DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/74/2023
Date of Institution: 23.06.2023
Date of Decision: 23.08.2024
Charanjit Kumar Mittal son of Sh. Hans Raj Mittal, H.No. B-XI-830, K.C. Road, Street No. 6, Barnala, Tehsil Barnala District Barnala, Punjab-148101.
…Complainant
Versus
1. The Oriental Insurance Company Ltd., Nabha Gate Opp. Aggarwal Book Depot, Sangrur through its Branch Manager.
2. The Manager, Regd. & Head Office M/s Medi Assist Insu, A-25/27, Asif Ali Road, New Delhi-110002.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Jashan Modi Adv counsel for complainant.
Sh. Varinder Kumar Goyal Adv counsel for opposite party No. 1.
Opposite party No. 2 exparte.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against The Oriental Insurance Company Ltd., Nabha Gate Opp. Aggarwal Book Depot, Sangrur through its Branch Manager & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant purchased Oriental Insurance Bank Saathi Policy (cashless Medical Insurance) for the period from 6.11.2022 to 5.11.2023 for sum insured of Rs. 10,00,000/- and the opposite party No. 1 issued policy No. 233599/48/2023/282 after accepting the premium and as per the condition of the policy the complainant is entitled to be reimbursed pre, post and expenses incurred in the hospital for treatment. It is further alleged that in the month of May 2023 complainant felt pain in the lower part of abdomen and the complainant approached doctors of Dayanand Medical College & Hospital, Ludhiana for the treatment where the doctors diagnosed left uncomplicated incomplete indirect inguinal Hernia and advised complainant to get admitted in the Hospital for further management. It is further alleged that on the advice of said doctors complainant informed the opposite party No. 1 office well in time and got admitted in the said Hospital on 16.05.2023 vide admission No.2023034584 for the surgery and complainant was discharged on 20.05.2023 and raised a bill of Rs.1,11,250/-. The complainant approached the opposite party No.1 and asked for payment to the hospital, being cashless policy and the opposite party No.1 assured complainant for the deposit of bill amount. It is alleged that the hospital authorities told complainant that the insurance company has deposited only Rs. 50,000/- and further asked for remaining amount to get discharged otherwise complainant will not be discharged. The complainant approached the opposite party No.1 for the deposit of the remaining amount but they asked complainant to deposit the amount on his own and the opposite party No.1 will refund the same to complainant. It is further alleged that on trusting the opposite party No.1 and under compelled circumstances complainant deposited remaining amount of Rs. 61,250/- on his own. It is further alleged that that the complainant incurred the expenses of Rs. 2380/- on his pre treatment, Rs.1800/- of travelling from Barnala to Ludhiana by car bearing Regd. No. PB-19P-2448, Rs.1800/- of travelling from Ludhiana to Barnala by car bearing Regd. No. PB-19P-2448. Thereafter on 29.05.2023 the complainant approached Dr. Ashwind Bawa at his clinic for treatment of pain in at the operation place and on this visit the complainant incurred expenses of Rs. 2636/- which include Rs.1800/- for car and Rs.836/- on medicines. Thereafter complainant approached the opposite party No.1 for the remaining amount of Rs.69,866/- i.e. Rs.61,250/- deposited with D.M.C. Ludhiana at the time of discharge, Rs.2380/- for pre treatment, Rs.1800/- car expenses on 16.05.2023, the date of admission, Rs.1800/- on 20.05.2023 on the date of discharge and Rs.836/- i.e. post paid medicines + Rs.1800/- car expenses on 29-05-2023 but all in vain. The complainant on 24.05.2023 served a Regd. Legal notice on the opposite parties but they did not reply to same. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to a sum of Rs. 69,866/- alongwith interest @ 18% per annum from the date of deposit till realization.
- To pay an amount of Rs. 1,00,000/- as compensation for causing physical pain and harassment to the complainant and Rs. 11,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version by taking preliminary legal objections on the grounds that as per the policy schedule 2.17 DISEASE /PROCEDURE WISE CAPPING of Oriental Insurance Bank Saathi Policy-Group, the opposite parties have already paid an amount of Rs. 50,000/- to the complainant. So that the complainant is not entitled to get any claim from the opposite parties. The complainant filed this complaint with malafide intention. This Commission has no jurisdiction to try, entertain and decide the present complaint. The complainant has not come to the commission with clean hands etc.
4. On merits, it is admitted to the extent that the complainant purchased Oriental Insurance Bank Saathi Policy (cashless Medical Insurance) for the period from 06.11.2022 to 05.11.2023 for sum insured of Rs. 10,00,000/- the opposite party No. 1 issued policy No. 233599/48/2023/282. It is denied that as per the condition of the said policy the complainant is entitled to be reimbursed pre, post and expenses incurred in the hospital for treatment. It is denied that in the month of May 2023 complainant felt pain in the lower part of abdomen and he approached doctors of Dayanand Medical College & Hospital, Ludhiana for the treatment. It is also denied that the doctors diagnosed left uncomplicated incomplete indirect inguinal Hernia and advised complainant to get admitted in the Hospital for further management. It is denied that on the advice of said doctors complainant informed the opposite party No. 1 office well in time and got admitted in the said Hospital on 16.05.2023 vide admission No. 2023034584 for the surgery. It is denied that complainant was discharged on 20.05.2023 and raised a bill of Rs. 1,11,250/-. It is denied that complainant approached the opposite party No. 1 and asked for payment to the hospital, being cashless policy. It is denied that the hospital authorities told complainant that the insurance company has deposited only Rs. 50,000/- and further asked for otherwise remaining amount get discharged complainant will not be discharged. It is denied that on trusting the opposite party No. 1 and under compelled circumstances complainant deposited remaining amount of Rs. 61,250/- on his own. It is denied that thereafter complainant approached the opposite party No. 1 for the remaining amount of Rs. 69,866/- i.e. Rs. 61250/- deposited with D.M.C. Ludhiana at the time of discharge Rs. 2380/- for pre treatment, Rs. 1800/- car expenses on 16.05.2023, the date of admission, Rs. 1800/- on 20.05.2023 on the date of discharge and Rs. 836/- i.e. post paid medicines + Rs. 1800/- car expenses on 29.05.2023. It is further alleged that TPA cashless claim reference Number (32828143) Medi Assist recommended the claim of Rs. 50,000/- as per policy terms claim bearing No. 32828143 has been paid to the complainant. It is further alleged that the terms of policy schedule 2.17 DISEASE/PROCEDURE WISE CAPPING of Oriental Insurance Bank Saathi Policy- Group, the opposite parties have already paid an amount of Rs. 50,000/- to the complainant. So that the complainant is not entitled to get any claim from them. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. The opposite party No. 2 was proceeded against exparte vide order dated 18.8.2023 due to non appearance.
6. Ld. Counsel for complainant has suffered the statement that I do not want to file any rejoinder in the present case.
7. The complainant tendered into evidence affidavit of complainant Ex.C-1, copy of insurance policy Ex.C-2, copy of discharge summary Ex.C-3, copy of bill dated 20.5.2023 Ex.C-4, copy of claim form Ex.C-5, copies of bills Ex.C-6 to Ex.C-11, copy of legal notice Ex.C-12, copies of postal receipts Ex.C-13 and Ex.C-14, copies of receipts Ex.C-15 to Ex.C-17, copy of prescription slip Ex.C-18, copies of bills Ex.C-19 to Ex.C-21 and closed the evidence.
8. The opposite party No. 1 tendered into evidence affidavit of Neelam Rani Ex.O.P1/1, policy Ex.O.P1/2 (3 pages), copy of policy terms and conditions Ex.O.P1/3 (30 pages) and closed the evidence.
9. We have heard the learned counsel for the parties and have gone through the record on the file.
10. It is admitted case of the opposite party No. 1 that the complainant purchased Oriental Insurance Bank Saathi Policy (cashless Medical Insurance) for the period from 06.11.2022 to 05.11.2023 for sum insured of Rs. 10,00,000/- the opposite party No. 1 issued policy No. 233599/48/2023/282 (as per Ex.C-2 & Ex.O.P1/2). It is also not disputed that the opposite parties have already paid an amount of Rs. 50,000/- to the complainant.
11. Ld. Counsel for the complainant argued that in the month of May 2023 complainant felt pain in the lower part of abdomen and the complainant approached doctors of Dayanand Medical College & Hospital, Ludhiana for the treatment where the doctors diagnosed left uncomplicated incomplete indirect inguinal Hernia and advised complainant to get admitted in the Hospital for further management. It is further argued that on the advice of said doctors complainant informed the opposite party No. 1 office well in time and got admitted in the said Hospital on 16.05.2023 vide admission No.2023034584 for the surgery and complainant was discharged on 20.05.2023 (as per Ex.C-3) and the hospital raised a bill of Rs.1,11,250/-. It is further argued that the complainant approached the opposite party No.1 and asked for payment to the hospital and the insurance company has deposited only Rs. 50,000/-. It is further argued that the complainant approached the opposite party No.1 for the deposit of the remaining amount but they asked complainant to deposit the amount on his own and the opposite party No.1 will refund the same to complainant and under compelled circumstances complainant deposited remaining amount of Rs. 61,250/- on his own. It is further argued that that the complainant incurred the expenses of Rs. 2,380/- on his pre treatment, Rs.1,800/- of travelling from Barnala to Ludhiana by car bearing Regd. No. PB-19P-2448, Rs. 1800/- of travelling from Ludhiana to Barnala by car bearing Regd. No. PB-19P-2448. It is further argued that on 29.05.2023 the complainant approached Dr. Ashwind Bawa at his clinic for treatment of pain in at the operation place and on this visit the complainant incurred expenses of Rs. 2636/- which include Rs.1800/- for car and Rs. 836/- on medicines and the complainant approached the opposite party No.1 for the remaining total amount of Rs. 69,866/- but till date the opposite party No. 1 has not paid the same.
12. On the other hand, Ld. Counsel for opposite party No. 1 argued that the TPA cashless claim reference Number (32828143) Medi Assist recommended the claim of Rs. 50,000/- as per policy terms claim bearing No. 32828143 has been paid to the complainant. It is further argued that the terms of policy schedule 2.17 DISEASE/PROCEDURE WISE CAPPING of Oriental Insurance Bank Saathi Policy- Group, the opposite parties have already paid an amount of Rs. 50,000/- to the complainant, so that the complainant is not entitled to get any claim from them.
13. Ld. Counsel for the complainant further argued that the terms and conditions of the policy were not supplied to the complainant alongwith policy. On the other hand, the opposite party No. 1 (insurance company) has failed to place on record any cogent evidence to prove that they have supplied the terms and conditions to the complainant alongwith policy. We have carefully gone through the insurance policy Ex.C-2 from which it established that the policy sent by the opposite party No. 1 (insurance company) is containing 3 pages and the terms and conditions of the policy are not the part of the said insurance policy. Moreover, the opposite party No. 1 (insurance company) has placed on record the copy of insurance policy Ex.O.P1/2 is also containing 3 pages and the terms and conditions of the policy are not the part of the said insurance policy. Therefore, the terms and conditions on which the opposite parties relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
14. Therefore, we are of the view that at this stage the insurance company cannot be escaped from its liabilities by raising these types of unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties. So, from the above discussion, it is proved that the complainant is entitled for the whole bill/claim amount i.e. Rs. 1,11,250/- (as per Ex.C-4) and out of which the insurance company has already paid an amount of Rs. 50,000/- to the complainant. Therefore, the complainant is entitled for the remaining amounts of Rs. 61,250/- which was deducted by the opposite parties vide Cashless Authorization Letter Ex.C-5. However, the complainant has claimed an another amount of Rs. 8,616/- on account of other expenses incurred by the complainant during treatment, but the complainant has failed to place on record any bill of the above said expenses.
15. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay the remaining amount of Rs. 61,250/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
23rd Day of August, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
