BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

                                                                   Complaint No.275 of 2017

                                                                   Date of Inst. 09.08.2017

                                                                   Date of Decision: 13.01.2020

Jagjit Singh aged 63 years son of Sardar Anup Singh, R/O 62/2, Garden Colony, Near GTB Nagar, Jalandhar-144008

..........Complainant

Versus

1.       The Oriental Insurance Company Ltd., Divisional Office, 32,    G. T. Road, Jalandhar, through its Senior Divisional Manager, Jalandhar.

2.       E-Meditek (TPA), Services Ltd., Corporate Office, Plot No.577, Udyog Vihar, Phase V, Gorgon (Haryana)-1220016.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:         Sh. Karnail Singh                    (President)

 Smt. Jyotsna                  (Member)

Present:        None  for the Complainant.

                   Sh. A. K. Arora, Adv. Counsel for the OP No.1.

                   OP No.2 exparte.

Order

Karnail Singh (President)

1.                The instant complaint has been filed by the complainant, wherein alleged that he obtained insurance policy from OP No.1 through its authorized agent for the period 11.03.2016 to 10.03.2017 and allotted policy No.233105/48/2017/7195 as per policy schedule dated 13.04.2016. The complainant has been continuously and uninterruptedly insured himself and his family members for mediclaim insurance policy since year 2011 without any gap/brake and strings by OP No.1. The policy schedule of Mediclaim Insurance Policy was issued in the name of the complainant insured. The total amount of renewal premium inclusive of all taxes of Rs.24,088/-, as consideration was paid to OP No.1 through its agent, which was accepted after fully satisfying the continue insurability and without questioning the credentials of the insured person without any demur. The OP delivered to the complainant policy schedule and Cover Note on 13.04.2016 only from the inception of the risk coverage under Mediclaim Insurance Policy and on its renewal. The policy document was not ever delivered to the complainant by OP No.1 even the terms and conditions including exclusion clauses were not ever communicated and explained nor made known to the complainant and were not part of the insurance.

2.                The OP No.1 has agreed and undertaken to indemnify for medical and surgical expenses or illness/sickness, accident and surgical operation etc. contracted within the period of insurance to the full extent without any limitation and deduction. Accordingly, the complainant has got the right of indemnification/reimbursement for the whole amount of mediclaim insurance policy expenses incurred against peril covered under the mediclaim insurance policy. The complainant had back ache problem and he was unable to walk and stand and pain both legs and accordingly, he was admitted in Dayanand Medical College & Hospital, Ludhiana on 14.12.2016 and discharged there from on 23.12.2016. The DMC hospital is on panel of OPs and authorized under Cashless Scheme of OPs Mediclaim expenses payment. Accordingly, DMC Hospital preferred mediclaim treatment and hospitalization expenses of the complainant insured from OP No.2, but OP No.2 approved and paid amount of Rs.64,718/- and coerced the complainant to bear balance expenses of amount of Rs.94,000/- of mediclaim himself. As such, the complainant paid amount of Rs.94,000/- from this own pocket against full and final payment against total bill of medical expenses treatment and expenses of Rs.1,38,718/-. The OP No.2 declined total medical expenses to the complainant just by invoking Clause 4.11 of the terms and conditions. The act and conduct of the OP by which deducted the same amount from the total medical expenses is clear cut deficiency in service as well as unfair trade practice and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OP No.1 be directed to reimburse the remaining medical expenses amount of Rs.94,000/- to the complainant alongwith interest @ 12% per annum from the date of payment to DMC Hospital, Ludhiana till actual payment and further, OPs be directed to pay compensation for causing mental tension and harassment to the complainant, to the tune of Rs.40,000/- and further, OPs be directed to pay Rs.10,000/- as litigation expenses.

3.                Notice of the complaint was given to the OPs, but despite service OP No.2 did not bother to appear and ultimately, OP No.2 was proceeded against exparte, whereas OP No.1 appeared through its counsel and filed a written reply, whereby contested the complaint by taking preliminary objections that there is no deficiency in service or unfair trade practice on the part of the answering OP and that being so, the present complaint is not maintainable. It is further averred that the amount due under the policy of insurance issued to the complainant has already been paid to the complainant. It is not out of place to mention here that the complainant has lodged claim for a sum of Rs.1,61,805/- with OP No.2 i.e. the claim settling agency of the OP No.1, for hospitalization of the complainant from 14.12.2016 to 22.12.2016 in Dayanand Medical College & Hospital, Ludhiana. The claim of the complainant was registered, vide claim No.103121600222 and accordingly, a sum of Rs.71,909/- was paid to the complainant as per the terms and conditions of the policy of insurance. The split of the deducted amount was also supplied to the complainant in claim settlement letter dated 30.08.2017. As per Mediclaim Insurance Policy (individual) under which the complainant is covered states as per Clause 1.2 coverage A, “Number of days of stay under ‘a’ and ‘b’ above should not exceed total number of days of admission in the hospital. Admissibility of all related expenses (c & d) except for medicine/pharmacy bill and body in plants shall also be as per the entitled category vis-à-vis room rent. The insurance policy of the complainant was Rs.2,00,000/- and accordingly, by applying the terms and conditions, the payment has been already made. On merits, it is categorically denied that the document i.e. terms and conditions were not supplied rather alleged that the insurance policy along with the terms and conditions were supplied to the complainant at the time of inception of the policy. It is also admitted that the complainant got insurance policy from the OP and also submitted a mediclaim bill, which was accepted according to terms and conditions. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

4.                Rejoinder not filed.

5.                In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB alongwith some documents Ex.C-1 to Ex.C-14 and closed the evidence.

6.                Similarly, counsel for the OP No.1 tendered into evidence affidavit of Sh. Yash Pal Ex.OP1/A alongwith some documents Ex.OP1/1 to Ex.OP1/5 and closed the evidence.

7.                We have heard the argument of learned counsel for the OP No.1 as none has come present on behalf of complainant at the time of argument and OP No.2 already exparte and also gone through the written arguments of OP No.1 as well as case file very minutely.

8.                After thoroughly going through the pleadings of both the parties as well as documents, we find that the factum in regard to purchase of insurance policy by the complainant and submitting of insurance claim and part payment thereof has been already made to the complainant, is not in disputed. Now, question remains whether the deduction has been rightly made by the OP by invoking Clause 4.11 of the terms and conditions. The complainant alleged that the terms and conditions including exclusion clauses were never supplied to the complainant nor the said terms and conditions were ever made known to the complainant or explained and as such, the same are not binding upon the complainant. But this version of the complainant is not acceptable because the complainant himself admitted that he received only policy schedule and if we go through the policy schedule produced on the file by the OP i.e. Ex.OP1/1, which contains two leaves and on the second page, it is categorically mentioned as under:-

“The insurance under this policy is subject to conditions, clauses, warranties, endorsements as per terms attached.”                                                        

It is categorically mentioned in the schedule of the insurance that this insurance is subject to terms and conditions, which are attached herewith, if so, then it is bounded duty of the complainant to ask for the terms and conditions if the same were not supplied at the time of inception of the policy, but simply not asking for supplying the copy of the terms and conditions itself established that the complainant had received the terms and conditions along with the schedule of the policy. So, this version of the complainant is not proved or established. If the policy is depending upon the terms and conditions, means there is an inter-se contract between the parties and both the parties are bound to obey the said terms and conditions, which are agreed and as per terms and conditions, the payment is to be made according to Clause 1.2 of the terms and conditions, if we see the case of the OP in the light of above terms and conditions i.e. Clause 1.2, then we can say without any hesitation that the deduction made by the OP is absolutely right and an amount of Rs.71,909/- has been already paid by the OP to the complainant as insurance claim and accordingly, we do not find any deficiency in service or negligence on the part of the OPs and thus, we find no merits in the case of the complainant and accordingly, the same is dismissed with no order of cost. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.

9.                Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated                                       Jyotsna                           Karnail Singh

13.01.2020                                        Member                          President