Complainant Sucha Singh has filed the present complaint U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short The Act) for issuance of the necessary directions to the opposite parties to make the payment of Rs.1,80,150/- to him alongwith original documents submitted to him at the time of availing reimbursement. Opposite parties be further directed to pay Rs.50,000/- as compensation for physical harassment and mental agony alongwith litigation expenses to him, in the interest of justice.
2. The case of the complainant in brief is that he and his wife namely Mohinder Kaur had got insured jointly from opposite parties no.2 and 3 vide policy introduced by the opposite party no.1 vide policy no.233106/48/2016/397 and under the policy, both he and his wife had been covered for the total sum of Rs.5,00,000/-. He had even paid premium of Rs.6930/- only in respect of the Insurance policy availed by him as insured vide PNB Oriental Royal Mediclaim Policy Schedule. He has next pleaded that he after availing the aforesaid policy had suffered shoulder pain and consequently had been admitted to Amandeep Hospital on 31.1.2016 and his treatment was given by Dr.Suresh Kaul and Dr.Neelam Kaul and thereafter had been discharged from the hospital on 5.2.2016. He had incurred an amount of Rs.1,80,150/- from 31.1.2016 to 5.2.2016 in Amandeep Hospital, Pathankot and thereafter he had contacted the opposite party no.2 and 3 to reimburse the aforesaid amount to him since he had also been insured for the sum of Rs.5,00,000/-. He had even deposited all the documents in original as required and demanded by the opposite party no.2 and 3 for getting the reimbursement of the amount of Rs.1,80,180/- but the opposite party no.2 and 3 had denied his claim arbitrarily. A legal notice dated 4.7.2016 was served upon the opposite party to admit his claim and to reimburse Rs.1,80,150/- alongwith the original documents submitted by him at the time of availing reimbursement but they have not admitted his claim. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.
3. Upon notice, the opposite party no.1 appeared through its counsel and filed its written version taking the preliminary objections that the complaint is not maintainable. On merits, it was submitted that the claim of the complainant has been repudiated by the opposite parties no.2 and 3 on the ground that the claim does not fall within the preview of the policy terms conditions. The claim was not admissible under Clause 4.2 of the Insurance Policy. Even otherwise the opposite party had been unnecessarily impleaded as opposite party since the dispute lies in between the insurer and the insured. It was just an agent to secure the Insurance policy. In case of violation of the terms and conditions of the Insurance Policy, no claim is maintainable. All other allegations/averments as made out in the complaint and specifically the prayer clause have been vehemently denied and lastly the complaint has been prayed to be dismissed.
4. The opposite parties no.2 and 3 appeared through their counsel and filed their written version taking the preliminary objections that the complaint is not maintainable. On merits, it was submitted that the complainant Sucha Singh had lodged his claim with the insurance company and after receiving the claim of the complainant, the same was referred to M/s.MEDI ASIST INDIA PVT.LTD for settling the claim as per the terms and conditions of the policy and as per the required record/documents, M/s.MEDI ASSIST INDIA PVT.LTD., is the claim settling authority, who settles the Claims under the terms and conditions of policy. On scrutinizing all the documents including medical treatment record, M/s.MEDI ASIST INDIA PVT.LTD observed that the case of the complainant Sucha Singh is the case of CAD HTN, DM i.e. Hypothyroidism/HTN and Type 2 DM and treated accordingly. The policy insured is the first year policy, which does not cover the claim of the insured. Hence, the claim of the complainant is not covered under the terms and condition of the policy and the opposite party has rightly repudiated the claim of the complainant under the terms and conditions of policy. All other allegations/averments as made out in the complaint and specifically the prayer clause have been vehemently denied and lastly the complaint has been prayed to be dismissed.
5. Counsel for the complainant tendered into evidence affidavit of complainant Ex.CI, along with the other documents exhibited as Ex. C2 to Ex C13 including Ex.C9-A and closed the evidence.
6. On the other hand, the opposite party no.1 tendered into evidence affidavit of Rakesh Nand Gupta Sr.Manager Ex.OP1/1 and closed the evidence.
7. Counsel for the opposite parties no.2 and 3 tendered into evidence affidavit of Sh.Karam Singh D.M. Oriental Insurance Co. Ex.OP-2,3/1 alongwith other documents Ex.OP-2,3/2 to Ex.OP-2,3/6 and closed the evidence.
8. We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective contestants. We find that the present dispute has arisen on account of the impugned ‘repudiation’ (Ex.C5) of 08.06.2016 of the insurance-claim (Ex.C4) pertaining to the complainant’s hospitalization-expenses for
Rs. 180,150/- under clause 4.2(xvii) and (xviii) of the PNB-Oriental Royal Medi-calim Policy.
9. The opposite party 2 and 3 insurers here, (hereinafter for short ‘the OP insurers’) have duly admitted the repudiation through their written statement and the accompanying affidavit (Ex.OP1) as having done by the TPA Medi Assist India Pvt. Ltd., under the terms of the applicable policy on the grounds that the ailment in question falls within the ‘two’ year period whereas the hospitalization has been within the first year of the policy. We are not convinced since the instant hospitalization was done for ‘shoulder’ pain and not for CAD/HTN/ II DM etc that were simply mentioned on Discharge Summary (Ex.C6) at the instance of the patient/ attendant etc.
10. We find that the complainant has successfully proved the contents of his present complaint pertaining to purchase of the health policy, absence of any pre-existing ailment, non-intimation & non-receipt of the terms of the related Policy, his subsequent hospitalization, medical treatment expenses incurred and filing of the related claim with its repudiation etc vide evidentiary documents exhibited here as: Ex.C1 to Ex.C13. The OP insurers, in rebuttal, have filed affidavit(s) Ex.OP1/1 & Ex.OP2,3/1 and the related Policy Ex.OP2,3/2 and other diagnosis indications only of the excluded ailments etc but with no treatment done.
11. Further, we find that the OP insurers have not proved the very ‘delivery’ or even communication of the related Policy along with its applicable ‘terms’ etc to the insured complainant that has been vital under the circumstances. Even, its very dispatch (of the Policy etc) has not been attempted to be proved, either. And as such the OP insurers are presently barred from availing any benefit of the ‘undisclosed’ terms of the related contact of insurance and that in turn also proves adoption of ‘unfair trade practice’ to turn down an otherwise a routine claim. To remove all ambiguity, it may be clarified here that an ‘insurance claim’ and for that matter any ‘issue’ can be neither legally ‘favored’ nor legally ‘ousted’ on the basis of mere ‘presumption’ how strong it might appear to be. We further find that the present policy in question was purchased through the services of the OP insures’ agents and thus it had been their duty to clearly disclose and make the insured understand all the applicable ‘terms’ of the Policy but no such agent’s declaration/ deposition has been put forth during the present proceedings. We are further strengthened in our above legal proposition by virtue of the orders (31.03.2011) of the honorable State Commission Punjab in FA # 537 of 2008 titled as Life insurance Corp. vs Priya Sharma.
12. Lastly, the OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial reviews and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. All the facts in issue need be appreciated while awarding sanctity to the current applicable law. The duty of settlement of insurance claims shall not be, in routine, delegated to the TPA (Third Party Insurers) who shall simply provide assistance on technical issues pertaining to the same. The insurance-contract has been between insured and the insurers and the TPA shall not repudiate the same.
13. In the matter pertaining to the present complaint and in the light of the all above, we set aside the OP’s impugned repudiation being arbitrary (contra to laws of natural justice) and amounting to ‘deficiency in service’ etc. Thus, we ORDER the OP insurers to pay the impugned ‘insurance claim’ pertaining to the Policy in question with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of the receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.
14. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (Jagdeep Kaur)
February 09, 2018 Member.
*MK*
