Punjab

Moga

CC/17/51

Kailash Garg - Complainant(s)

Versus

The New India Inssurance Co. Ltd. - Opp.Party(s)

Sh. Satnam Singh

20 Sep 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                      CC No. 51 of 2017

                                                                                      Instituted on: 18.05.2017

                                                                                      Decided on: 20.09.2017

 

Kailash Garg c/o Madras Jewellers, Street no.6, 4^th Chowk, near Shani Mandir, Abohar, Tehsil Abohar, District Fazilka.

                                                                                ……… Complainant

 

Versus

The New India Insurance Company, Branch Moga, through its Branch Manager, opposite Bhai Petrol Pump, Ludhiana Road, Moga.

 

                                                                           ……….. Opposite Party

 

 

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

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Vinod Bala, Member

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Satnam Singh, Advocate Cl. for complainant.

                   Sh. Ajay Gulati, Advocate Cl. for opposite party.

 

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against The New India Insurance Company, Branch Moga, through its Branch Manager, opposite Bhai Petrol Pump, Ludhiana Road, Moga (hereinafter referred to as the opposite party) directing them to pay amount of Rs.23,020/- out of amount of Rs.46,988/- in first claim and Rs.15,588/- out of total Rs.32,476/- of second claim submitted by the complainant on the basis of Health Insurance Policy no.36110034152800000027 issued by opposite party with interest @ 2% per month on the above mentioned amount from the date of submission of claim till actual realization alongwith costs of this complaint. Further opposite party may be directed to pay Rs.1,00,000/- as compensation which includes refund of above mentioned amount to the complainant or any other appropriate relief which this Forum deems fit and proper be awarded to the complainant.

2.                Briefly stated the facts of the case are that the complainant had purchased Health Insurance policy no.36110034152800000027 from opposite party. Unfortunately the wife of the complainant faced some health problem in the month of October, 2015 and December 2015 and she was hospitalized for the same. To clear the medical bills, the complainant submitted first claim of Rs.46,988/- regarding the treatment of his wife named Aarti and the opposite party has paid only 23,968/- and the balance amount of 23,020/- was not paid to the complainant. The complainant submitted second medical claim of Rs.32,476/- and the opposite paid only Rs.16,918/- and the balance amount of 15,558/- was not paid to him. The above claims of the complainant are absolutely genuine claims and that the complainant has actually spent the above said amount on the treatment of this wife, but the opposite party refused to pay the abovesaid amount to the complainant without any reason by violating the terms and conditions of the policy. Moreover, the opposite party has failed to disclose any sufficient reason that the claim filed by the complainant has been refused. As per provisions of the insurance policy, the complainant is entitled to get the total amount spent by him on medicines and treatment of his wife, but opposite party failed to pay the said amount to complainant, which amounts to deficiency in service on their part. The complainant approached to opposite parties a number of times, but the opposite party putt off the matter on one pretext or the other. The complainant also served a legal notice dated 08.03.2017 upon the opposite party, but all in vain. Due to the acts of opposite party, the complainant has to face mental tension, harassment and agony. Hence this complaint.

3.                Upon notice, opposite parties appeared through counsel and filed written reply taking certain preliminary objections that this Forum has got no territorial jurisdiction to try and entertain the present complaint; that the complaint is not maintainable; that the complainant is estopped to file the present complaint by her own act and conduct. The complainant has already accepted the claim amount without any objection, which were paid strictly in accordance with terms and conditions of insurance policy in question; that no deficient services have been rendered by the opposite party as alleged by the complainant. The claim was immediately entertained, inquired, investigated and after due application of mind, the same was paid to the complainant without any delay whatsoever. On merits, it is correct upto the extent that the complainant has submitted a claim of Rs.46,988/- and an amount of Rs.23,968/- were found to be net payable to the complainant after the reasonable deductions. The complainant is not entitled for the amount of Rs.23,020/- as per the terms and conditions of the insurance policy in question. The reasons of deductions have been mentioned upon a claim audit sheet. It is further correct upto the extent that the complainant had submitted a claim of Rs.32,476/- and an amount of Rs.16,918/- were found to be net payable to the complainant after the reasonable deductions. The complainant is not entitled for the amount of Rs.15,558/- as per terms and conditions of the insurance policy in question. The reasons for deductions have been mentioned upon a claim ordered sheet. On merits, all other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with compensatory cost has been made.

4.                In order to prove the case, complainant tendered in evidence copies of documents Ex.C-1 to Ex.C-7 and his duly sworn affidavit as Ex. C-8 and closed the evidence. 

5.                On the other hand, opposite parties tendered in evidence affidavit of Sh. Pankaj Dua, Deputy Manager Ex.OP-1 and copies of documents Ex.OP-2 to Ex.OP-4 and closed the evidence.

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

7.                The case of the complainant is that he purchased a health insurance policy from opposite party covering himself and his family members including his wife. During the policy period, wife of the complainant faced some health problems and she was hospitalized for the first time in October, 2015 and secondly in December, 2015. The complainant lodged claim for the reimbursement of medical bills with opposite parties to the tune of Rs.46,988/- and Rs.32,476/- respectively for the treatment taken in October and December, 2015. But out of these claims opposite party paid Rs.23,968/- out of first claim and Rs.16,918/- out of second claim and did not pay the balance amount of Rs.23,020/- and Rs.15,558/- respectively. Both the claims of the complainant were genuine and the complainant actually spent that amount for the treatment of his wife, but the opposite party refused to pay this amount to complainant without any reason against the terms and conditions of the policy. The complainant requested the opposite party to pay this amount to him, but they refused to pay this amount, which amounts to deficiency in service and trade mal practice on their part.

8.                On the other hand, ld. counsel for opposite party admitted that the complainant alongwith his family insured with them. They further admitted that the complainant lodged the claim with them for Rs.46,988/- and Rs.32,476/- for the reimbursement of medical bills of his wife. He argued that on receipt of both the claims of the complainant, the same were immediately entertained, enquired and investigated and after due application of mind the same was paid to the complainant without any delay as per terms and conditions of the policy. He argued that out of the claim of Rs.46,988/- an amount of Rs.23,968/- was found to be payable after reasonable deduction as per terms and conditions of the policy and the complainant is not entitled for the balance amount i.e. Rs.23,020/-. Further out of second claim of Rs.32,476/- an amount of Rs.16,918/- was found payable after reasonable deduction and complainant is not entitled for the balance amount i.e. Rs.15,558/-. These deductions are mentioned on the claim audit sheets and these deductions are rightly made as per terms and conditions of the policy. The complainant cannot claim balance amount.

9.                On it, ld. counsel for complainant argued that the opposite party cannot deduct this amount on the ground of alleged terms and conditions, which were never supplied and explained to the complainant at the time of purchase of insurance policy. Moreover, from the claim audit sheets produced by the opposite party as Ex.OP-2 and Ex.OP-3, the opposite party assessed the claim on the basis of capping assessed as sum assured of Rs.3,75,000/-, whereas under the policy in question, the sum assured is Rs.8 lacs, which is also clear from the policy schedule Ex.OP-4. Admittedly the sum assured is Rs.8 lacs, then how the opposite party can assess the claim on the basis of sum assured of Rs.3,75,000/-. All these acts of opposite party, amounts to deficiency in service and trade mal practice on their part. On it, ld. counsel for complainant placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court 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. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court 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. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim 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 and case law produced by the complainant, we are of considered opinion that opposite party has wrongly and illegally deducted this amount. Hence the present complaint is hereby allowed with a direction to opposite party to pay the balance amount i.e. Rs.23,020/- out of first claim and Rs.15,558/- out of second claim of the complainant with interest @ 9% per annum from 18.05.2017 i.e. from the filing of this complaint till realization. Further opposite party is directed to pay Rs.3000/-(Three thousand only) as compensation on account of mental tension, harassment and agony suffered by the complainant and Rs.2000/-(Two thousand only) as litigation expenses to the complainant. Compliance of the order be made within 30 days of receipt of the copy of this order, failing which, the complainant shall be entitled to initiate proceedings under section 25 & 27 of the Consumer Protection Act. Copy of the order be supplied to the parties, free of costs. File be consigned to record room.

Announced in Open Forum.

Dated: 20.09.2017.

 

                              (Bhupinder Kaur)                   (Vinod Bala)        (Ajit Aggarwal)

                                     Member                              Member                 President