Punjab

Fatehgarh Sahib

RBT/CC/1004/2018

Sheila Mamik - Complainant(s)

Versus

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

Inderjit Kaushal

11 May 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATHGARH SAHIB.

 

                                                                          RBT/CC/1004/2018

                                                                   Complaint No.1004/2018

                                                          Date of Institution: 25.09.2018

                                                             Date of Decision: 11.05.2022

 

Sheila Mamik wife of Shri Harmeet Singh Mamik, aged 71years, Senior Citizen, resident of House No.34, Sector Chandigarh.

                                                                          ...........Complainant

                                            Vs.

The Oriental Insurance Company Ltd., through its authorized signatory/Agency Manager, SCO No.20, Phase-1, Mohali, District SAS Nagar (Punjab)-160055.

                                                                     .............Opposite Party

 

Complaint under Section 12 of Consumer Protection Act 1986(Old)

Quorum

Sh.Pushvinder  Singh, President

Ms.Shivani Bhargava, Member

Sh.Manjit Singh Bhinder, Member

 

Present: Sh. Inderjit Kaushal, counsel for the Complainant.                                                                                                                               Sh.Kultar Singh  Bhangu, counsel for OP.

Order by Pushvinder Singh, President

 

 1.                     The present complaint has been filed by the complainant against the Opposite Party (hereinafter referred to as “OP” for short) for directing the OP/insurance Company to reimburse the entire amount of the bill of Rs.1,24,076/- and the deductions made by OP are due to invalid reasons.

 2.                   In this complaint, Sheila Mamik/complainant stated that she had taken an individual Medical Insurance Policy no.231400/48/2019/135 w.e.f 20.06.2018 to 21.06.2018. At the time of taking the Medical Policy, the OP has assured that it is a cashless policy, and all the diseases are covered under the said policy. On that assurance, the complainant had paid a premium of Rs.27,350/- for the above said policy. On 12.07.2017, complainant was admitted in emergency in Fortis Hospital, Mohali due to severe breathing problem and remained admitted for four days and was discharged on 16.7.2018. The complainant had submitted all the relevant documents pertaining to the above said policy to the Fortis Hospital, Mohali at the time of admission and accordingly a detailed bill was forwarded by Hospital to the OP for payment. On dated 17.7.2018, the OP allowed a payment of Rs.26,173/- out of the total bill of Rs.1,24,076/-  and the balance amount had to be paid by  the complainant  to the Fortis Hospital  as the OP had repudiated to pay the claim of the complainant on the following reasons:-

a.Cost of non-medical items.

b.Expenses incurred for material and services irrelevant to the cause.

c.Non-payable items as per IRDA/Insurer Guidelines advised from    time to time.

3.                 Complainant requested the OP to pay the remaining amount as the Policy taken by the complainant is a cashless policy,  but the OP remained adamant it was told to the complainant that the claim was repudiated as per the Policy. The complainant got issued a legal notice  and submitted that none of repudiation clause found mentioned in the Insurance Policy issued to the complaint.  The OP has not communicated any schedule mentioning the repudiation of claim in the cashless policy. The action of the OP for not compensating the claimant by way of paying the hospitalization bill to the Fortis Hospital, Mohali amounts to deficiency in service. Hence, this complaint filed for giving directions to the OPs to pay/refund an amount of Rs.87,903/-  along with interest @ 18% P.A. from 17.7.2018 till its final payment and   an amount of  Rs.50,000/-  as  a compensation for physical agony and harassment  and unfair trade practice  and deficiency in service on the part of OP.

 4.                Notice of complaint was given to the OP, who appeared and filed its written reply/version,  raising preliminary objections, that the present complaint is not maintainable as the complainant has not approached this  Commission  with clean hands,  The complainant has failed to present any consumer dispute before this complainant as the claim of the complainant has been settled as per the admitted terms and conditions. The complainant has failed to challenge the terms and conditions of the Insurance Policy as well as the final settlement report of aforesaid expert. On merit, OPs further alleged that as per the records of the hospital, complainant is an old lady of 71 years having history of Hypertension since 20 years, Bronchial Asthma Exacerbation, Diabetes for 1 and ½ years. Worsening of Hyper Glycemi-Steroid  included hypertension & severe obstructive sleep Apnea since Jan 2018. The complainant had purchased Mediclaim Insurance Policy (Individual) no.231400/48/2019/135 effective from 22.6.2018 to 21.6.2019. At the time of sale of said Policy, complainant was well acquainted with the limitations as per the terms &  Conditions of the Insurance Policy purchased by her.  Even on the insurance certificate, it is clearly mentioned that Policy is subject to limitations as per terms and conditions, which are readily available on the website of the Insurance Co. or can be supplied on demand. On 14.7.2018, complainant had sent a request form through hospital for cashless facility. On 16.7.2018, out of final bill of Rs.1,23,076/- an amount of Rs.26,173/- has been approved. The said amount has been accepted by the complainant as a full and final settlement of claim. During the verification  and processing of the claim of the complainant it was found that as per policy clause 1.2(a) Insured’s  entitlement of room is Rs.3,000/- Per day (1% of sum assured), but the complainant opted for Room rent with higher than the entitled category i.e Suite Room @17,500/-x 3 days & Rs.9000/- for one day, excluding Nursing charges of Rs.1150/- The intimation of settlement as per Policy was given to the hospital  as well as the complainant. For which the hospital has submitted a bill no.1002/18/1Cr/003630 dated 17.7.2018 for total Rs.124076/- showing patient’s share as Rs.97903/- and Insurance share as Rs.26173/- . The said bill received on 20.7.2018 by the aforesaid TPA was settled and amount of Rs.26,173/- was released in favour of the complainant, which was duly received under proper receipt by the complainant. Hence, the claim of the complainant has been settled in accordance with the terms  and conditions of the Policy purchased by her. The legal notice dated 1.8.2018 sent by the complainant was duly replied vide reply dated 17.8.2018 along with all concerned information and fully satisfied the complainant. All the applicable terms and conditions are readily available on the web site of insurance company or insured can get the same on demand. But, no request for supply of the terms and conditions of the Policy was ever made by the complainant. The  claim was  settled for Rs.26,173/ as per terms and conditions of the Policy. Accordingly, OP prayed for dismissal of the complaint with costs.

5.                  The complainant in support of his complaint tendered in his evidence affidavit Ex.CW-1/A along with documents Ex.C-1 to Ex.C-3. In rebuttal, the OP tendered in his evidence affidavit Ex.OP-1 and Ex.OP-1/2 along with documents Ex.OP-1 to Ex.OP-7.

6.                  We have heard learned counsel for the parties and have also gone through the record.

7.                The complainant has alleged that along with the policy the OP did not supply/communicate any schedule mentioned in the repudiation of the claim and in this regard the counsel for complainant has relied upon the pronouncements of Hon’ble National Consumer Disputes Redressal Commission, New Delhi passed in case titled as Oriental Insurance Co. Ltd. Vs Brahmdeo Panjiyara reported as 2012(63) RCR(Civil) page 495 and also relied upon another pronouncement of the Hon’ble National Commission, New Delhi passed in case titled as Oriental Insurance Co. Ltd. Vs Satpal Singh thoughts its MD reported as 2014(38) RCR (Civil) page 845.

8.              On the other hand the counsel for OP contended that the complainant did not come to the Court with clean hands and in fact he has concealed material facts. The complete insurance policy along with terms and conditions of the insurance were supplied to the complainant but at the time of filing this complaint the complainant concealed other two pages of the insurance policy because on the second page of insurance policy it was clearly mentioned that all terms and conditions were attached with the policy and he has also conteded that the pronouncements of the Hon’ble National Consumer Disputes Redressal Commission, New Delhi as relied upon by the counsel for complainant are not applicable to the present case.

9.              After giving thoughtful consideration to the rival contentions and after going through the file we find that the complainant has produced copy of only first page of insurance policy as Ex.C-1. The policy was of three pages, which is clearly mentioned on the first page of policy itself. The second page was on the backside of first page but the complainant produced only first page having its back blank.

10.                 On the other hand the OP has produced the certified copy of insurance policy as Ex.OP-1 and on the second page which is on the back of first page it has been clearly mentioned that “The insurance under this policy is subject to conditions, clauses, warranties, endorsements as per forms attached.” which shows that the terms and conditions of the policy and other clauses were also supplied to the complainant at the time of insurance. On the second page of policy, it is also clearly mentioned that “for complete details please refer to policy conditions”. Apparently, the complainant did not produce the second page of the insurance policy intentionally because the clauses mentioned on it are against the claim of complainant.

11.               We have gone through the pronouncements of the Hon’ble National Consumer Disputes Redressal Commission, New Delhi passed in case titled as Oriental Insurance Co. Ltd. Vs Brahmdeo Panjiyara and in case titled as Oriental Insurance Co. Ltd. Vs Satpal Singh thoughts its MD and we find that the same are not applicable to the facts and circumstances of the present case and are distinguishable. In the abovementioned Brahmdeo Panjiyara’s case only cover note along with schedule of policy was supplied to the insurer and clause pertaining to special exceptions of insurance policy was not made available to him. But in present case this is specifically mentioned on the second page of the policy that the terms and conditions with clauses were attached with the policy itself. Similarly in the Satpal Singh thoughts its MD’case there was a note on the insurance policy that “The insurance under this policy is subject to conditions, clauses, warranties exclusions are available on the website of company or on demand from policy issuing office.” The terms and conditions and other clauses were not attached with the said policy but in the present case it is clearly mentioned in the policy itself that the terms and conditions and other clauses warrantees etc. were attached with the policy when it was supplied to the complainant.

12.                    Admittedly the OP has paid an amount of Rs.26,173/- to the complainant out of bill. As per the bill produced by the complainant the amount of Rs.71,400/- has been claimed as room rent but the OP disallowed the amount of Rs.57,000/- as room rent because policy clause 1.2(a) provides only 1% of sum assured as room rent. In the present case the sum assured is Rs.3,00,000/-  and accordingly Rs.3000/- per day has been rightly paid by the OP. The complainant allegedly stayed in suite room on rent of Rs.17,500/- per day which cannot be allowed keeping in view the assured sum.

13.                 In view of our aforementioned discussions, we are of the opinion that the terms and conditions of the policy, clauses and other warrantees were supplied to the complainant at the time of policy and the complainant was made aware of the same. The OP has rightly repudiated the remaining claim and has rightly paid the amount of Rs.26,173/-. So the complaint is dismissed with no order as to cost. Copy of this order be provided to the complainant and OP free of cost. The file be returned back to the District Consumer Commission, Mohali for consignment.  

Announced:

11.05.2022

(Pushvinder Singh)

                                                                 President

 

                                                               

(Shivani Bhargava)

                                                                 Member

                                                               

                                                               

 

     (Manjit Singh Bhinder)

                                                                       Member