant Nagar, Moga.

                                                                                ……… Complainant

 

Versus

1.       The Branch Manager, United India Insurance Company Limited, Kotkapura Road, Baghapurana District Moga, Punjab, PIN- 142038.

 

2.       The Chief Manager, United India Insurance Company Limited, Regd. & Head Office, United India House, P.O. Box no.676, 24 Whites Road, Chennai-600014.

 

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Vinod Bala, Member

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Radhey Mohan Garg, Advocate Cl. for complainant.

                   Sh. Vaneet Jaidka, Advocate Cl. for opposite parties.

 

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against The Branch Manager, United India Insurance Company Limited, Kotkapura Road, Baghapurana, District Moga and others (hereinafter referred to as the opposite parties) directing them to pay monetary compensation of Rs.2,55,965/- alongiwth interest @ 12%  till its realization and Rs.25,000/- as litigation expenses to the complainant and to take punitive and deterrent action against the errant company in order to avoid such like complaints in future.

2.                Briefly stated the facts of the case are that the complainant has purchased 'Family Medicare Policy 2014' bearing policy no.2012042816P100459158 vide cover note no.703527 dated 07.04.2016 on payment of premium Rs.5565/- from opposite party no.2. On dated 17.07.2016 the complainant has been hospitalized at Dayanand Medical Hospital, Ludhiana on the pretext of indigestion, vomiting, fatigue and fever, wherein opposite party no.1 was duly intimated. After the necessary treatment as required according to the advice of concerned Doctor, the complainant was discharged on 23.07.2016. The complainant has filed her mediclaim on dated 7.8.2016 with opposite party no.1 under the able guidance and supervision of agent of opposite party no.2 and surprisingly the same remains unattended despite there being passage of about 4 months from the date of filing of claim, meaning thereby that opposite party nos.1 & 2 being accustomed to exploit, harass and provide deficient service did not file any reply against the claim application which clearly shows careless, casual & negligent act and conduct of opposite party nos.1 & 2. The complainant has forwarded various requests and reminders in person at the local District & Branch Office whereas the same remains unattended citing irrational and extraneous reasons. After exhausting all the possible options at opposite party nos.1 & 2 behest and left with no alternative, the complainant forwarded various e-mails dated 20.10.2016 & 19.11.2016 to the concerned officials of opposite party nos.1 & 2, Ombudsman IRDA and also lodged online complaints with opposite party no.2 & IRDA and finally received reply repudiating the claim. From the bare perusal of the aforesaid reply, it is evident that the complainant's claim has been processes in haste and proceeded irrationally, without application of mind and thus ultra vires to the terms and conditions of the policy. Pertinent to state that opposite party nos.1 & 2 did not even bothered to adduce necessary documents, reports, findings and file nothings which form the basis of claim analysis and subsequent repudiation, hence opposite parties undermined the provisions of Consumer Protection Act and transgressed the Consumer Rights namely 'Right to be informed', Right to be Heard & Right to Redressal'. Such an arbitrary, unreasonable and deliberate practices squarely reveals the contrary and contradictory stand of opposite party nos.1 & 2 whereby they have failed to substantiate the basis on which medical treatment advanced to the complainant is found to be related to the pregnancy whereas from the perusal of discharge summary, diagnosis and treatment chart; no medical expert of common parlance exercising due diligence, directly or undoubtedly opine that such a generic medical complication could only relates to pregnancy. Being infuriated the complainant filed application dated 17.11.2016 under the Right to Information Act, 2005 for requesting the Public Information Officer to supply the information on the basis of which complainant's claim has been repudiated whereas again opposite party nos.1 & 2 made mockery of the complainant's plight by supplying incomplete information and therefore such an act &  conduct of opposite party nos.1 & 2 infringes the complainant's right to take further appropriate legal action against them. No assistance or solution had been extended till date by opposite party nos.1 & 2 to avoid harassment, exploitation and inconvenience to the complainant, who has limited financial resources, which resultantly lead her to prolonged mental agony during pregnancy and therefore has caused various medical complications to her new born baby. A legal notice dated 20.02.2017 has also been sent to opposite parties. Due to the act of opposite parties, the complainant has suffered mental tension agony and harassment. Hence this complaint.

3.                Upon notice, opposite parties appeared through counsel and filed written reply taking certain preliminary objections that the present complaint is not maintainable and is liable to be dismissed, as there is no deficiency in rendering services on the part of opposite parties. On lodging of the claim, the requirements were called for and the claim was referred to Third Party Administrator (TPA) namely M/s Raksha TPA for scrutinizing the medical record submitted by complainant alongwith the claim papers. After going through the medical treatment record it transpired that the hospitalization and the treatment obtained by the complainant/patient is related to pregnancy. As per permanent exclusion clause 4.14 of the policy, treatment related to pregnancy/maternity and its complications falls outside the scope of the policy, hence the claim is not tenable and the same was repudiated. The intimation to this effect was given to the complainant, which has been duly received by her; that the complainant has got no cause of action to file the instant complaint; that the complaint has been filed on the basis of contradictory pleas, which are not tenable; that the present complaint is liable to be dismissed as untenable and exaggerated claim has been put forth by the complainant by fabricating the story, which has no concern, even remotely with the controversy in hand; that the present complaint has been filed intentionally on false and frivolous facts. On merits, it is admitted correct to the extent that the claim was lodged with opposite parties. Further submitted that after the lodging of the claim the requirements were called for and the claim was referred to Third Party Administrator (TPA) for scrutinizing the medical record of the patient. After receipt of the recommendation of the TPA, the claim was repudiated as having fallen under the exclusion clause 4.14 of the policy and intimation to this effect was also given to the complainant. The claim has been repudiated after due application of the mind and as per terms and conditions of the policy. Further submitted that as per medical record, treatment taken by the complainant relates to pregnancy/maternity & its complications. Further submitted that there is no ambiguity under the terms and conditions of the policy. However, it is correct that while interpreting, the terms of policy have to be strictly construed. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with special costs has been made.

4.                In order to prove the case, complainant tendered in evidence her duly sworn affidavit Ex. C-1 alongwith copies of documents Ex.C-2 to Ex.C-6 and closed the evidence. 

5.                On the other hand, opposite parties tendered in evidence affidavit of Sh.Baldev Singh, Divisional Manager, United India Insurance Company Limited Ex.OPs-1 and closed the evidence.

6.                We have heard ld. counsel for the parties and have very carefully gone through record placed on file.

7.                The case of the complainant is that he purchased a family Mediclaim policy from opposite parties valid for 11.04.2016 to 10.04.2017. During the currency of the policy, on 17.07.2016, the complainant has been hospitalized at DMC and Hospital, Ludhiana with the complaint of indigestion, vomiting, fatigue and fever. She duly intimated regarding the same to opposite parties. She discharged on 23.07.2016. The complainant lodged claim with opposite parties on 07.08.2016 alongwith all the required documents, medical bills, discharge summary, bills etc. and fulfilling all the formalities for the processing of her claim. But the opposite parties did not decide her claim within time despite several visits and requests and finally repudiated the claim of the complainant vide letter dated 15.11.2016 on false excuses that the ailment of complainant is relating to pregnancy and as per exclusion clause the claim is not payable, whereas, the ailment of the complainant was not related to pregnancy and opposite parties wrongly and illegally repudiated her claim. On the other hand, ld. counsel for opposite parties admitted that the complainant was covered under mediclaim policy of opposite parties and she was hospitalized from 17.07.2016 to 23.07.2016. He further admitted that the complainant lodged the claim for the reimbursement of expenses born by her for her treatment. On receiving the claim from the complainant, the opposite parties referred the claim to Third Party Administration for scrutinition of medical record submitted by the complainant. After going through the medical treatment record, it transpired that medical hospitalization and treatment related to pregnancy. As per permanent exclusion clause 4.14 of the policy, treatment related to pregnancy/maternity and its complications falls outside the scope of the policy, hence the claim was not tenable and on the recommendation of Third Party Administrator, the claim was repudiated after due application of mind and as per terms and conditions of the policy. The claim of the complainant has rightly been repudiated as per terms and conditions of the policy.

8.                On it, ld. counsel for complainant argued that the ailment of the complainant was not related to pregnancy. She was suffering from indigestion, vomiting, fatigue and fever and for the treatment of same she was hospitalized and this ailment has no concern with pregnancy even in the medical record i.e. discharge summary nowhere the treating doctor mentioned that the problem of complainant is due to pregnancy or relating to pregnancy. In the discharge summary doctors mentioned the reason for admission pain in abdomen and vomiting for 15 days and diagnosis as Hypertension Gravidasum. Meaning thereby for severe vomiting and it is not due to pregnancy. Now, the opposite parties are avoiding their liability to pay the claim of the complainant on the basis of false exclusion clause. Ld. counsel for complainant put reliance on case titled as Avneet G. Singh Vs ICICI Lombard General Insurance Company Limited and others- 2014 (2) CLT 374, whereas Chandigarh State Commission held that Exclusion clause. Pregnancy, infertility and congenital diseases are excluded under the major exclusions of the Insurance policy. Complainant was primarily treated for dengue fever. If during course of treatment for dengue fever, some related treatment with regard to her pregnancy was also given that did not meant that her main disease was excluded under the exclusion clause of her insurance policy. Claim could not be repudiated. Further put reliance on Oriental Insurance Company Ltd., Chandigarh Vs Permanent Lok Adalat, Faridabad and others - 2014 (2) PLR 686, whereas Punjab and Haryana High Court held that Hole in the heart. Claim of claimant was rejected by insurance company on the ground that she had undergone a LSCS (Caesarean operation) which was to her admission in the Fortis Hospital. As per the policy terms under which claim was made that it did not cover any expenditure occurred on a disease traceable to pregnancy, child birth, miscarriage or Caesarean Section or Abortion etc. Hence her case was rejected under clause 4.13 of the Exclusion clauses of the policy. There was no expert evidence led by the Insurance Company that this disease was related to the above said clause. Therefore, a direction was given to make the payment. Impugned order upheld. No interference warranted. Petition liable to be dismissed. He further put reliance on New India Assurance Company Ltd. and Anr. Vs Jagrut Nagrik and anr. - 2008 (2) CPJ 382, whereas Gujrat State Commission, Ahemdabad held that Reptured Ectopic Pregnancy. Complainant had undergone emergency surgery in relation to. Claim repudiated on the basis of exclusion clause. Surgery undergone by complainant neither or pregnancy nor for pregnancy, but for bleeding, shock damaged fallopian tube which incidentally had pregnancy. Exclusion clause does not apply. Thus, repudiation held unjustified. Insurance company is liable. Ld. counsel for complainant further argued that moreover, at the time of issuing policy no terms and conditions were ever explained to the complainant. No copy of said terms and conditions and exclusions clause was ever supplied to the complainant. It is tendency of the insurance companies to sell policies by showing green gesture to the customers and lateron at the time of payment, companies rejected the claims of insurance on the pretext of false terms and conditions and exclusions clauses, which were never explained to customers. 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 premiums and find 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.

9.                From the above discussion, we are of the considered opinion that opposite parties wrongly repudiated the claim of the complainant on false grounds, as from the medical record, it transpires that the complications of the complainant is not due to pregnancy. Hence the present complaint stands allowed and opposite parties are directed to pay Rs.35,400/- i.e. medilcaim of the complainant alongwith interest @ 9% per annum from 15.11.2016 i.e. from the repudiation of the claim till final realization. Further opposite parties are directed to pay Rs.3000/-(Three thousand only) as compensation on account of harassment and mental agony suffered by the complainant and Rs.2000/-(Two thousand only) as litigation expenses to the complainant. Compliance of this order be made within one month from date of receipt of the copy of this order, failing which, the complainant shall be entitled to initiate proceedings against under Section 25 and 27 of the Consumer Protection Act. Copy of order be supplied to the parties free of costs. File be consigned to record room.

Announced in Open Forum

Dated: 23.08.2017

 

                               (Bhupinder Kaur)                   (Vinod Bala)                     (Ajit Aggarwal)

                                     Member                               Member                              President