Chandigarh

DF-II

CC/609/2018

Pawan K. Katia - Complainant(s)

Versus

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

Amit Sen Adv. & Pankaj Katia Adv.

16 May 2019

ORDER

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

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Consumer Complaint  No	:	609 of 2018
Date  of  Institution	:	02.11.2018
Date   of   Decision	:	16.05.2019

 

 

 

 

Pawan K. Katia s/o Sh.Laxmi Narain Katia, r/o Shanki Kunj, #7, Sector 7, Panchkula        

                  

             ……..Complainant

 

Versus

 

1]  The Oriental Insurance Company Ltd., through its Managing Director having its office at A-25/27, Asaf Ali Road, New Delhi 110002

 

2]  The Oriental Insurance Company Ltd., through its Branch Incharge/Manager having its Branch Office at SCO 325, 2^nd Floor, Sector 9, Panchkula.

 

3]  Raksha Health Insurance TPA Pvt. Ltd., through its Manager/Incharge having its Office at SCO 39, F.F. Sector 26, Madhya Marg, above Barbeque Nation, Chandigarh.

 

………. Opposite Parties

 

BEFORE:  SMT.PRITI MALHOTRA    PRESIDING MEMBER

            SH.RAVINDER SINGH     MEMBER

 

 

Argued By:       Sh.Pankaj Katia, Adv. for Complainant.

Sh.Ram Avtar, Adv. for OPs.   

 

 

PER PRITI MALHOTRA, PRESIDING MEMBER

 

                                The case of the complainant in brief is that he is availing Mediclaim Insurance Policy from OPs No.1 & 2 for more than one decade and also, the complainant is insured for the current period from 2.7.2018 to 1.7.2019 (Ann.C-1).  It is stated that no terms & conditions of the policy were supplied to the complainants.  As per the policy, the complainant is insured for an amount of Rs.4 lacs. 

         It is averred that during the coverage period of the policy, the complainant was treated for Pituitary Adenoma (a form of gland/tumor which had formed in the Brain which was pressing the Pituitary gland) by conducting surgery and as such remained admitted for said treatment from 27.8.2018 to 29.8.2018.  The Opposite Party Insurance Company was intimated about this fact.  It is also averred that after the treatment, the complainant lodged reimbursement claim of Rs.2,39,539/-, incurred by him on the said treatment, with the Opposite Party Insurance Company, but they approved it only for Rs.1,54,568/-.  It is stated that the OPs have wrongly & illegal reduced & less settled the claim of the complainant.  It is also stated that the OPs have treated the case of the complainant for a sum assured of Rs.3.50 lacs whereas he was having sum assured cover of Rs.4 lacs. Alleging the said act & conduct of the OPs as gross deficiency in service and unfair trade practice, hence this complaint has been filed. 

 

2]       The Opposite Parties have filed joint reply and while admitting the factual matrix of the case, stated that the claim lodged by the complainant has been thoroughly examined and after due application of mind and as per terms & conditions of the policy, the claim has been rightly settled by TPA/OP No.3 for a sum of Rs.1,54,568/- considering the total sum insured of Rs.3.50 lacs.  It is stated that the claim has been righty settled by OP No.3 as per hospitalization benefits payable to the complainant. It is submitted that the complainant is entitled for room rent @1% of the sum insured i.e. Rs.3500/- instead of Rs.6500/- as claimed.  It is also submitted that the claim has been settled as per entitlement of the complainant after making deductions of consumable and registration charges, which are not payable as per terms & conditions of the policy.  It is further submitted that the complainant is not entitled to get the claim more than his eligibility/entitlement and the claim, which has been paid, was payable as per policy. Denying all other allegations and pleading no deficiency in service, the Opposite Parties have prayed for dismissal of the complaint.

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the Opposite Parties in reply.

 

4]      Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       Admittedly, the complainant being insured with OPs for the current period from 2.7.2018 to 1.7.2019 (Ann.C-1) took treatment for Pituitary Adenoma, incurred expenses thereon to the tune of Rs.2,39,539/- and lodged claim with OPs.

 

7]       The dispute in the present complaint revolves around the less settlement of the claim of complainant by the OPs. 

 

8]       The complainant claims that for the treatment underwent by him during the insurance coverage period from 2.7.2018 to 1.7.2019, he incurred expenses to the tune of Rs.2,39,539/- for which he lodged claim with the Opposite Parties, but it was settled for an amount of Rs.1,54,568/-. 

 

9]       Justifying the less settlement of claim, the OPs submitted that the claim of the complainant has rightly been settled by TPA/OP No.3 for an amount of Rs.1,54,568/- considering the total sum insured of Rs.3.50 lacs.

 

10]      The thorough perusal of the record reveals that the complainant is availing the Mediclaim policy from the OP Insurance Company since the year 2014 (as per record) and initially was insured for an amount of Rs.3.50 lacs and his wife was also insured for an amount of Rs.3.50 lacs and thereafter, the policy was renewed for a sum insured of Rs.4.00 lacs each for complainant and his wife.  The further renewal of the policy reveals that the complainant was having coverage of sum insured of Rs.4.00 lacs. In this pretext, it is concluded that the OPs have wrongly settled the claim of the complainant by taking the sum insured amount as Rs.3.50 lacs instead of Rs.4 lacs for which the complainant is insured vide present policy.  In our considered opinion, the Opposite Parties intentionally overlooked this fact firstly while deciding the claim of the complainant and dishonestly never considered it despite being apprised about the correct sum insured amount in the present complaint.  The OPs not only failed to admit their mistake ever, also not offered the balance payment taking into account the correct sum insured amount of Rs.4.00 lacs.  This act & conduct of the Opposite Parties reflect their highhandedness, which is highly condemnable. 

 

11]      For deciding the present issue, we are also guided by the judgment in case Oriental Insurance Company Limited, Chandigarh Vs. Khursheed and another, Civil Writ Petition No.3996 of 2011 of Hon’ble Punjab & Haryana High Court, decided on 22.3.2011, wherein it has been held that :-

 

“…Insurance Companies are charging hefty premium for insuring the vehicles. Once the question of liability arises, the companies resort to one technical objection and the other.  These Companies really chase people and literally promise everything at the time of selling policy.  It is usual to see people struggle to run after agents and surveyors to get their rightful claims.  Such agents then look other way and make insurers to make rounds to Company offices.  Insurers are then made to approach the Courts and are even dragged to this Court on one technical plea or the other.  No one really is made to read the terms while making him to sign on the printed forms for selling policies.  This attitude must change. At least, the Courts should not be burdened with this uncalled for litigation”

 

12]      In view of the above judgment, we are of the considered opinion that the only motive of the insurance companies is to collect hefty premiums and less inclined to genuinely settle the claims. It is also observed that the Insurance Companies either are inclined to reject the claims on whimsical grounds or settle the claims with less amount, bothering the policyholders to further fight for rightful claim even for meager amount which further causes them mental & physical harassment besides financial burden.

 

13]      It is clear that the claim of the complainant has wrongly been settled by taking into account the sum insured amount of Rs.3.50 lacs instead of Rs.4.00 lacs as per current policy.  Thus, the deficiency in service on the part of OPs is proved. 

 

14]     In view of the discussion & findings, as made in the preceding paragraphs, the present complaint is allowed with directions to the Opposite Parties to pay the difference amount of the claim to the complainant by taking into account the sum insured amount of Rs.4.00 lacs instead of Rs.3.50 lacs. The OPs are also directed to pay compensation of Rs.10000/- for causing harassment to the complainant due to their deficient act, along with litigation cost of Rs.7000/-.

         This order shall be complied with by the OPs within a period of 30 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional compensatory cost of Rs.5,000/- apart from the above relief.  

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

16^th May, 2019                                                                        Sd/-

                                                                    (PRITI MALHOTRA)

PRESIDING MEMBER

 

 

Sd/-

(RAVINDER SINGH)

MEMBER