BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 243 of 2014

Date of Institution: 05-05-2014

Date of Decision: 03-09-2015  

1. Ranju Pasricha wife of late Ashok Pasricha
2. Sahil Pasricha son of late Ashok Pasricha, both residents of H.No. 1576, Gali No.7, Street Thakurdwara, Qila Bhangian, Amritsar.
3. Sakshi Arora daughter of late Ashok Pasricha, wife of Anurag, resident of H.No.941/1, Katra Bhaggian, Amritsar.

Complainants

Versus

1. The Oriental Insurance Company Limited, Oriental House, A-25/27, Asaf Ali Road, New Delhi through its Divisional Incharge/ Person Over All Incharge.
2. The Oriental Insurance Company Limited, Divisional Office No.1, Dwarkadish Ji Complex, Queens Road, Amritsar, through its Divisional Manager.
3. E-Meditek (TPA) Services Limited, SCO No. 56, First Floor, Sector 30-C, Chandigarh, through its Officer Incharge/ Person Over All Incharge.   

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act, 1986.

Present: For the Complainant: Sh. Amit Bhatia, Advocate

              For the Opposite Parties No.1 and 2: Subodh Salwan, Advocate

             For the Opposite Party No.3: Exparte.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by the complainants  under the provisions of the Consumer Protection Act alleging therein that Ashok Kumar husband of complainant No.1 and father of complainant No.2 and 3 was purchasing mediclaim insurance policies from the Opposite Parties and was earning bonus on claim free insurance on the said policies and the policy in question is in continuity and without any claim and the detail of the policies is as under:-

1. Policy No. 233300/48/2009/1615 valid from 20.3.2009 to 19.3.2010.
2. Policy No.233300/48/2010/2901 valid from 20.3.2010 to 19.3.2011.
3. Policy No. 233300/48/2011/3645 valid from 20.3.2011 to 19.3.2012.

Ashok Pasricha, insured, husband of complainant No.1 and father of complainants No.2 and 3 expired on 29.8.2013 and after his death, the complainants being the first class legal heirs of deceased Ashok Pasricha, insured, have stepped into his shoes and became ‘consumer’ of the Opposite Parties as defined under the Act. It is important to mention here that only cover note and schedule of the insurance were supplied, but the Opposite Parties  never supplied terms and conditions of the impugned insurance, much less the alleged,  terms and conditions ever formed part of contract between the parties. During the validity period of policy  No.233300/48/2010/2901 valid from 20.3.2010 to 19.3.2011, Ashok Pasricha insured,  suddenly fell followed by left upper & lower limb weakened  a/w vertify and at the time when he reached hospital his GCS as E2 V3 M6 which deteriorated to E1 V2 M3 by that time. Ashok Pasricha, insured was not having any past disease and as per the check up by the concerned doctors, he suddenly suffered from said disease due to hypertension and as such, he was got admitted in an unconsciousness state in EMC Hospital, Shakti Nagar, Amritsar on 14.2.2011 and Ashok Pasricha insured,  was discharged on 20.4.2011 and he continued on certain medicines. He had spent huge amount on his treatment and even in respect thereof the original bills, cash memos and other documents were submitted to the Opposite Parties for payment of claim under  the impugned insurance which was in force at the relevant time. The complainants lodged the claim for reimbursement of medical expenses with Opposite Party No.3-TPA and all the requisite documents and original bills etc. were supplied to the Opposite Party No.3-TPA, but instead of paying the claim, Opposite Party No.3 treated the claim as no claim on the ground that no proper documents have been supplied, while fact remains that all the requisite documents have been supplied to the Opposite Parties, but the Opposite Parties  did not settle the claim on false excuses. Thereafter, Ashok Pasricha insured,  had filed a complaint on 8.5.2012 which was decided by this Forum and direction was given to the Opposite Parties  to decide the claim of Ashok Pasricha insured,  within 2 months from the date of filing of documents by him. The Opposite Parties  have not complied with the said order and in the meantime, unfortunately Ashok Pasricha, insured  expired on 29.8.2013 and as such ultimately, the present complainants being legal heirs of Ashok Pasricha insured,  have filed the execution of the said order and in that execution, the Opposite Parties  have placed on record repudiation letter dated 6.8.2013 thereby repudiating the claim of the complainants on the basis of false, vague and ambiguous plea.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the Opposite Parties  to pay the sum insured amount to the tune of Rs.2 lacs alongwith interest @ 12% per annum to the complainants.   Compensation and litigation expenses were also demanded.

2. On notice, Opposite Parties  No.1 & 2 appeared and filed written version in which it was submitted that the medical record submitted by the complainants has been scrutinized, processed and thereafter, repudiation letter dated 6.8.2013 was rightly issued to the Ashok Pasricha, insured. It is denied that Ashok Pasricha insured, was not having any past disease or he suddenly fell ill. It is  denied that  only cover note or schedule of the insurance was supplied and the terms and conditions of the policy were not supplied to  Ashok Pasricha insured. It is further mentioned that no complaint was ever got lodged by the complainants prior to the filing of the present complaint with Opposite Parties  with respect to the non supply of policy and its terms and conditions, therefore it is unbelievable that policy in question alongwith its  terms and conditions were not supplied to Ashok Pasricha, insured. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Party No.3-TPA was duly served, but none appeared on behalf of Opposite Party No.3-TPA, so Opposite Party No.3-TPA was proceeded against exparte vide order dated 7.7.2014 of this Forum. 
4. Complainants tendered into evidence the documents Ex.C1 to Ex.C19 and closed the evidence on behalf of the complainants.
5. Opposite Parties  No.1 & 2 tendered into evidence affidavit of Sh.Sandeep Thapa, Divisional Manager Ex.OP1,2/1 alongwith documents Ex.OP1,2/2 to Ex.OP1,2/8 and closed the evidence on behalf of the Opposite Parties  No.1 & 2.
6. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
7. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that Ashok Kumar husband of complainant No.1 and father of complainants No.2 and 3 purchased mediclaim insurance policies bearing Policy No. 233300/48/2009/1615 valid from 20.3.2009 to 19.3.2010 Ex.C12 and thereafter Policy No.233300/48/2010/2901 valid from 20.3.2010 to 19.3.2011 Ex.C13 and thereafter Policy No. 233300/48/2011/3645 valid from 20.3.2011 to 19.3.2012 Ex.C14 and thereafter, policy valid for the period from 20.3.2012 to 19.3.2013 Ex.C5 and policy for the period from 20.3.2013 to 19.3.2014. Complainants submitted that during the validity period of policy No.233300/48/2010/2901 valid from 20.3.2010 to 19.3.2011 Ex.C13, Ashok Pasricha, insured  fell ill on 14.2.2011 as a result of which his left upper & lower limb weakened a/w veryify and at the time when he reached hospital his GCS as E2 V3 M6 which deteriorated to E1 V2 M3 by that time. He was admitted in EMC Hospital, Shakti Nagar, Amritsar on 14.2.2011 and was discharged on 20.4.2011 as per record of EMC Hospital, Shakti Nagar, Amritsar Ex.C8 and Ex.10 and Ashok Pasricha, insured  paid a sum of Rs.4,83,130/- to the aforesaid hospital as per bill detail Ex.C10. The claim was lodged with the Opposite Parties  No.1 & 2, but the Opposite Parties  No.1 & 2 repudiated the claim vide letter dated 6.8.2013 Ex.C2 on the ground that as per exclusion clause 4.3 of the terms and conditions of the policy. Insurance Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by the insured in connection with or in respect of during the first year of the operation of the insurance cover, the expenses on treatment of the diseases including hypertension. Ld.counsel for the complainants submitted Ashok Pasricha, insured was not suffering from any disease prior to the taking of the policy. Opposite Parties never supplied terms and conditions of the policy to Ashok Pasricha, insured. As such, terms and conditions of the policy particularly this exclusion clause is not applicable/ binding on the complainants. Opposite Parties  have wrongly repudiated the claim of the complainants regarding the medical treatment of Ashok Pasricha, insured. Ld.counsel for the   complainants  submitted that all this amounts to deficiency of service on the part of the opposite parties.
8. Whereas the case of the Opposite Parties  No.1 & 2 is that on receipt of the claim of the complainants, the Opposite Parties  No.1 & 2 scrutinized the medical record of Ashok Pasricha, insured   and rightly repudiated the claim of the complainant as per exclusion clause 4.3 of the policy Ex.OP1,2/5. As per this clause, the expenses of treatment of hypertension are not payable if contracted and / or manifested during the currency of the policy for the period of 2 years. The Ashok Pasricha, insured   had 2^nd year policy, as  such, this claim is not payable to the complainants. Ld.counsel for the complainants submitted that Opposite Parties  No.1 & 2 have rightly repudiated the claim of the complainants. As such, there is no deficiency of service on the part of the Opposite Parties.     
9. From the entire above discussion, we have come to the conclusion that Ashok Pasricha, insured,   had been continuously getting mediclaim insurance policy from Opposite Parties  No.1 & 2 since 20.3.2009 i.e. bearing Policy No. 233300/48/2009/1615 valid from 20.3.2009 to 19.3.2010 Ex.C12 and thereafter Policy No.233300/48/2010/2901 valid from 20.3.2010 to 19.3.2011 Ex.C13 and thereafter Policy No. 233300/48/2011/3645 valid from 20.3.2011 to 19.3.2012 Ex.C14 and thereafter, policy valid for the period from 20.3.2012 to 19.3.2013 Ex.C5 and policy for the period from 20.3.2013 to 19.3.2014. Said Ashok Pasricha, insured  during the validity period of policy No.233300/48/2010/2901 valid from 20.3.2010 to 19.3.2011 Ex.C13, fell ill on 14.2.2011 as a result of which his Lt.upper & lower lim weaken a/w vertify and at the time when he reached hospital his GCS was E2 V3 M6 which deteriorated to E1 V2 M3 by that time. He was admitted  in an unconscious  state in EMC Hospital, Shakti Nagar, Amritsar on 14.2.2011 where he remained admitted for 65 days and was  discharged on 20.4.2011 and he paid Rs.4,83,130/- to  EMC Hospital, Shakti Nagar, Amritsar as per bill Ex.10. The medical treatment record is Ex.C8. Said Ashok Pasricha insured,  lodged claim with the Opposite Parties  No.1 & 2, but the Opposite Parties  No.1 & 2 did not decide the claim case of Ashok Pasricha insured. Ashok Pasricha insured,   expired on 29.8.2013. copy  of death certificate is Ex.C1. Opposite Parties  No.1 & 2 vide letter dated 6.8.2013 Ex.C2 repudiated the claim of Ashok Pasricha insured,   on the ground that as per exclusion clause 4.3 of the terms and conditions of the policy, expenses of treatment of diseases i.e. hypertension, are not payable during the first year of the operation of the insurance cover. Admittedly, this was the second year of the regular policy being obtained by Ashok Pasricha, insured   because he had taken mediclaim insurance policy in the year 2009 i.e. Policy bearing No. 233300/48/2009/1615 valid from 20.3.2009 to 19.3.2010 Ex.C12 and thereafter Policy No.233300/48/2010/2901 valid from 20.3.2010 to 19.3.2011 Ex.C13 and thereafter Policy No. 233300/48/2011/3645 valid from 20.3.2011 to 19.3.2012 Ex.C14. So, the Opposite Parties  No.1 & 2 have wrongly repudiated the claim of Ashok Pasricha  insured,   only on the ground that the expenses  on his treatment are not payable during the first year of the operation of the insurance cover as per their repudiation letter dated 6.8.2013 Ex.C2. Further,  ld.counsel for the Opposite Parties  No.1 & 2 submitted that as per exclusion clause 4.3 of the terms and conditions of the policy Ex.OP1,2/5, the expenses on the treatment of hypertension are not payable during the first two years of the policy. As per the complainant’s version, they have categorically stated in para No.2 of their complaint that except cover note of the insurance, Ashok Pasricha insured,  was never supplied with any document of terms and conditions of the insurance policy. Opposite Parties  No.1 & 2 have simply denied this averment in their written version in para No.2 on merits. However, Opposite Parties  No.1 & 2 could not produce  any evidence to prove that terms and conditions of the policy were supplied to Ashok Pasricha insured, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insruance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite Parties  No.1 & 2, it is clear that Opposite Parties  No.1 & 2-Insurance Company have failed to prove on record that they did supply the terms and conditions of the policy to Ashok Pasricha insured. As such, these terms and conditions, particularly the exclusion clause 4.3 of the policy is not binding upon the insured Ashok Pasricha. Apart from this, Opposite Parties  No.1 & 2 in their repudiation letter dated 6.8.2013 Ex.C2  have stated that the insurance company is not liable to pay the expenses  on the treatment of disease of hypertension by the insurance company during the first year of the operation of the insurance cover, whereas the Ashok Pasricha, insured   has  second year of operation of the insurance cover given by Opposite Parties  No.1 & 2. Consequently, we hold that the Opposite Parties  No.1 & 2 have wrongly repudiated the claim of the complainants.
10. As per policy Ex.C13, Ashok Pasricha, insured   was insured upto Rs.2 lacs only. However, Ashok Pasricha, insured   has spent Rs.4,83,130/- on his medical treatment as per bill Ex.C10 which he has paid to EMC Hospital, Shakti Nagar, Amritsar, as such, the complainants are only entitled to claim of Rs.2 lacs  only i.e. sum insured.
11. Resultantly, we partly allow the complaint with costs and the Opposite Parties  No.1 & 2 are directed to pay this amount of Rs.2 lacs (Two lacs) to the complainants, who are the legal heirs of Ashok Pasricha, insured (Deceased Life Assured), within one month from the date of receipt of copy of this order, failing which the Opposite Parties  No.1 & 2 shall be liable to pay interest @ 9% per annum on the aforesaid amount of Rs.2 lacs, from the date of filing the complaint till the payment is made to the complainants. Opposite Parties  No.1 & 2 are also directed to pay the litigation expenses to the complainants to the tune of Rs.2,000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 03-09-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member