DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FAZILKA.
Complaint No. RBT/CC/148/2023 - CC/62/2022
Date of Institution: 03.03.2022
Date of Decision: 06.09.2024
Sunita Rani aged 49 years wife of Jagdish Kumar S/o Shivaditta R/o New Abadi, Gali No.15, House No.1160, Abohar, Tehsil Abohar, District Fazilka. 98760-60993.
...Complainant
Versus
- The New India Assurance Company Ltd, Ground Floor, LIC Building, Near Gaushala, Abohar-152116, District Fazilka through its Branch Manager.
- The New India Assurance Company Ltd, Raksha Health Madhya Marg, Sector 26, Chandigarh through its Authorized Signatory. ...... Opposite Parties
Complaint under Section 35 of the Consumer Protection Act, 2019.
Quorum: Sh. Vishal Arora, President.
Sh. Raghbir Singh Sukhija, Member.
Smt. Tajinder Kaur, Member.
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Present: Sh. S.S.Gill, Advocate, Counsel for Complainant.
Sh. Ashwani Dhingra, Advocate, Counsel for opposite parties.
ORDER
(Vishal Arora, President):
Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against opposite parties for seeking directions to the opposite parties to pay Rs.15,559/- to the complainant which was spent by her on treatment besides a sum of Rs.50,000/- as compensation and cost on account of harassment, mental agony to the tune of Rs.11,000/-.
2. Briefly stated, the case of complainant is that her husband Jagdish Kumar paid the premium and got Raksha Health Insurance Policy No. 3607033420190000006 from opposite parties effective for the period 16.03.2021 to 15.03.2022. It has been pleaded that complainant is also covered in this insurance policy being wife. The husband of the complainant suffered from corona virus and the complainant Sunita Rani also suffered from high fever in the month of May 2021 and they got medically treated
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from 11.05.2021 to 27.05.2021 from Dr. L.D.Bhardwaj, 5-K-1, Jawahar Nagar, Sri Gangnagar (Rajasthan). The complainant spent Rs.15,559/- on her treatment as well as tests etc. including medicines and during this period husband of the complainant also gave written intimation on 17.05.2021 to the opposite parties regarding the treatment of himself and complainant. The complainant approached and requested the opposite parties many a times to make the payment of Rs.15,559/- but every time they have been putting off the complainant on one pretext or the other. Husband of complainant also served a legal notice dated 29.07.2021 upon the opposite parties but to no effect and even the opposite parties did not bother to give any reply. Pleading deficiency in service and unfair trade practice, the complainant has prayed for acceptance of the present complaint.
3. The Counsel for complainant was heard with regard to admission of the complaint and vide order dated 29.04.2022, complaint was admitted and notice was ordered to be issued to the opposite parties.
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writing in the form of Insurance Policy and parties of insurance contract are bound by the terms and conditions of the insurance policy. It has been pleaded that in the present case, complainant has claimed reimbursement of medical expenses allegedly incurred by her on medical treatment of her illness during the period from 11.05.2021 to 27.05.2021 from Dr. L.D.Bhardwaj, Sri Ganga Nagar (Rajashthan). Complainant also relied upon O.P.D slips of different other doctors in addition to O.P.D slip of Dr. H.S Mann showing treatment on 09.05.2021 as outdoor patient. The production of mere proof of treatment does not make a claimant entitled to re-imbursement of claim. Only the admissible and genuine claim is to be paid by the insurance company as per terms and conditions of the policy. After scrutiny of claim file, TPA requested the husband of complainant vide query letter dated 24.06.2021 to submit original documents within 15 days as mentioned below to enable the TPA to process the claim:-
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It has been averred that inspite of query letter, first and final reminder issued by TPA, complainant failed to submit requisite documents to TPA. Ultimately, after processing the claim, TPA found that claim was not payable and recommended to repudiate the claim under Clause 5.3(a) of terms of policy for non-compliance of query sought by TPA. So, on the basis of said recommendation of TPA, the Insurance Company has rightly closed the claim as No Claim on 08.11.2021 due to non submission of deficit documents and reply to query under clause 5.3 (a) by the complainant. The said policy Clause No.5.3 ( a ) is reproduced as under:-
Clause 5.3 (a):-
Final claim along with claim form and documents listed below should be submitted to the policy issuing office/TPA not later than 7 days from the date of discharge from the Hospital. The insured may also be required to give the company/TPA such additional information and assistance as the company/TPA may require in dealing with the claim.
(b) Bill receipt and discharge certificate/card from the hospital.
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On merits, the preliminary objections have been reiterated, other allegations of the complaint have been denied and the opposite parties have prayed for dismissal of the present complaint.
5. The complainant along with the present complaint has placed on record affidavit Ex C-1, Copy of Insurance policy Ex C-2, Copies of medical record, bill & receipts Ex C-3 to Ex C-28, intimation dated 14.05.2021 Ex C-29 and legal notice Ex C-30. Per contra, opposite parties along with their written statement have placed on record affidavit of Sh.Sandeep Kumar, Manager of insurance company Ex O.P. 1&2/1, query letter Ex O.P.1&2/2, reminder Ex. O.P-1&2/3 to Ex O.P.1&2/4, Repudiation recommendation Ex O.P.1&2/5, Repudiation letter Ex.O.P.1&2/6, Terms and conditions of policy Ex. O.P.1&2/7 and prescription slip dated 09.05.2021 Ex. O.P.1&2/8.
6. We have heard the learned counsel for the parties and have also carefully gone through the record. The learned counsel for complainant and opposite parties have argued on the same lines as per their respective pleadings.
7. The issuance of Policy no.36070334201900000006 for the period 16.03.2021 to 15.03.2022 issued by New India Assurance
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Company Ltd, opposite party no.1 covering the complainant is admitted by the opposite parties. Incurring of medical expenditure amounting to Rs.15,559/- by complainant in the month of may 2021 stands proved from bills and receipts Ex.C-8 to Ex.C-28. Only ground put forward by opposite parties for repudiating the claim of the complainant in repudiation letter Ex.OP-1&2/6 is non submission of deficit documents after final reminder by Raksha TPA and non payable remarks as below:-
“As per clause 5.3(a), query reply not submitted even after final reminder”.
So, repudiation letter dated 08.11.2021 Ex.OP-1&2/6 reveals that the claim of the complainant has been repudiated due to non submission of deficit documents after issuance of letter dated 24.06.2021 Ex.OP-1&2/2 and reminders Ex.OP-1&2/3 to Ex. OP-1&2/4.
8. Perusal of file reveals that the opposite parties have neither placed on record any opinion/recommendation of doctor of opposite party no.2 T.P.A nor affidavit of the concerned doctor of opposite party no.2 on whose opinion the said documents have been demanded and claim has been repudiated.
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9. Four documents i.e. discharge summary, final bill, break up of bill amount and its receipt have been demanded by the opposite party no.2 Raksha T.P.A for hospitalization of the complainant dated 08.05.2021 vide letter dated 24.06.2021 Ex.OP-1&2/2 and reminders Ex.OP-1&2/3 to Ex. OP-1&2/4 and opposite parties have placed on record O.P.D slip of Dr.H.S Maan dated 09.05.2021 Ex.OP-1&2/8. However, perusal of file reveals that the bill, receipt and discharge similarly from hospital of Dr.H.S. Maan have been wrongly demanded by the TPA/insurance company in the said letter and reminders and there is no requirement of the discharge summary as the complainant has already placed on record certificate of complainant Sunita Rani from Dr.H.S Maan Ex. C-9 for her hospitalization with complete diagnosis and medicine prescription where date of admission and date of discharge have been duly certified as 08.05.2021 at 09:00 AM to 09.05.2021 at 11:00 AM. And receipt of said hospital amounting to Rs.1000/- has also been placed on record by the complainant as Ex.C-11. So, repudiation of claim for want of documents vide letter dated 08.11.2021 Ex.OP-1&2/6 is wrong and is hereby quashed. Remaining bills/receipts of the complainant do not pertain to Dr H.S Maan and various receipt/bills of the remaining amount incurred in the month of 05/2021 (May 2021) are Ex.C-8 to Ex. C-28. So, the complainant has incurred a total amount of
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Rs.15,559/-on her treatment, tests and medicines from Dr.L.D Bharadwaj, Dr.Atul Gupta, Dr.H.S Maan and Dr.B.S Kalra, etc in May 2021 which is not disputed by the opposite parties and the claim of the complainant has been wrongly repudiated by the insurance company as detailed above.
It has been vehemently argued by Ld.counsel for complainant that the complainant and her husband were only supplied the cover note of the policy in question Ex.C-2 and no terms and conditions were supplied at the time of selling the policy by opposite party no.1. The argument put forth by Ld. counsel for the opposite party no.1 to the effect that “The parties of insurance contract are bound by the terms and conditions of the insurance policy which were duly explained to the complainant at the time of proposing policy and same was also served to the complainant along with policy schedule" is of no significance as the opposite party no.1 has failed to produce on record any postal/courier receipt or any other documentary evidence to prove that the terms and conditions of the insurance policy in question including clause 5.3(a) were ever supplied to the complainant. The insurance company merely by placing on record the printout of the terms and conditions cannot get discharged from the onus to prove the delivery of terms and conditions of the policy to the insured
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and the same are not binding on the insured. Even no policy number and date has been mentioned on the print out of terms and conditions placed on record by opposite party no.1 as Ex.OP-1&2/7 and the column of the issuing office has also been left blank.
10. From the aforesaid discussion, it transpires that the genuine claim of the complainant has been wrongly repudiated. It is usual with the insurance companies to show green pastures to the consumers when they are to sell their policies. But however when it comes to the payment for claim, they invent all sort of excuses to deny the claim. Reliance in this connection can be placed on the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) which is fully attracted, wherein it was held that Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only
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interested in earning the premiums and find ways and means to decline claims.
11. Therefore, repudiation of the claim of the complainant in such an event is not justified at all. Accordingly, repudiation letter Ex.OP-1&2/6 is hereby quashed and the complainant is held entitled for a claim of Rs.15,559/- as detailed above along with suitable compensation and interest.
12. As regards interest, reliance can be placed on law laid down by Hon'ble National Commission in case titled as M/s. New Mark Knitwears Vs. Universal Sompo General Insurance Company Ltd. and others, Consumer Case No.2990 of 2017 decided on 25.04.2023.
13. In view of the discussion made above, the present complaint is allowed against opposite party no.1 New India Assurance Company Ltd with compensation of Rs.5000/- on account of mental pain/tension & harassment and Rs.3000/- as litigation expenses. The opposite party no.1 is directed to pay to the complainant a sum of Rs.15,559/- incurred by the complainant along with interest @ 9% per annum from the date of repudiation of claim i.e. 08.11.2021 till actual
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realization within a period of forty five days from the date of receipt of certified copy of this order. If the payment is not made within the stipulated period of 45 days, the awarded amount will carry interest @ 12% per annum. The present complaint qua opposite party no.2 Raksha Health Insurance T.P.A Pvt. Ltd stands dismissed. Copies of order be supplied to the parties free of costs under the rules. File be indexed and consigned to the record room.
ANNOUNCED IN THE OPEN COMMISSION:
6th Day of September, 2024
(Vishal Arora)
President
(Raghbir Singh Sukhija)
Member
(Tajinder Kaur )
Member
