DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II U.T. CHANDIGARH [Complaint Case No: 361 of 2011] Date of Institution : 11.08.2011 Date of Decision : 09.04.2012 -------------------------------------- Ekjot Singh s/o Sh. Tarlok Singh, H.No.144, Sector 20-A, Chandigarh. ….Complainant. (VERSUS) [1] The E-Meditek Solution Limited, Plot No. 577, Udyog Vihar, Phase-V, Gurgaon 122 016 (Haryana), through authorized signatory Dr. Vasu Pawar. [2] Life Insurance Corporation of India, through Senior Divisional Manager, Jeevan Parkash Building, Sector 17-B, Chandigarh. ---Opposite Parties. BEFORE: SHRI LAKSHMAN SHARMA PRESIDENT MRS. MADHU MUTNEJA MEMBER SHRI JASWINDER SINGH SIDHU MEMBER Argued By: Sh. B.S. Jolly, Advocate for the Complainant. Opposite Party No.1 Ex-parte. Sh. Ravi Kumar, Advocate for the OP No.2. PER JASWINDER SINGH SIDHU, MEMBER [1] Complainant has filed the present complaint against the Opposite Parties on the grounds that the Complainant on being advised by the agents of Opposite Party No.2 purchased a Health Protection Policy on 12.7.2008 on half-yearly premium of Rs.14,250/-. Policy issued to the Complainant bears the number 163804195. At the time of subscribing for the policy, Opposite Party No.1 was declared as Third Party Administrator (TPA) for the settlement of the claim, if any. The Complainant claims to have been paying premium for the last 3 years and the whole family members of the Complainant were covered under the said Health Policy. The surgical benefits of the Complainant alone to a sum of Rs.5,00,000/- were assured. The Complainant received the policy bond, TPA booklet and Health card which are annexed at Annexure C-1 to C-3. [2] The Complainant on 28.4.2011, suffered a severe pain in his Chest and was immediately admitted to INSCOL Hospital, Sector 34, Chandigarh, where the doctor diagnosed a Heart Attack and advised for Angiography. The results of angiography revealed that one of the arteries of the Complainant was blocked and required to be stunted. The Complainant was operated upon by a team of doctors and PTCA + Stunt to RCA was done. The Complainant was discharged from the Hospital on 30.4.2011. Complainant incurred Rs.2,14,470/- on account of his treatment. The copy of the bills raised along with discharge summary is at Annexure C-4 to C-5. [3] The Complainant claims that he immediately lodged the claim with Opposite Party No. 1 for the reimbursement of Rs.2,14,470/- spent by him on his treatment, along with all the requisite documents. The Complainant is aggrieved by the repudiation of the claim which was conveyed to him through letter dated 25.5.2011 on the ground that he was not eligible as the claim does not fall under the purview of the policy conditions and the claim was rejected on account of three reasons namely: - i) Surgery not listed in the allowed surgeries (1-49) ii) Total hospitalization period less than 52 hrs. iii) Surgery not listed in the allowed surgeries (1-49) [4] The Complainant claims to be totally traumatized to receive letter dated 25.5.2011 and further claims that the Opposite Parties never disclosed this so called list of allowed surgeries (1-49) till today and the mention about this list in their letter while rejecting the claim of the Complainant is a deficiency in service on their part. The Complainant further claims that at the time of registering the policy, only policy, health card and TPA booklet were received by him and the list of surgeries mentioned from 1- 49 did not form the part of these documents supplied to him by the Opposite Parties. [5] The Complainant also claimed to have suffered a shock on the disclosure of the fact that the heart surgery is not covered under major surgical benefits as mentioned in the letter dated 25.5.2011. Complainant claims that this act of the Opposite Parties amounts to fleecing in the name of the health policy, as the list which is referred in the letter dated 25.5.2011 is claimed to have been deliberately concealed from the Complainant. The Complainant further made an effort by writing a letter dated 6.6.2011 (Annexure C-6) but no response is forthcoming from the OPs end. [6] The Complainant thus alleging deficiency in service as well as unfair trade practice on the part of the Opposite Parties in rejecting the genuine claim prays for the following relief: - [i] Direction to Opposite Parties to pay the claim amount of Rs.2,14,470/- along with interest @18% p.a. [ii] Damages/ Compensation to the tune of Rs.1,00,000/- on account of mental agony and harassment caused at the instance of the Opposite Parties. [iii] Litigation expenses to the tune of Rs.21,000/-. [7] The complaint of the Complainant is supported by an affidavit. [8] On being properly served, Opposite Party No.1 failed to make an appearance and hence, was proceeded against exparte vide order dated 23.11.2011. [9] The Opposite Party No.2 has contested the claim of the complainant by filing its reply, taking preliminary objections to the effect that the present complaint is not maintainable on the grounds of concealment of material facts which makes the claim of the Complainant untenable. Secondly, the Opposite Party No.2 claims that the Complainant who was supplied with Welcome Kit along with the policy document which contained the terms & conditions and had the option to return the policy, within the “Cooling off Period “of 15 days, from the receipt of the policy. The Complainant not having availed this option has faulted on his own account. [10] On merits, the Opposite Party No. 2 has contested the claim of the Complainant by giving a para-wise reply to all the averments of the present complaint. In reply to para no. 1 the contents are admitted to the extent of the same being the part of their record. Whereas in reply to para no. 2 it is admitted only to the extent that the maximum coverage under the said policy was as per the terms & condition of the policy. The Complainant is claimed to have admittedly received the terms and conditions as the reference made in 2nd page of Annexure OP-1/2 at Pg.12 of the reply. Opposite Party No. 2 further admits the contents of para no. 3 about the factum of the treatment undergone by the Complainant as Planned Angiography with PTCA + Stent to RCA. The same being the matter of record deserves no reply. [11] In reply to para no. 4, Opposite Party No. 2 claims that while processing the claim of the Complainant, which was submitted along with all the required relevant documents of the hospital concerned and the same are annexed as Annexure OP-2/2 (Colly). It is also mentioned that Opposite Party No.1 after thoroughly processing the claim of the Complainant, repudiated it vide their letter dated 25.5.2011 (Annexure OP-2/3). Furthermore, it is mentioned that Opposite Party No.2 also sought opinion from Dr. Gurwinder Singh of Sector 22-A, Chandigarh, through their communication dated 9.6.2011 (Annexure OP-2/4 Colly) and that on receiving the opinion of the doctor who verified that as only one Stent was implanted to the Complainant, and the same was not covered under the Policy as 40% of the coverage is only in the case 02 or more Coronary Arteries are Stented. The copy of the communications dated 6.6.2011 and 9.6.2011 are annexed at Annexure OP-2/4 (colly). In reply to para 5, it is claimed that the Complainant is misleading this Forum by concealing the fact of non-receipt of terms & conditions. It is claimed that in the said terms & conditions of the policy under clause 3 Benefit Limits, it is clearly mentioned under the heading (i) Hospital Cash Benefit Limits that “for every hospitalization, no benefit would be paid for the first 48 hours (two days) of hospitalization, regardless of whether the insured was admitted in a general or special ward or in an intensive care unit”. Furthermore, in reply to Para 6, while mentioning about “Cooling-Off Period” the relevant portion of the policy document is reproduced as under:- 26. Cooling-Off Period:- If the policy holder is not satisfied with the “Terms and Conditions” of the policy, he/ she may return the policy to the Corporation within 15 days from the date of receipt of the policy. The amount to be refunded in case the policy is returned within the cooling-off period shall be determined as under:- xxx xxx xxx xxx Rest of the allegations of the Complainant in para 5 & 6 are denied. The Opposite Party No.2 in reply to contents of para 7 claimed that the same are admitted to be correct and it is denied that the Complainant was not given any response. Contents of para 8 are denied being incorrect. In reply to para 9, it is claimed that the judgment referred does not apply to the present case, as the Complainant himself is guilty of concealment and misleading this Forum. Rest of the contents of the complaint being legal requiring no reply. Finally, the Opposite Party No.2 prays for the dismissal of the present complaint with exemplary costs in its favour. The reply of Opposite Party No. 2 is supported by affidavit of the authorized signatory on its behalf along with annexures as quoted in their reply. [12] Parties led their respective evidences. [13] Having gone through the entire complaint, version of the Opposite Parties, the evidence of the parties and with the able assistance of the ld. Counsel for the parties, we have come to the following conclusions. [14] The Complainant in para 5 of his complaint has claimed that the intimation received by him from Opposite Party No. 1 dated 25.5.2011 which had listed the 3 conditions as the grounds for the rejection of his medical claim were actually never disclosed to him at the time of subscription of the policy. The Complainant claims that he was traumatized on receipt of this letter as at the time of registering the policy only policy, health card and TPA booklet were received by him and there is no mentioned of this so called list of allowed surgeries and even while rejecting the claim of the Complainant, Opposite Party No. 1 did not send the same list along with its letter dated 25.5.2011. In reply to para 5, the Opposite Party No. 2 has categorically stated that the Complainant while raising this objection has mislead this forum because the policy bond itself refers to welcome kit which contains the conditions and privileges/ terms & conditions of the policy sent along with the policy bond. We have gone through the 1st page of the policy bond document wherein its 3rd paragraph it is mentioned that:- “The welcome kit contains your policy bond, conditions and privileges under your health plus policy. The health cards for you and your family members covered under this policy will be sent by you by the TPA (Third Party Administrator). Health card serves as an identity card and will be useful to you at the time of claiming benefits under the policy. The TPA will send you the details of his contact, name and address. This is also available at your servicing branch office.” As per the averments of the complaint in para 2 (Page 2), the Complainant claims to have received these documents from Opposite Party No. 1 and not Opposite Party No.2; whereas, Opposite Party No. 2 in its reply has not denied this fact.The Opposite Party No. 2 is also not categorical in its reply that these documents as claimed by it were supplied by it and not by Opposite Party No. 1. Hence, the conclusion that flows from this aspect is that the Opposite Party No.2 had actually delegated the process of sending these documents, to the complainant, to the Opposite Party No. 1 and as the Opposite Party No. 1 has failed to put up appearance, and contest the claim of the Complainant, the claims made by the Complainant in para 2 and para 5 have gone un-rebutted. Hence, the allegations of the Complainant that the Opposite Parties failed to deliver the terms and conditions of the policy to him at the very onset are proved beyond doubt and as such, the Complainant was denied the benefit of Cooling Off Period as mentioned in para 6 of their reply. [15] It is also noticed that the three conditions mentioned in the repudiation letter dated 25.5.2011 could not be located as the Opposite Parties had failed to bring on record the terms & conditions wherein the condition of 52 hrs. of hospitalization is mentioned nor the list of surgeries numbered 1-49 is also not made available. Hence, we feel that as the Opposite Parties had not only failed to supply these documents to the Complainant at the very first instance, but has also failed to bring on record the same documents while submitting their reply/ version which is supported by an affidavit of their authorized signatory. [16] As the Opposite Party No.2 has not come up with a reliable, cogent and trust worthy evidence to prove that they had supplied the terms & conditions of the policy to the Complainant, while the policy bond was made available to him, as they have failed to bring on record any such proof hence it is established beyond all reasonable doubts that the Complainant was not supplied with the terms and conditions of the policy which were binding on him. At the same time they too denied him the opportunity to exercise his option of Cooling Off Period. As such this particular complaint falls squarely under the observations of the Hon’ble Supreme Court, as mentioned, in the case titled M/S Modern Insulators Ltd Vs The Oriental Insurance Co. Ltd. Hon’ble Apex Court has observed that:- “It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the lads which the parties known. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agents to disclose ill material facts in their knowledge since obligation of good faith applies to both equally. In view of the above settled position of law we are of the opinion that the view expressed by the National Commission is not correct. 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 disclosed to the appellant respondent cannot claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.” [17] Hence, according the above judgment, it is a settled law that non-supply of terms & conditions of the policy, and, thereafter, repudiating the claim of the Complainant on these terms & conditions, is a clear deficiency in service on the part of the Opposite Parties. The present complaint of the Complainant succeeds against the OPs, jointly & severally, and the same is allowed. The Opposite Parties are directed to: - (i) | Reimburse Rs.2,14,470/- the amount paid by the Complainant on his treatment. | | ii) | Pay compensation of Rs.20,000/- for mental harassment and agony to the Complainant; | | iii) | Litigation expenses to the tune of Rs.7,000/-; | |
[18] The above said order shall be complied within 30 days of its receipt by Opposite Parties; thereafter, Opposite Parties shall be liable for an interest @18% per annum on the awarded amount Rs.2,14,470/- + Rs.20,000/-, till it is paid. [19] Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. Announced 09th April, 2012. Sd/- (LAKSHMAN SHARMA) PRESIDENT Sd/- (MADHU MUTNEJA) MEMBER Sd/- (JASWINDER SINGH SIDHU)
| | MRS. MADHU MUTNEJA, MEMBER | HONABLE MR. LAKSHMAN SHARMA, PRESIDENT | MR. JASWINDER SINGH SIDHU, MEMBER | | 
