PER:

Charanjit Singh, President;

1        The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.

2        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11/12 against the opposite parties on the allegations that the complainant is a senior citizen, her husband purchased a Medi-claim policy for himself as well as for the complainant, from opposite party bearing policy No. 23531/48/2011/2541 for sum assured of Rs. 1,25,000/- each for the husband of the complainant as well as the complainant, valid for the period from 27.11.2010 to 26.11.2011 after paying the requisite premium to the opposite party. The complainant has been renewing the said policy since then by paying regular premium amount to the opposite party and the latest policy issued to her vide policy issued to her is 23501/48/2017/2044 vide cover note dated 24.11.2016 valid up to 26.11.2017. The complainant availed the services of opposite party and he is consumer qua the opposite party as defined under Consumer Protection Act. The opposite party had assured the complainant of providing efficient service without being negligent. the complainant had been regularly getting medi-claim policies from the opposite party since 2010 vide policy No. 235301/48/2011/2541 valid from 27.11.2010 to 26.11.2011 for sum assured of Rs. 2,50,000/-, policy bearing No. 235301/48/2012/2709 valid from 27.11.2011 to 26.11.2012 for sum assured of Rs. 3,00,000/- , policy bearing No. 235301/48/2013/2863 valid from 27.11.2012 to 26.11.2013 for sum assured of Rs. 4,00,000/-, policy bearing No. 235301/48/2014/2623 valid from 27.11.2013 to 26.11.2014 for sum assured of Rs. 4,00,000/-. The complainant had opted for the above health insurance policies accepting the offer of the opposite party to meet any health claim in future, thereby providing mediclaim insurance to the complainant. The opposite party had been receiving regular premium amount from the complainant and assuring of providing proper medical cover.  The complainant felt some pain in her knee in the month of October 2016 around 16.10.2015 and thereafter went for her medical checkup from Amandeep Hospital Amritsar wherein, she was advised surgery for knee replacement. Accordingly, the complainant underwent the knee surgery on 1.11.2015 and was discharged on 7.11.2015. The hospital authorities were informed on the day of admission by the complainant regarding her medicalim policy who immediately intimated the opposite party for meeting out the necessary expenses to be incurred by the complainant. The complainant having availed the services of the opposite party and duly covered for such emergency under the policy so obtained by him, immediately, informed the opposite party for meeting out the necessary medical expenses as per the policy. The complainant incurred a total expenses of Rs. 2,53,000/- upon the treatment. The complainant is insured and having a mediclaim policy but the opposite party only reimbursed an amount of Rs. 1,25,000/- without disclosing the reasons for such deficiency in service and arbitrary deductions not permissible under the law. the complainant has time and again approached the opposite party to reimburse her claim and pay the balance charges incurred on her surgery and hospitalization etc. to the tune of Rs. 1,28,000/- but the opposite party has totally proved to be negligent and deficient in providing efficient services to the complainant by refusing to pay the balance amount. The requisite documents were provided to the opposite parties, but the opposite parties did not pay the claim to the complainant and rejected the same on false and frivolous grounds, by only paying Rs. 1,25,000/- out of total claim amount of Rs. 2,53,000/-. The claim has been rejected on the false and frivolous ground. The complainant has prayed as under:-

(a)     The opposite party may kindly be directed to make the payment of Rs. 1,28,000/- i.e. the amount less paid out of total claim amount of Rs. 2,53,000/- alongwith interest 18% p.a.

(b)     The compensation of Rs. 50,000/- may also be awarded to the complainant for the harassment, mental pain and agony suffered by him.

(c)      The cost of the complaint to tune tune of Rs. 22,000/-  may be awarded to the complainant .

3        After formal admission of the complaint, notice was issued to Opposite Party and opposite party appeared through counsel and filed written version and contested the complaint by interalia pleadings that  the present complaint is not legally maintainable as the amount claimed is not within the insurance cover obtained by the husband of the complainant from the opposite party much less there is any deficiency in service and unfair trade practice on the part of the opposite party and as such the present complaint merits dismissal on this simple score only. In the present case the payable amount was to the tune of Rs. 1,25,000/-  which has already been paid by the opposite party in lieu of settlement of claim of the complainant as per the insurance coverage. The husband of complainant purchased individual Mediclaim Insurance Policy from the replying opposite party vide policy number 23501/48/2011/2541 for himself and for his wife covering mediclaim risk of Rs. 1,25,000/- each valid from 27.11.2010 to midnight of 26.11.2011. As per terms and conditions of the impugned policy as per General Exclusion under exclusion clause 4, 4.1, 4.3. Rs. 1,25,000/- has already been paid by the opposite party in lieu of settlement of claim of the complainant as per the insurance cover and as such it cannot be attributed that there is any lapse, deficiency in service and unfair trade practice on the part of the opposite party. The complainant has not adduced any cogent and convincing material in order to substantiate the pleas as alleged in the complaint especially when the insurance coverage is only as per the insurance policy schedule and its terms and conditions and even otherwise, it is not open to the complainant to defeat the rights of the opposite party by way of raising concocted and afterthought pleas as the claim is to be dealt within the insurance coverage only.  The complainant has not come to this commission with clean hands and has concealed material facts from this commission and as such, the present complaint merits dismissal as this simple score only.  The opposite party has already settled the claim of the complainant as the payable amount was to the tune of Rs. 1,25,000/- as per terms and conditions of policy. The present complaint is an abuse of process of court. No consumer dispute survives between the parties much less any cause of action has arisen in favour of the complainant. The complainant is not a consumer within the purview of the Consumer Protection Act. There is no deficiency in service on the part of the opposite party.  The opposite party has denied the other contents of the complaint and prayed for dismissal of the same.

4        To prove his case, Ld. counsel for the complainant has tendered in evidence affidavit of complainant Ex. C-1 along with documents Ex. C-2 to Ex. C-65 and closed the evidence.  On the other hands, Ld. counsel for the opposite party tendered in evidence affidavit of Sh. R.K. Sharma Divisional Manager Ex. OP1 along with documents i.e. attested copies of the individual medical policy schedule along with its terms and conditions Ex. OP2 to OP9 and closed the evidence.

5        We have heard the Ld. counsel for the parties and have carefully gone through the record.

6        In the present case, insurance is not disputed, the complainant has placed on record insurance policy Ex. C-18 on record. It is also not disputed that the complainant admitted in the hospital and get treatment. After admitting the insurance and treatment of the complainant, the opposite party has made the insurance claim to the complainant to the tune of Rs. 1,25,000/-. However, the complainant has submitted the claim to the tune of Rs. 2,53,000/- but the opposite party has made the claim to the tune of Rs. 1,25,000/- only and the stand of the opposite party is that as per terms and conditions of impugned policy as General Exclusion Under exclusion clause 4, 4.1, 4.3 which are reproduced as follows:-

4.       General Exclusion: The company shall not be liable to make any payment under this policy in respect of any expense whatsoever incurred by any insured person in connection with or in respect of:

4.1     All Pre-existing disease (whether treated/ untreated, declared or not declared in the proposal form), which are excluded up to 48 months of the Policy being in force, Pre-existing diseases shall be covered only after the policy has been continuously in force for 48 months. 

For the purpose of applying the condition, the date of inception of the first indemnity based health policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability condition.

This exclusion shall also apply to any complication(s) arising from pre-existing disease ….”

And as per exclusion clause 4.3 Joint replacement is excluded up to 4 years and it is also mentioned therein that if the sum insured is enhanced subsequent to the inception of first policy, the exclusion cause 4.1, 4.2, 4.3 will apply afresh for the enhanced portion of the sum insured.

7        Now question arises whether the complainant covered under this condition or not ?  The husband of complainant covering the risk of complainant is taking the policy from the opposite parties for the period 27.11.2010 to 26.11.2011 as per policy Ex. OP-2,  from 27.11.2011 to 26.11.2022 as per policy Ex. OP-3, from 27.11.2012 to 26.11.2013 as per policy Ex. OP-4, from 27.11.2013 to 26.11.2014 as per policy Ex. OP-5, from 27.11.2014 to 26.11.2015 as per policy Ex. OP-6. In this way, the husband of complainant covering the risk of complainant is taking the policy from the year 2010 which up to the year 2015 which is continuous more than 48 months. Therefore, the terms and conditions as mentioned by the opposite party is not adhered to the present case and the opposite party has wrongly rejected the claim of the complainant.  Furthermore, it is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All 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 clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

8        Now the next question is to determine that the how much amount the complainant is entitled to. The complainant has prayed that the opposite party may be directed to make the payment of Rs. 1,28,000/- i.e. less paid amount out of claim amount of Rs. 2,53,000/-. But as per insurance policy Ex. C-18, sum insured (overall liability) is Rs. 2,00,000/- only. As per complainant, the opposite party has already made the payment of Rs. 1,25,000/- therefore, the complainant is entitled to Rs. 75,000/- only as per insurance policy Ex. C- 18.

9        In light of the above discussion, the complaint is partly allowed. The opposite Party is directed to make the balance insurance claim of Rs. 75,000/- to the complainant. The complainant has been harassed by the opposite party unnecessarily for a long time. The complainant is also entitled to Rs. 8,000/- ( Rs. Eight Thousand only) as compensation on account of harassment and mental agony and Rs 7,000/-(Rs. Seven Thousand only) as litigation expenses. Opposite Party  is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.

Announced in Open Commission

20.09.2022