BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAS NAGAR, MOHALI
Consumer Complaint No.617 of 2014
Date of institution: 14.10.2014
Date of Decision: 22.06.2015
Kuldip Mittal son of Late D.C. Mittal resident of House No.78, Subhash Colony, Ambala Cantt., Haryana.
……..Complainant
Versus
1. The Oriental Insurance Company Limited through its Branch Manager, CBO, Ground Floor, LIC Building, Ambala City (Haryana).
2. M/s. Medi Assist India TPA Pvt. Ltd., SCO No.521, 2nd Floor, Sector 70, Mohali Punjab 160071.
3. Punjab National Bank through its Branch Manager, Nicholson Road, Ambala Cantt.
………. Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
CORAM
Mrs. Madhu. P. Singh, President.
Shri Amrinder Singh, Member
Mrs. R.K. Aulakh, Member.
Present: Shri Puneet Kumar, counsel for the complainant.
Shri K.S. Bhangu, counsel for OP No.1.
Shri Rajinder Sharma, counsel for OP No.3.
OP No.2 exparte.
(Mrs. Madhu P. Singh, President)
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 for issuance of following directions to the Opposite Parties (for short ‘the OPs’):
- to pay him Rs.12,100/- with interest @ 18% per annum from the date of lodging the claim i.e. 19.10.2013 till actual payment.
- to pay him Rs.55,000/- for causing mental torture, agony and physical harassment and Rs.22,000/- as litigation charges.
The complainant’s case is that he is a retired person and having saving bank account with OP No.3 vide Account No.0014000100343149. OP No.3 had a tie with OP No.1 who has floated a scheme for medical insurance of account holders of OP No.3. The scheme is known as PNB Oriental Royal Mediclaim Policy Schedule Scheme. The complainant took the aforesaid policy from OP No.1 through OP No.3 by paying premium to OP No.1. OP No.1 insured the complainant and his wife with a sum assured of Rs.3,00,000/- under the policy. At the time of taking the policy by the complainant, OP No.1 has not got any medical done of the complainant and his wife. OP No.1 also did not send the terms and conditions with the policy. The policy was lastly renewed w.e.f. 28.07.2013 to 27.07.2014 vide policy No.261101/48/2014/1578 by taking premium of Rs.4620/- from the complainant. On 09.10.2013 at about 5.00 a.m. the complainant suffered pain in his chest and became unconscious. The complainant was admitted in Monga Hospital & Stone Centre, Ambala Cantt and was discharged on 10.10.2013 with the advise to take medicines and get conducted some tests like stress Echocardiography and Color Doppler Tests. The complainant got conducted these tests at Chandigarh. The complainant lodged the claim for reimbursement of Rs.12,100/- with the OP No.1 on 19.10.2013 and submitted all the original documents. After lapse of three months, the complainant received a letter dated 27.01.2014 from OP No.2 bearing wrong address of the complainant. In the letter it was stated to be final reminder for seeking documents. OP No.2 demanded the original discharge summary in proper hospital format, original final hospital bill in proper format and original pre-numbered payment receipt of final hospital bill. The complainant vide his letter dated 03.02.2014 informed OP No.2 that the hospital has issued a certificate clarifying that all the discharge summaries are handwritten and on the hospital pad only and there is no separate format and the given summary covers all the essential things in a concise manner. It was also certified that no separate bill is issued. Thereafter complainant vide his letter dated 04.04.2014 requested OP No.2 for reimbursement of medical expenses. However, the OP No.2 vide letter dated 07.04.2014 denied the claim on the ground that as per policy terms and conditions, the expenses on treatment of ailment/disease/surgeries for age related Osteoarthritis and Osteoporosis for specified period of 3 years are not payable. The terms and conditions mentioned in the letter dated 07.04.2014 were never supplied to the complainant nor these were sent with the letter vide which the claim of the complainant has been denied. Thus, with these allegations the complainant has filed the present complaint.
2. Upon notice, the OP No.1 and 3 appeared and filed separate written statements. OP No.1 pleaded that at the time of issuance of the policy the complainant and his wife disclosed that they were having no pre existing ailment. It is denied that the terms and conditions of the policy were not supplied with the policies to the complainant. Moreover, the terms and conditions are also available on net. The complainant submitted his claim on 18.10.2013 which was forwarded to OP No.2 for further processing it. The insured had not submitted the complete documents as required by the TPA and the complainant also failed to file satisfactory reply to the objections raised by OP No.2. The claim of the complainant has rightly been repudiated under Exclusion Clause No.4.2 and 4.10 of the terms and conditions of the policy. Thus, denying any deficiency in service on its part OP No.1 has sought dismissal of the complaint against it.
3. OP No.3 in the reply has pleaded that this Forum has no jurisdiction to entertain the complaint as both the parties are residing and doing their business at Ambala and also the policy in question was made at Ambala. On merits, it is admitted that the complainant is its account holder and has taken the policy in question. OP No.2 is a duly licensed TPA agency for considering the Medi Claims under the relevant clauses of insurance by medical field persons. OP No.3 has also sought dismissal of the complaint against it.
4. As per report of India post, the notice sent to OP No.2 was duly delivered on 29.10.2014 but none appeared for it. Thus, OP No.2 was proceeded against exparte vide order dated 24.12.2014.
5. To succeed in the complaint, the complainant proved on record his affidavit Ex.CW-1/1 and tendered in evidence documents Ex.C-1 to C-8.
6. To rebut the allegations of the complainant, OP No.1 proved the affidavit of Amir Khurshid Ahmed, its Sr. Divisional Manager Ex.OP-1/1 and tendered in evidence documents Ex.OP-1 to OP-8.
7. OP No.3 tendered in evidence affidavit of Parmod Pande, Chief Manager Ex.OP-3/1.
8. We have heard learned counsel for the parties and have also carefully gone through the evidence and written arguments produced by them.
9. It is admitted that the complainant is subscriber of PNB Oriental Royal Mediclaim Policy Schedule Scheme floated by OP Nos.1 and 3. The complainant has purchased the medi claim policy and paid three annual premiums w.e.f. 28.07.2011 to 27.07.2013 and the last premium of Rs.4620/- paid on 28.07.2013 was for policy No.261101/48/2014/1578 valid w.e.f. 28.07.2013 to 27.07.2014. For the previous two years the complainant has not availed any medi claim. However, during the currency of third premium year, the complainant on 09.10.2013 suffered chest pain while walking and was admitted in Monga Hospital & Stone Centre, Ambala Cantt. The complainant remained in the hospital as an indoor patient for one day and was discharged on 10.10.2013 with the advice to undergo stress Echocardiography and Color Doppler Tests. During stay with Monga Hospital at Ambala, the complainant was given some medication and has also undergone certain tests and as per the medical claim duly signed by the treating doctor, the complainant has spent Rs.8800/- at Monga Hospital and the rest Rs.4300/- as diagnostic charges for ECG and Doppler Test conducted by the Prime Diagnostic Centre, Chandigarh. In all, the claim was lodged for Rs.12,100/-. The claim of the complainant has been repudiated by OP No.2 on the ground that the claim is covered under exclusion clause 4.2 and 4.10 of the terms and conditions of the policy. The grievance of the complainant is that he has never been provided the terms and conditions of the policy as no policy document was ever provided to him by the OPs. Therefore, without any knowledge of terms and conditions governing the exclusion clause the repudiation of the claim of the complainant unilaterally at the instance of OP No.2 is an act of deficiency in service and unfair trade practice.
10. The issues involved in the complaint are whether the OPs have not provided the terms and conditions of the policy to the complainant and whether the claim of the complainant has been rightly or otherwise repudiated under the exclusion clause 4.2 and 4.10 of the terms and conditions of the policy. To look into the first issue regarding non providing of terms and conditions of the policy, the complainant in his complaint as well as affidavit has raised a contention that no such document was ever provided to him. It is only the cover note and schedule of the policy which were supplied to him and other terms and conditions containing the exclusion clause were never communicated to him. In the reply filed by OP No.1 it was not specifically mentioned that the exclusion clause is also communicated to the complainant. Rather OP No.1 took a stand that the terms and conditions of the policy are available on net and the policy issued to the complainant only at his demand. Such a response of the OP No.1 in this regard has no legal mandate. In fact it is the duty of the insurance company and its agents to disclose all material facts in their knowledge. Thus, non providing of terms and conditions of the policy by OP No.1 is an act of unfair trade practice on its part.
11. So far repudiation of claim of the complainant vide Ex.C-5 by OP No.2 is concerned, it will be relevant to refer to the salient features of the policy Ex.OP-7. Since the claim has been repudiated under clause 4.2 and 4.10 of the Exclusion Clause, therefore, it will be appropriate to appreciate the said two clauses. The relevant clause 4.2 and 4.10 are reproduced here below:
“4.2 The expenses on treatment of following ailment/disease/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy. If these diseases are pre-existing at the time of proposal the exclusion No.4.1 for pre-existing condition shall be applicable in such cases.
4.10 Expenses incurred at Hospital or Nursing Home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period OR expenses incurred for investigation or treatment irrelevant to the disease diagnosed during hospitalization or primary reasons for admission, referral fee to family doctors out station consultants/surgeons fees. Doctor’s home visit charges/attendant/nursing charges during pre and post hospitalization period etc.
12. So far Clause 4.2 of exclusion clause of policy document is concerned, perusal of the record shows that the complainant was admitted in the hospital on 09.10.2013 and remained in hospital f upto 10.10.2013 and during the investigation it was found that he was suffering from cervical spondylite for which the hospital has given him treatment and medication and charged for investigation, hospitalization and treatment. Further as per the assessment of the treating doctor the complainant required further investigation regarding heart problem as the complainant has visited the hospital with chest pain. Therefore, to rule out any heart problem, the investigations were required. Upon the advice of the treating doctor the complainant on 14.10.2013 has undertaken two tests of Echocardiography and Color Doppler Tests from Prime Diagnostic and paid Rs.4300/-. However, the diagnostic report ruled out any heart ailment. Therefore, no treatment for heart ailment was given to the complainant. In order to cover the case of the complainant under Clause 4.2 the plea of the OPs that since the complainant remained hospitalized for one day from 09.10.2013 to 10.10.2013 and he was only evaluated and investigated and no active treatment was provided, warranting hospital, therefore, his claim is not maintainable under exclusion 4.2 as the list showing the diseases under Clause 4.2 does not show cervical spondylite. Therefore, the complaint’s case falls under Clause 4.2 of exclusion clause. We have gone through the contents of Clause 4.2 of the policy documents and found that Clause 4.2 is applicable only if the diseases mentioned under Clause 4.2 are pre-existing at the time of proposal. The cervical spondylite is not a pre-existing disease as the proposal form of the complainant does not reflect the existence of the same. Therefore, the application of clause 4.2 for repudiation of the claim of the complainant is not maintainable.
13. So far clause 4.10 of the terms and condition of policy, is concerned, as per the OP No.2 any expenses incurred at the hospital for evaluation/diagnosis purposes which is not followed by active treatment is not covered under the terms of policy for honouring the claim of the complainant. As per OP No.2 the complainant has spent Rs.4300/- for Echo Cardiography and Doppler test and the test report do not reveal any heart ailment, therefore, no active treatment for heart ailment has been undertaken by the complainant. So amount Rs.4300/- spent on diagnosis falls under the exclusion clause and the claim has rightly repudiated while invoking clause 4.10 of the policy.
14. As per OP No.1 the complainant himself has admitted that no treatment for heart was given to him by the doctors. The claim form submitted by the complainant clearly shows the total amount of Rs.12,100/- spent by him for both indoor investigation and treatment at Ambala Hospital and investigations diagnostic report by Prime Diagnostic Hospital, Chandigarh on the recommendation of treating doctor of Ambala Hospital. On both occasions the complainant has undergone the tests and treatment as per the recommendations and diagnosis of the treating doctor. Therefore, the amount spent by him both as indoor patient for diagnostic as well as treatment at Ambala Hospital and as an outdoor patient for diagnostic purposes at Prime Diagnostic Hospital, Chandigarh without following any active treatment for heart ailment, as admitted by the complainant himself, falls within the exclusion clause and the claim has been rightly repudiated.
15. We are not in agreement with the contentions so raised by OP No.1 while justifying the repudiation letter issued by OP No.2. It is well settled law that when 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 complainant, the OP cannot claim the benefit of said exclusion clause. The Hon’ble Supreme Court has settled in M/s. Modern Insulators Ltd. Vs. The Oriental Insurance Co. decided on 22.02.2000 the issue of non supply of terms and conditions of the policy including exclusion clause by the insurer is unfair trade practice.
16. It is an admitted fact that the OP No.1 has never provided the copy of terms and conditions of the standard policy having exclusion clause to the complainant. Therefore, in such a situation the act of the OPs in repudiating the claim of the complainant under the shelter of exclusion clause is not tenable in law and is, thus an act of deficiency in service and unfair trade practice on the part of OP No.1.
17. So far as OP No.3 is concerned, it has admitted that the complainant is an account holder with it and has further admitted that he took the medi claim policy from OP No.1. So far the claim is concerned it is the OP No.2 duly licensed TPA to act as a medi claim investigator to honour or dishonour of the claim of the complainant. No relief has been claim against OP No.3. We are in full agreement with OP No.3 in this regard and, therefore, complaint against OP No.3 is dismissed.
18. Since no policy document containing the exclusion clause was ever provided to the complainant by OP No.1 and repudiation of the claim by OP No.2 under the shelter of exclusion Clause 4.2 and 4.10 is an act of deficiency in service and unfair trade practice on the part of the both the OPs. Therefore, the complaint deserves to be allowed and the complainant deserves to be compensated.
19. Hence the complaint is allowed against OP No.1 and 2 with the following directions to:
(a) to pay a sum of Rs.12,100/- (Rs. Twelve thousand one hundred only) with interest thereon @ 9% per annum w.e.f. 19.10.2013 i.e. the date of submission of the claim till actual payment.
(b) to pay lump sum compensation of Rs.20,000/- (Rs. Twenty thousand only) towards mental agony, harassment and costs of litigation.
Compliance of this order be made within a period of thirty days from the date of receipt of a certified copy of this order. Certified copies of the order be furnished to the parties forthwith free of cost and thereafter the file be consigned to the record room.
Pronounced.
June 22, 2015.
(Mrs. Madhu P. Singh)
President
(Amrinder Singh)
Member
(Mrs. R.K. Aulakh)
Member
