Punjab

Faridkot

CC/17/234

Pawan kumar - Complainant(s)

Versus

The Oriental Insurance Co. Ltd. - Opp.Party(s)

Jatinder Bansal

19 Dec 2018

ORDER

      DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      234

Date of Institution:  21.07.2017

Date of Decision :   19.12.2018

 

Pawan Kumar Bansal s/o Sh Piare Lal Bansal, r/o Bansal Street,  Kotkapura, Tehsil Kotkapura, District Faridkot.

...Complainant

Versus

1. The Oriental Insurance Company Ltd, Regd & Head Office at A-25/27, Asaf Ali road, New Delhi-110 002 through its authorized signatory/ Managing Director.
2. The Oriental Insurance Company Ltd, Branch Office, Near Old Grain Market, Kotkapura, Tehsil Kotkapura, District Faridkot through its Branch Manager.
3. M/s Park Mediclaim TPA Pvt Ltd, 702, Vikrant Towers, Rajendra Palace, Delhi-110008 through its Managing Director/authorized representative.                                         

 .....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Ms Param Pal Kaur, Member.

 

Present: Sh  Jatinder Bansal, Ld Counsel for complainant,

              Sh Vinod Monga, Ld Counsel for OPs.

ORDER

(Ajit Aggarwal, President)

                                      Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of Rs.67,504/- on account of Mediclaim of complainant and for further directing OPs to pay Rs. 01 lac as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.25,000/-.

2                               Briefly stated, the case of the complainant is that complainant purchased a Mediclaim insurance policy bearing no.233702/48/2017/1077 valid for period from 14.09.2016 to 13.09.2017 and paid a sum of Rs.14,578/-as gross premium to OPs and both complainant and his wife Suparana were covered under said Mediclaim insurance policy to the tune of Rs.1,50,000/-. It is submitted that on 6.02.2017, complainant suffered from high grade fever and he was admitted in Dayanand Medical College and Hospital, Ludhiana where after examination concerned doctor diagnosed complainant with Bladder Neck Stenosis with BPH Grade I and Asymptomatic. In said hospital surgical operation was conducted and Bladder Neck  Incision was performed upon complainant on 9.02.2017. complainant remained admitted there for his medical and surgical treatment and was discharged from DMC, Ludhiana on 11.02.2017 and he spent an amount of Rs.96,488/-for his treatment. After getting discharged from hospital, complainant submitted his claim with OPs alongwith all relevant documents required for processing the claim. Thereafter, OP-3 issued letter dated 28.02.2017 to complainant requiring him to submit detailed break up of Rs.3211/-, original discharge summary of hospitalization and prescription of consultation dt 6.02.2017 and then, complainant duly sent the same to OPs, but instead of making payment of insurance claim, OPs further issued letter to complainant whereby they repudiated the claim of Rs.67,504/- and stated that only sum of Rs.28,984/- is payable to complainant. Action of Ops in withholding the remaining amount of Rs.67,504/-out of total amount incurred by him on his treatment, amounts to deficiency in service. Complainant made several requests to Ops to release the remaining insurance claim amount but they paid no heed to hear his genuine requests. Legal notice issued by complainant to OPs through counsel also served no purpose. It is further submitted that complainant completed all the formalities to obtain insurance claim and paid several visits to the office of Ops, but all in vain. Due to non payment of entire insurance claim by OPs, complainant has been suffering great economic loss and hardships. This act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. Hence, the present complaint.

3                                       The counsel for complainant was heard with regard to admission of the complaint and vide order dated 27.07.2017, complaint was admitted and notice was ordered to be issued to the opposite parties.

4       On receipt of the notice, OPs filed written statement taking preliminary objections that complainants have no cause of action to file the present complaint as the claim submitted by complainant has already been duly processed and amount of Rs.28,984/- stands paid to complainant and there is no deficiency in service on the part of OPs. As per terms and conditions of policy in question, the amount admissible to complainant has already been paid to him and nothing remains payable by Ops on account of insurance claim. All the terms and conditions of said policy were duly explained to complainant and are easily available on website of Ops and same have also been supplied to complainant. OPs have already paid the amount covered under policy in question and claim sought by complainant for remaining amount is not permissible. It is reiterated that there is no deficiency in service on the part of answering OPs. All the other allegations and allegations with regard to relief sought too were refuted with prayer to dismiss the complaint with costs.

5                                        Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to 36 and then, closed his evidence.

6                               In order to rebut the evidence given by complainant, the ld Counsel for OPs tendered in evidence, affidavit of Ashwani Kumar as Ex OP-1 and documents Ex OP-2 to 3 and then, closed the same on behalf of OPs.

7                                              We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

8                                       The case of complainant is that he alongwith his wife Suparana was insured with OPs for Rs.1,50,000/- vide policy issued by OP-1 and 2 and during the period of insurance, complainant suffered from high grade fever and he was admitted in Dayanand Medical College and Hospital, Ludhiana where concerned doctor diagnosed him with Bladder Neck Stenosis with BPH Grade I and Asymptomatic. In DMC, Ludhiana surgical operation was conducted and Bladder Neck  Incision was performed upon him and he remained admitted there for his medical and surgical treatment and was discharged from there on 11.02.2017. It is clear from the bills that he spent an amount of Rs.96,488/-for his treatment. After getting discharged from hospital, complainant submitted his claim with OPs alongwith all relevant documents required for processing the claim. After that, OP-3 issued letter dated 28.02.2017 to complainant requiring him to submit detailed break up of Rs.3211/-, original discharge summary of hospitalization and prescription of consultation dt 6.02.2017 , which were duly sent by him to OPs, but instead of making payment of insurance claim, OPs further issued letter to complainant whereby they withheld the claim amount of Rs.67,504/- and paid Rs.28,984/- only to complainant. Action of Ops in withholding the remaining amount of Rs.67,504/-out of total amount incurred by him on his treatment, amounts to deficiency in service. Despite several requests and Legal notice issued by complainant to OPs, they did not make payment of remaining claim amount of Rs.67,504/-. Complainant completed all the formalities to obtain his genuine insurance claim and paid several visits to the office of Ops, but all in vain. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of remaining claim amount to him which amounts to deficiency in service. He has prayed for accepting the complaint alongwith compensation and litigation expenses. He has also stressed on documents produced by him as Ex C-1 to C-36. In reply, OPs stressed mainly on the point that complainant  has no cause of action to file the present complaint as the claim of complainant has already been passed and amount of Rs.28,984/- is also duly paid to him. There is no deficiency in service on their part because as per terms and conditions of policy, the amount admissible to complainant has already been paid to him and nothing remains payable on account of insurance claim. All the terms and conditions of policy in question were duly explained to him and are easily available on website of Ops and same have also been supplied to complainant. OPs have already paid the amount covered under policy in question and claim sought by complainant for remaining amount is not permissible. There is no deficiency in service on the part of Ops and have prayed for dismissal of complaint with costs.

9                     To prove his case complainant has relied upon documents Ex C-13 to 33 from which it is clear that complainant availed treatment from DMC, Ludhiana and spent the amount in question on his treatment. Discharge Summary Ex C-8 proves the pleadings of complainant that he suffered from Bladder Neck Stenosis with BPH (Grade-I) and UTI Fever with Cholelithiasis (Asymptomatic) and he remained admitted in DMC Hospital from 6.02.2017 to 11.02.2017. Treatment given to complainant by medical authorities is also fully described on it. There is no iota of doubt that during the subsistence of mediclaim insurance policy in question, complainant suffered from some problem and being insured under the said policy, he was entitled to get insurance claim on account of expenses incurred by him on his treatment.

10                                                From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that he was insured with them as per Mediclaim Insurance Policy issued by them. OPs argued that as per policy terms and conditions and scheduled rate for the treatment under policy in question, the complainant is entitled only for Rs.28,984/- as insurance claim for his treatment at DMC Hero Heart Hospital, Ludhiana. As per scheduled rate he is not entitled for any other amount than this and this amount has already been paid to complainant and now, he is not entitled for anything else. Out of total amount of Rs.96,488/- spent by complainant on his treatment, OPs made payment of Rs.28,894/-and illegally withhold the remaining insurance claim amount of Rs.67,504/-, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement that how they calculated this amount on their own. Admittedly, the complainant spent Rs.96.488/- for his treatment and paid this amount to hospital authorities, the Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the person.

11                                                            Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He 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.

12                                         From the above discussion and case law produced by the complainant, we are of considered opinion that OPs have wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy out of entire amount, spent on treatment by complainant, which was covered under the Mediclaim insurance policy. The present complaint is hereby accepted. OPs are directed to pay the remaining claim amount of Rs.67,504/-to complainant, which was wrongly deducted by them out of amount spent by him on his treatment alongwith interest at the rate of 9 % per anum from the date when they made less payment to complainant till final realization. They are further directed to pay Rs.5,000/-to complainant as compensation for harassment and mental agony suffered by him besides Rs.3000/- as litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 19.12.2017       

                                             Member                          President

               (Param Pal Kaur)        (Ajit Aggarwal)