Punjab

Moga

CC/14/118

Kiran Partap Singh - Complainant(s)

Versus

The New India Assuranace Company Limited - Opp.Party(s)

In person

23 Nov 2016

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                      CC No. 118 of 2014

                                                                                      Instituted on: 22.09.2014

                                                                                      Decided on: 23.11.2016

 

Kiran Partap Singh aged about 54 years son of Bharpur Singh, r/o House No.905, Shanti Nagar, Moga.  

Complainant 

Versus 

1.       The New India Assurance Company Limited, Registered & Head Office, 87 Mahatma Gandhi Road, Mumbai.

 

2.       The New India Assurance Company Limited, G.T. Road, Moga, through its Divisional Manager.

                                               

                                               Opposite Parties

 

 

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

 

 

Quorum:    Sh. Ajit Aggarwal,  President,

                   Smt. Bhupinder Kaur, Member.

 

Present:       Sh. Gurpreet Kaur Malke, Advocate Cl. for complainant.

                   Sh. Jasvinder Singh, Advocate Cl. for opposite parties. 

 

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                The present complaint was filed by the complainant before this Forum, which was decided by this Forum vide order dated 09.12.2014. Feeling aggrieved by order dated 09.12.2014, the complainant filed appeal against the order of this Forum before Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh and Hon'ble State Commission vide its order dated 09.09.2016 set aside the order dated 09.12.2014 passed by this Forum and remanded back the present complaint to this Forum with a direction to decide the present complaint afresh.

2.                Briefly stated, the facts of the case are that the complainant had purchased Health Insurance Policy bearing No.361100341325000000031 from the opposite parties for his entire family by paying the premium, which was valid w.e.f. 18.02.2014 to 17.02.2015. During the subsistence of the policy, the complainant remained hospitalized in the Dhami Eye Care Hospital, Ludhiana on different dates i.e. 26.03.2014, 04.04.2014, 09.05.2014, 14.05.2014, 14.06.2014 and 21.06.2014. He was treated by the concerned doctor. The complainant spent an amount of Rs.66,500/- on his treatment. After discharge from the hospital, the complainant approached the opposite parties and submitted all the requisite documents with opposite parties for the reimbursement of the medi-claim bills under the policy. However, to the dismay and surprise of the complainant, the opposite parties, vide letter dated 23.07.2014 repudiated the claim of the complainant. Due to the negligent act of the opposite parties, the complainant had suffered mental tension, harassment and agony. Hence the present complaint.

3.                Opposite parties filed written reply, through their counsel by taking certain preliminary objections that the present complaint is not maintainable; that the complainant has got no locus standi; that there is no deficiency in service on the part of the opposite parties; that complicated questions of law and facts are involved in the present complaint. Moreover, lengthy examination-in-chief and cross-examination of the parties/witnesses are required in the complaint. So, the complaint is required to be decided by Civil court and this Forum has got no jurisdiction to entertain, try and dispose of the complaint; that the complainant has not come to this Forum with clean hands and he has concealed the material and patent facts from this Forum. Further submitted that the claim of the complainant was promptly attended to and was submitted for processing to Raksha TPA immediately and vide its letter dated 23.07.2014 Raksha TPA has observed and opined that C/O B/L ISC + PPDR/PDR/CME. Intravitreal injection avastin given on different dates and this treatment did not require hospitalization. Moreover, it did not come under day care procedure and this was an OPD based treatment. The tests done come under OPD based Diagnostic Procedures. As per the policy conditions it does not fall under the scope of the policy. Thus, the claim is notn payable. In view of the above, facts and observations, the claim falls out of the scope of the policy, therefore, not payable as per policy terms and conditions. That the complaint of the complainant is false, frivolous, baseless, vague and malicious. On merits, the preliminary objections have been reiterated and all other allegations made in the complaint have been denied and a prayer for dismissal of the complaint has been made. 

4.                In order to prove the case, complainant tendered in evidence his duly sworn affidavit Ex.C-1 and copies of documents Ex.C-2 to Ex.C-75 and closed 
his evidence.

5.                To rebut the evidence of the complainant, the opposite parties tendered affidavit of Sh. R.K. Malhotra, Authorized Signatory Ex.OP1, 2/1 and copies of documents Ex.OP1, 2/2 to Ex. OP1, 2/6 and closed evidence on behalf of opposite parties.

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

7.                Ld. Counsel for complainant argued that the complainant purchased a mediclaim policy from opposite parties securing himself and his family valid from 18.02.2014 to 17.02.2015. During the policy period he remained hospitalized in Dhami Eye Care Hospital, Ludhiana for the treatment of his eyes from 25.03.2014 to 26.03.3014, 03.04.2014 to 04.04.2014, 08.05.2014 to 09.05.2014, 13.05.2014 to 14.05.2014, 13.06.2014 to 14.06.2014, 20.06.2014 to 21.06.2014. The discharge cards are Ex.C-29, C-26, C-21, C-18, C-15, C-12 respectively. During the period of hospitalization he was treated by the concerned doctors. He spent Rs.66,500/- in total for his treatment. After discharge from the hospital he filed claim for reimbursement of his medical expenses alongwith original bills, discharge summaries and other required documents with opposite parties. He fulfilled all the formalities for the payment of his medical claim, but the opposite parties vide letter dated 23.07.2014 wrongly and illegally repudiate his claim on false grounds, copy of policy schedule is Ex.C-3, copy of repudiation letter dated 23.07.2014 is Ex.C-7. Due to this act of opposite parties he suffered huge mental tension and agony and financial loss. All these acts of opposite parties amounts to deficiency in service and trade mal practice on their part.

8.                To controvert the arguments of complainant, ld. Counsel for opposite parties argued that the present complaint is not maintainable; that the complainant has no locus standi to file the present complaint; that there is no deficiency in service on the part of opposite parties. They admitted that complainant alongwith his family members was insured under mediclaim policy issued by them. They further admitted that the complainant lodged the claim for the reimbursement of his medical expenses as alleged by the complainant. He argued that on receiving the claim from the complainant it was promptly attended  and forwarded for processing to Raksha TPA immediately and vide its letter dated 23.07.2014 the Raksha TPA had observed and opined that "C/O B/L ISC + PPDR/PDR+ CME. Intravitreal Injection Avastin Given on 20.06.2014,   13.06.2014,    13.05.2014,    08.05.2014,    03.04.2014,    25.03.2014. This treatment does not required hospitalization. Moreover it does not come under Daycare procedure. This is an OPD based treatment. Secondly the tests done comes under OPD based Diagnostic procedures. As per the policy conditions it does not fall under the scope of the policy. Thus the claim non payable B/L ISC + PPDR/PDR + CME".

          In view of the above facts and observations of Raksha TPA the claim falls out of the scope of the policy and is not payable and as per the policy terms and conditions. So, opposite parties rightly repudiate the claim of the complainant and complainant is not entitled to get any amount, as his mediclaim. There is no deficiency in service on the part of opposite parties. The complaint has filed the false and frivolous complaint against opposite parties only to extract money from them. The present complaint may be dismissed with costs.

9.                We have thoroughly gone through the file, evidence and arguments led by ld. Counsel for both the parties. It is admitted case of the parties that the complainant purchased mediclaim policy from opposite parties and it is further admitted that the complainant remained hospitalized during the policy period for the treatment of his eyes and after discharge from the hospital he lodged the claim for the reimbursement of medical expenses alongwith all other required documents with opposite parties. In order to prove that complainant remained in the hospital for his treatment, he produced his medical record and discharge summaries as Ex.C-12, C-15, C-18, C-21, C-26, C-29 and certificate of treating doctor of Dhami Eye Care Hospital, Ludhiana dated 26.08.2014 as Ex.C-6, whereby he certified that complainant remained admitted in their hospital for the treatment. In order to prove that he spent Rs. 66,500/- for his treatment, he produced summary of bills on file as Ex.C-8 and also produced copies of bills and receipts. From these documents it is proved that the complainant remained hospitalized for the treatment of his eyes and spent Rs.66,500/- for his treatment. The only plea of the opposite parties is that after receiving the claim from the complainant it was referred to Raksha TPA for their opinion and observation, but said TPA repudiated the claim of the complainant on the ground that the treatment taken by the complainant does not require hospitalization and moreover it does not come under daycare procedure and the same is OPD basis treatment and does not require hospitalization. So, the claim of the complainant 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 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.   Further Hon'ble Apex Court in case titled as M/s Modern Insulators Ltd. Vs The Oriental Insurance Company Ltd. - 2000(1) CPR 93 (Supreme Court) 242 held that clauses which are not explained to complainant are not binding upon the Insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims.   Further Hon'ble Punjab and Haryana High Court in case tilted as IFFCO TOKYO General Insurance company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others - 2012 (1) RCR(Civil) 901 held that  Contract Act, 1872 – Insurance Act, 1938 – contract among unequal – Validity – Medicalim Policy – Exclusion clause – Pre existing disease – Exclusion clause is standard form of contracts – When bargaining power of the party is unequal and consumer has no real freedom to contract – Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

10.              In view of above discussion, we are of considered opinion that opposite parties 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 opposite parties to pay Rs.66,500/- as insurance claim to complainant alongwith interest at the rate of 9 % per annum from 23.07.2014 when they repudiated the claim of complainant till final realization. Opposite parties are further directed to pay Rs.3000/-(Three thousand only) as  litigation expenses to the complainant. Compliance of this order be made within one month from the 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 : 23.11.2016

                                                  (Bhupinder Kaur)                    (Ajit Aggarwal)

                                                                Member                                  President