DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)
Consumer Complaint No. 488 of 2016 Date of institution: 16.08.2016 Date of decision : 26.10.2017
Satish Kumar Vij son of Krishan Lal Vij, resident of Flat No.1312 (G.F.), Shri Guru Teg Bahadur Coop. Housing Complex, Sector 70, SAS Nagar, Mohali (Pb.).
……..Complainant
Versus
The New India Assurance Co. Ltd., SCO 46-47, First Floor, Phase-2, SAS Nagar, Mohali (Pb.) through its Divisional Manager.
………. Opposite Party
Complaint under Sections 12 of
Consumer Protection Act, 1986.
Quorum
Shri Ajit Pal Singh Rajput, President
Mrs. Natasha Chopra, Member
Present: Complainant in person.
Shri J.P. Nahar, counsel for the OP.
ORDER
By Ajit Pal Singh Rajput, President
Complainant Satish Kumar Vij has filed the present complaint against the Opposite Party (hereinafter referred to as the OP) under Section 12 of the Consumer Protection Act. The brief facts of the complaint are as under:
2. The complainant and his wife are insured with the OP since 1997 and the insurance policies are being regularly renewed within prescribed time. There has been no claim against the policies. Against the policy which was valid from 10.01.2014 to 09.01.2015 the sum assured was Rs. Three lakhs each for the complainant and his wife and there was no claim and the cumulative bonus buffer of Rs.27,500/- was granted on this policy. For the policy which was valid from 10.01.2015 to 09.01.2016 the sum assured was Rs.5.00 lakhs and there was no claim against this policy also. The last policy of the complainant and his wife was valid from 10.01.2016 to 09.01.2017 with assured sum of Rs.5.00 lakhs. The complainant suddenly fell ill on 26.04.2016 and he was admitted to Fortis Hospital, Mohali. The hospital charged Rs.3,89,150/- for treatment of the complainant. Out of this sum an amount of Rs.3.00 lakhs only was paid by the TPA and Rs.89,150/- was not paid due to the reason that since the limit for this ailment is exhausted in the main claim (cashless), no further balance is due to be paid for this ailment, hence the claim is non payable. The complainant was insured with the OP in the year 1997 and since then the insurance policies have been regularly renewed without any break. There has been no claim against all these policies except the present one. Terming the act of nonpayment of Rs.89,150/- as deficiency in service on the part of the OP, the complainant has sought direction to the OP to pay him the balance amount of Rs.89,150/- alongwith interest @ 12% from the date of rejection of the claim; Rs.1.00 lakh as compensation for harassment and agony and Rs.10,000/- as litigation charges.
3. The complaint has been contested by the OP by filing written statement in which it has admitted that the Floater Mediclaim policy was valid from 10.01.2016 to 09.01.2017 for Rs.5.00 lakhs which was the renewal of previous policy. The OP has denied that the policy is continuously renewed since 1997 and the hospitalization for two years is not applicable. Since the expenses incurred were within 24 months of the increase of sum insured, the claim in excess of Rs.3.00 lakhs was declined as per Condition No.4 of the policy terms and conditions. The complainant has mistaken that the remaining claim was declined due to pre-existing disease. The claim has been declined under Condition No.4.3.1 and not under condition No.4.1. Justifying the nonpayment of Rs.89,150/- to the complainant, the OP has sought dismissal of the complaint.
4. In order to prove the case, the complainant tendered in evidence his affidavit Ex.CW-1/1 and copies of medi claim policy 2014-15 Ex.C-1; medi claim policy for the year 2016-17 Ex.C-2; reply Ex.C-3; terms and conditions of the policy Ex.C-4; notice Ex.C-5 and reply of notice by the OP Ex.C-6. In rebuttal, the evidence of the OP consists of affidavit of Shri Surinder Pal Sharma, Sr. Divisional Manager Ex.OP-1/1 and copy of insurance policy Ex.OP-1/2.
5. The complainant has submitted that the policy was being renewed by the OP since 1997 and on the day when he was admitted in the hospital, the policy was valid, however, the OP has without any reason did not pay the amount of Rs.89,150/-. He has further submitted that the sum assured under the policy was Rs.5.00 lakhs and besides there was no claim bonus against the previous policy. He has also submitted that the terms and conditions being relied upon by the OP for not paying him Rs.89,150/- were never supplied to him. Thus, the OP has illegally not paid the total amount of the medical expenses of the complainant.
6. On the other hand learned counsel for the OP has argued that the policy was being renewed from the year 2014 and not since 1997. He has further argued that the claim of the complainant was payable only upto Rs.3.00 lakhs as per Condition 4.3.1 of the terms and conditions of the policy, which has been duly paid and the balance amount of Rs.89,150/- is not to be paid by the OP. This amount has to be paid by the complainant. Learned counsel has thus submitted that there is no deficiency in service on the part of the OP.
7. After hearing the complainant and learned counsel for the OP and going through the pleadings, evidence and the written as well as oral submissions of both the sides, we are of the opinion that nonpayment of Rs.89,150/- by the OP is an act of deficiency in service and unfair trade practice on the part of the OP. The complainant has attached with the written arguments copies of policies for the year 2007-08 to 2013-14 in addition to the policies of the subsequent years already produced by the complainant as Ex.C-1 and C-2 which shows that the policy is continuously getting renewed from the OP by the complainant. The contention of the OP that as the expenses incurred were within 24 months of the increase of sum insured, the claim in excess of Rs.3.00 lakhs was declined as per Condition No.4.3.1 of the policy terms and conditions is also not tenable. The Hon’ble Supreme Court in M/s Modern Insulater Ltd. Versus Oriental Insurance Co. Ltd. I (2000) CPJ 1 (SC) has held that the terms and conditions which have not been supplied to the complainant by the OP are not applicable on him. Same view has also been held by the Hon’ble Punjab State Consumer Disputes Redressal Commission, Punjab in First Appeal No. 1583 of 2005, titled as National Insurance Company Ltd. versus Mona Ohri and another. Thus, when the OP has failed to prove that the terms and conditions were duly supplied to the complainant alongwith the policy, the same cannot be applicable to the complainant. Accordingly, the nonpayment of Rs.89,150/- to the complainant by the OP is not justified.
8. Accordingly, in view of our aforesaid discussion and the case law, we direct the OP to pay to the complainant Rs.89,150/- (Rs. Eighty Nine Thousand One Hundred Fifty only) alongwith interest @ 9% per annum w.e.f. 01.06.2016 i.e. the date of rejection of the claim of this amount till the actual date of refund. We also find that complainant is entitled to a lump sum compensation of Rs.25,000/- (Rs. Twenty five thousand only) on account of mental agony, harassment and litigation cost. The present complaint stands allowed.
The OP is further directed to comply with the order of this Forum within 30 days from the date of receipt of this order, failing which the amount of compensation awarded shall carry interest at the rate of 9% per annum from the date of this order till realisation.
The arguments on the complaint were heard and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.
Pronounced
Dated: 26.10.2017
(A.P.S.Rajput) President
(Mrs. Natasha Chopra)
Member
