Chandigarh

DF-II

CC/125/2020

Sarbjit Singh - Complainant(s)

Versus

The Oriental Insurance Company Limite - Opp.Party(s)

Adv. Devinder Kumar

04 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	125 of 2020
Date  of  Institution	:	18.02.2020
Date   of   Decision	:	04.09.2024

 

 

 

 

Sarbjit Singh son of Sh.Ravinder Singh, aged about 44 years, r/o House No.1034, Sector 44-B, Chandigarh.

             … … … Complainant

 

Versus

1.  The Oriental Insurance Company Limited, SCO     No.45, Sector 20-C, Chandigarh through its   Branch Manager.

2.  Raksha Health Insurance TPA Private Limited,    SCO No.39, Sector 26, Madhya Marg, Chandigarh     through its Managing Director.

   … … … Opposite Parties

 

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                MR.S.K.SARDANA,                MEMBER

                               

Argued by:    Sh.Devinder Kumar, Counsel for Complainant.

Sh.J.P.Nahar, Advocate for Sh.Krishan Kant, Counsel for OPs.

 

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

 

1]       The complainant has filed the present complaint pleading that he purchased Happy Family Floater Insurance Policy No.231110/48/2019/1233 for the period from 27.03.2019 to 26.03.2020 and paid a sum of Rs.40,815/- as premium to the OP. It is stated that in the month of June, 2019, complainant faced hip joint pain and visited to the Apollo Clinic, Sector 8, Chandigarh and Cheema Medical Complex, Phase-4, Mohali and conducted the test. On the basis of reports, for the treatment of the same, complainant visited Max Super Speciality Hospital, Phase 6, Mohali, where the Doctor of OP, on the basis of reports and going through the condition of the complainant, admitted the complainant in the hospital and surgery was conducted. The complainant was admitted in the hospital on 03.07.2019 and discharge on 06.07.2019. It is stated that complainant spent a sum of Rs.1,38,394.63 in hospital during treatment. It is alleged that instead of recommending the complete bill amounting to Rs.1,38,394.63, OP recommended only a sum of Rs.57,360/-. For non recommended claim amount of Rs.81,034/-, complainant visited the premises of the OP No.2 and submitted all required documents. It is alleged that complainant approached the OPs number of times with the request to release the balance claim amount, but to no avail. Hence, this complaint has been filed alleging deficiency in service and unfair trade practice on the part of OPs with a prayer to direct the OPs to pay balance claim amount of Rs.81,034/- along with interest, compensation for mental agony and harassment, litigation expenses.

 

2]       After service of notice, OPs appeared and filed written version and while admitting the factual matrix of the case about treatment taken by the complainant-insured during the policy period stated that the claim of the complainant was settled as per the terms and conditions of the insurance policy and the amount deducted by the OPs was as per the terms of the policy.

    It is submitted that the discharge summary dated 06.07.2019 issued by the hospital has a clear mention of ‘Surgery done Core decompression and Stem Cell injection-Right hip’. It is submitted that the ‘Genetic disorders and stem cell implantation/surgery’ falls under the Exclusion Clause No.4.15 of the insurance policy and thus not payable. It is further submitted that the complainant incurred the medical expense of Rs.60,000/- towards the stem cell transplant and the same was rightly deducted by the OPs as per the terms and conditions of the insurance policy while settling the claim. It is submitted that policy of insurance is a contract like any other contract and both parties to the contract are bound by the terms of the policy. It is further submitted that the deductions made by the OPs were as per the coverage under the insurance policy Clause 1.2. It is denied that OP No.2 assured to release the remaining amount to the complainant in addition to already approved amount. It is stated that complainant is not entitled to any further amount from the OPs. Denying any deficiency in service or unfair trade practice as well as all other allegations, the OPs have prayed for dismissal of the complaint. 

3]       Parties led evidence in support of their contention.

4]       We have heard the learned counsels for the parties and have gone through entire documents on record.

5]       The main issue involved in the present complaint is whether terms & conditions specially containing ‘Exclusion Clause’ are binding upon the complainant, even if, in fact, not signed by complainant, or not?

6]       The OPs have taken a stand that they have deducted the payable amount to the complainant on the basis of exclusion clause 4.15 of the terms & conditions of the insurance policy which states that ‘Genetic Disorders and Stem Cell Implantation/Surgery’ are not payable. Hence, medical expenses of Rs.60,000/- spent by complainant on Stem Cell Transplant was deducted by OPs and settled the rest of the claim of the complainant. The complainant has objection that exclusion clause of the terms & conditions of the insurance policy cannot be imposed on the complainant in case where it is not signed or supplied to the complainant and thus OPs are wrongly deducted the payable amount.

7]       OPs have relied upon the judgement of the Hon’ble National Consumer Disputes Redressal Commission titled as ‘Aman Kapoor vs. National Insurance Co. Ltd. & ors.’ Revision Petition No.429 of 2017 Decided on 17.04.2017, wherein the Hon’ble National Consumer Disputes Redressal Commission has held that:-

   “Plea taken by the petitioner/     complainant that he was not aware of the terms and conditions of the    policy as the same had never been supplied to him. This too has been   taken into account by the State    Commission which has found itself unable to accept this plea on the    ground that there seems to have been    no effort on the part of the   petitioner/complainant to obtain a     copy of the terms and conditions. We    are inclined to also agree with this   view. We further contend that it is   incumbent upon the consumer to be an   informed and responsible consumer in   order to be able to avail of relief    under the Consumer Protection Act,     1986. Ignorance of terms and    conditions of the policy is no excuse and provides no shelter to the   petitioner complainant” 

8]       However, the complainant has relied upon judgement of the Hon’ble Supreme Court titled as ‘M/s Modern Insulators Ltd. vs. The Oriental Insurance Co. Ltd.’ decided on 22.02.2000, wherein Hon’ble Supreme Court has held that:-

   “In view of the above settled position of law we are of the opinion that the view expressed by the    National Commission is not correct.    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 disclosed to the    appellant respondent cannot claim the benefit of the said exclusion clause.   Therefore, the finding of the    National Commission is untenable in    law”

9]       In view of the judgement of the Hon’ble Supreme Court, it can safely be concluded that where terms & conditions of the insurance policy containing exclusion clause, cannot be a ground to take benefit of the said exclusion clause by OPs. In the present complaint, there is nothing on record that terms & conditions of the insurance policy were ever supplied to or signed by complainant. Moreover, there is specifically stand of the complainant that terms & conditions of the insurance policy containing exclusion clause never informed/supplied to him.

10]      Hence, in view of the above said discussions, it can safely be concluded that exclusion clause 4.15 of the terms & conditions of the insurance policy is not applicable and binding upon the complainant being never supplied to the complainant and held that deduction on the part of the OPs of an amount of Rs.81,034/- is wrong and arbitrary. Therefore, it is deficiency on the part of the OPs, firstly for not supplying insurance policy containing terms & conditions and secondly for deduction of the said amount Rs.81,034/-. The complaint is partly allowed. OPs are directed to pay balance claim amount of Rs.81,034/- to the complainant along with interest @6% per annum payable from 06.07.2019, i.e. the date of discharge from the hospital, till the date of actual realization.

        The above said order shall be complied with by the OPs within a period of 45 days from the date of receipt of certified copy of this order.

11]      The pending application(s) if any, stands disposed of accordingly.

         The Office is directed to send certified copy of this order to the parties, free of cost, as per rules & law under The Consumer Protection Rules & Act accordingly. After compliance file be consigned to record room.

Announced

04.09.2024                                                      

Sd/-

 (AMRINDER SINGH SIDHU)

PRESIDENT

 

 

Sd/-

 (S.K.SARDANA)

MEMBER

as