Punjab

Faridkot

CC/18/72

Santosh Kataria - Complainant(s)

Versus

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

Anil Kumar Chawla

24 Apr 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     72 of 2018

Date of Institution: 26.04.2018

Date of Decision :   24.04.2019

 

Santosh Kataria aged about 68 years wife of Yash Pal Kataria resident of H.No. DV-14/5, Krishna Street no.1 Fouji Road, Kotkapura Tehsil Kotkapura District

Faridkot.

                                         

                                                                            .........Complainant

Versus   

1.  The Oriental Insurance Company Ltd. Divisional Office, 4501, 1^st Floor, Bank bazaar, Bathinda through its Divisional Manager.
2. M/s. Raksha Health Insurance, 215/5 Mathura road, Faridabad through its Manager.
3. Punjab National Bank, near Phawara chowk, Muktsar  Road, Kotkapura.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt. Param Pal Kaur, Member.

 

Present:  Sh Anil Chawla, Ld Counsel for Complainant,

               Sh. Deep Chand Goyal , Ld Counsel for OPs-1,

               Sh. Amardeep Singh on behalf of OP-2,

     Sh. Ranjeet Singh Kakkar, Ld Counsel for OP-3,

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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 insurance claim of Rs.32,610/- with interest and for further directing OPs to pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.10,000/-.

2                                   Briefly stated, the case of the complainant is that complainant purchased a mediclaim insurance policy bearing no.233200/48/2017/690 from OPs through OP-3 valid from 26.05.2016 to 25.05.2017 for a sum of Rs. 5,00,000/- and continued the same for the period from 26.05.2017 to 25.05.2018. It is submitted that complainant suffered from heart problem and she was admitted in Rajan Hospital and Heart Centre, Kotkapura on 8.01.2018 and was discharged therefrom on 12.01.2018 and she spent Rs.32,610/-on her treatment. Thereafter, complainant lodged the claim with Ops and submitted requisite documents for processing the same, but vide letter dated 27.02.2018, they refused to accept her claim on the ground that there is concealment of disease by her part. It is further submitted that complainant has never concealed any fact regarding her health from OPs as she never suffered from any such heart problem prior to January, 2018. Complainant made several requests to OPs to pass her genuine claim, but all in vain. All this act and conduct of OPs amounts to deficiency in service and has caused

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harassment and mental tension to complainant. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 1.05.2018, complaint was admitted and notice was ordered to be issued to the OPs.

4                                     On receipt of the notice, the OP No. 1 filed written statement wherein asserted that complainant has no locus standi to file the present complaint and he has not come to the Forum with clean hands and has suppressed the real facts. Complainant has not fulfilled the terms and conditions of the policy and present complaint involves complicated questions of law and facts requiring voluminous evidence which is not possible in summary proceedings of this Forum. It is averred that complainant did not fulfil the requisite conditions of terms and conditions of policy in question and therefore her claim has been rightly repudiated in view of clause 4.1 of Mediclaim Insurance Policy, vide which claim is not permissible if there is any concealment regarding pre-existing disease and in present case, complainant did not disclose about her heart problem prior to obtaining the policy in question. It is averred that there is no deficiency in service on the part of OP-1 and prayed for dismissal of complaint with costs.

 5                                         OP-2 filed reply through their representative where asserted that mediclaim policy in question under which

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complainant has sought claim is issued by OP-1 and answering OP acts only as a facilitator in processing the claim. Contract of insurance is between insurer and insured that is between OP-1 and complainant and they have no role in making payment of insurance claim. However, it is admitted that complainant was covered under insurance policy in question and they recommended the claim of complainant as non payable in the light of clause 4.1 of terms and conditions of policy. It is reiterated that there is no deficiency in service on the part of OP-2 and prayed for dismissal of complaint with costs.

6                                 Ld counsel for OP-3 filed written statement wherein they have denied all the allegations levelled by complainant being wrong and incorrect and asserted that complainant never approached them for lodging his claim and they are not competent to receive the claim or adjudicate upon the claim matters. It is averred that complainant has sought claim under policy in question from OP-1 and they have no role in making payment of claims. It is averred that there is no deficiency in service on their part and prayed for dismissal of complaint with costs.

7                                                        Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-4 and then, closed their evidence.

 

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8                                               In order to rebut the evidence of the complainant, Counsel for OP-1 tendered in evidence affidavit of Ashwani Kumar Ex OP-1/1 and document Ex OP-1/2 to Ex OP-1/8 and then, closed the evidence. Representative of OP-2 tendered in evidence affidavit of Vinay Batra Ex OP-2/1 and closed the same on behalf of OP-2. Ld Counsel for OP-3 tendered in evidence affidavit of  Satish Gandhi Ex OP-3/1 and closed the evidence on behalf of OP-3.

9                                       We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

10                                   The case of the complainant is that complainant was insured under the policy in question and during the subsistence of said policy, she suffered from heart trouble. She was admitted in Rajan Hospital, Kotkapura on 8.01.2018 and was got discharged therefrom on 12.01.2018. Complainant spent Rs.32,610/-on her treatment. Grievance of complainant is that OPs repudiated the claim of complainant on false pretext of concealment of facts, though complainant has never concealed anything regarding her health from OPs while purchasing the policy in question. Despite repeated requests, OPs have not paid any heed to listen to her genuine requests which amounts to deficiency in service. She has prayed for accepting the present complaint. In reply, OP-1 stressed mainly on the point that there is no deficiency in service on their part and they have rightly repudiated

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the claim of complainant as per clause 4.1 of terms and conditions of policy in question. Complainant was having pre-existing disease of heart problem about which she did not disclose to Ops before purchasing the policy in question. She has herself violated the terms and conditions of policy in question and therefore, she is not entitled for any claim sought by her. As per OP-2, it acts only as a facilitator in processing the claim and contract of insurance is between insurer / OP-1 and between insured/ complainant and they have no role in making payment of insurance claim. However, it is admitted that complainant was insured under said policy. Ld counsel for OP-3 has refuted all the allegations against them and asserted that claim sought by complainant is from OP-1 and they have no role in making payment of insurance claim and  even OP-1 is not competent to receive the claim or adjudicate upon the claim matters. All the OPs have prayed for dismissal of complaint with costs.

 11                                                         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 complainant was insured with them under mediclaim policy in question. It is also admitted that complainant suffered from heart problem and she underwent treatment in the Rajan Hospital, Kotkapura, remained admitted there from 8.01.2018 to 12.01.2018 and paid Rs.32,610/-on her  treatment. Plea taken by OP-1 for repudiation of insurance claim is that complainant was already suffering from heart trouble but while

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procuring the policy in question, she did not disclose this fact to them and has herself violated the terms and conditions of policy in question and now, nothing is payable to her on account of expenses spent by her on her treatment. OP-2 and OP-3 asserted that complainant has sought her insurance claim from OP-1 and they have no role in making payment of insurance claim to her.

12                                     Ld Counsel for complainant argued that it is wrong that complainant concealed any fact regarding her health at the time of purchasing the insurance policy. It is incorrect that complainant was suffering from heart disease prior to issuance of insurance policy. Complainant came to know regarding her heart ailment first time in the month of January, 2018 when she was admitted in hospital. Prior to that, she had no knowledge regarding her heart trouble. Even Ops have not placed on record any evidence or document to prove that complainant was suffering from heart ailment prior to issuance of insurance policy or even prior to her present hospitalization or she had any knowledge about her heart ailment. OPs have repudiated the claim of complainant on false ground only to avoid the payment of claim amount. Ld counsel for complainant further argued that OPs cannot deny the amount in dispute regarding 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

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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.

13                                         From the above discussion and case law produced by the complainant, we are of considered opinion that OPs have wrongly and illegally not processed the claim of complainant, which amounts to deficiency in service. Therefore, present complaint is  hereby accepted against OP-1 and 2 and stands dismissed against OP-3 as OP-3 has no role in making payment of insurance claim. OP-1 and OP-2 are directed to pay the claim amount of Rs.32,610/-to complainant, which she incurred on her treatment alongwith interest at the rate of 9 % per anum from 26.04.2018 i.e from the date of filing the present complaint till final realization. They are further directed to pay Rs.4,000/-to complainant as consolidated compensation for harassment and mental agony suffered by her and for 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

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under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 24.04.2019

                                      (Param Pal Kaur)              (Ajit Aggarwal)

                                       Member                                     President