BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

                                                                   Complaint  No.194 of 2018

                                                                   Date of Instt. 07.05.2018

                                                                   Date of Decision: 15.07.2019

Balbir Kumar Aeron alias Balbir Kumar aged 70 years S/o Sh. Murari Lal, Neel Kamal Textile, Old G. T. Road, Jalandhar-144001 also R/o of H. No.26, Mohalla No.7, Jalandhar Cantt.

                                                                             ..........Complainant

Versus

1.       The Oriental Insurance Company Ltd., Branch Office, Unit No.3, Top Floor, Samsung Showroom, Near State Bank of India, Civil Line, Jalandhar.

2.       E-Meditek, Corporate Office: Plot No.577, Udog Vihar, Phase-V, Gurgaon, Haryana-122016.

                                                                       ….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Sh. Karnail Singh              (President)

                              Smt. Jyotsna                      (Member)

Present:        Sh. K. C. Malhotra, Adv Counsel for the Complainant.

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

                   OP No.2 exparte.

Order

                             Karnail Singh (President)

1.                This complaint has been presented by the complainant, wherein alleged that the policy was taken by the complainant from OP No.1 through its authorized agent for the period stated in the Policy Schedule by renewal for the period of insurance from 19.09.2016 to 18.09.2017 and allotted policy No.233102/48/2017/683 as per the policy schedule dated 16.09.2016. The complainant has been continuously and uninterruptedly insured himself and his family members for mediclaim insurance policy since year 2002 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.6972/- as consideration was paid to the OP No.1, through its agent, which was accepted after fully satisfying the continuance of insurance and without questioning the credentials of the insured person without any demur. The OP No.1 issued to the complainant policy schedule and cover note No.CHD-C141851 dated 15.09.2016 only from the inception of the risk coverage under mediclaim insurance policy on its renewal, the policy document was not ever issued to the complainant by OP No.1, during the whole period of the policy. It is pertinent to submit that it was mandatory and obligatory upon OP No.1 to have issued policy document, which expresses the contract of insurance between the insurer i.e. OP No.1 and the insured complainant. 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. 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. The complainant insured with the OP No.1 was diagnosed with Benign Enlargement of prostate and was admitted in Patel Hospital on 16.09.2017 and discharged on 20.09.2017 and was treated upon by Dr. Swapan Sood, Dr. Suresh Aggarwal etc. Thereafter, the complainant submitted claim form vide claim No.103091700274 with supportive documents and also completed and complied with all the requirements and formalities which ever were asked for by the OP No.1.

2.                That the complainant was awe struck on receipt of claim settlement letter dated 23.11.2017 that the OP No.2 had made deduction to the tune of Rs.81,677/- from the claim amount of Rs.1,11,344/- thereby remitted amount of Rs.29,667/- through NEFT in bank account of the complainant unauthorizedly and illegally. The OP No.2 has no competence and jurisdiction being Third Party Administrator either to make any deduction or reject claim of the insured. To utter surprise and dismay of the complainant, the OP No.2 has wrongly and perversely, malaise and arbitrarily on whims and fancy drastically reduced mediclaim reimbursement claim for an amount, to the tune of Rs.81,677/- out of the total claim amount of Rs.1,11,344/- paid by the complainant to Patel Hospital, Jalandhar. It is also important and significant to mention that Consultant Expert Doctor of renewed well reputed hospital who treated the complainant was only the best judge to decide and determine line and manner of treatment of the complainant-patient according to his professional expertise knowledge skill and experience to remove pain and suffering to heal helpless complainant patient hustler free and joyful. The OPs are guilty of rendering deficient and negligent services and arbitrary adopted unfair trade practice unilaterally and accordingly, 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 amount of Rs.81,677/- to the complainant along with interest @ 12% per annum and further OPs be directed to pay damages/compensation, to the tune of Rs.40,000/- for causing mental tension and harassment and OP No.1 be also directed to pay litigation expenses of Rs.10,000/-.

3.                     Notice of the complaint was given to the OPs, but despite service OP No.2 did not come present and ultimately OP No.2 was proceeded against exparte, whereas OP No.1 duly served and appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that there is no deficiency in service or unfair trade practices 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 a claim for a sum of Rs.1,11,344/- with the OP No.2 i.e. the claim settling agency of OP No.1, for hospitalization of the complainant from 16.09.2017 to 20.09.2017 in Patel Hospital. The claim of the complainant was registered vide claim No.103091700274 and accordingly, a sum of Rs.29,667/- was paid to the complainant as per the terms and conditions of the policy of insurance. The split up of the deducted amount was also supplied to the complainant in claim settlement letter dated 23.11.2017. As per Mediclaim Insurance Policy individual under which the complainant is covered states as per Clause 1.2 and accordingly, due illegible amount has been already paid. On merits, it is admitted that the complainant got insurance policy and also submitted mediclaim insurance claim and accordingly, the same was settled as per the terms and conditions. The other averments as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

4.                In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB along with some documents Ex.C-1 to Ex.C-58 and closed the evidence.

5.                Similarly, counsel for the OP No.1 tendered into evidence affidavit of Sh. Sandeep Thapa as Ex.OP1/A along with some documents Ex.OP1/1 to Ex.OP1/4 and closed the evidence.

6.                We bestowed our thoughtful consideration to the submissions made by learned counsel for the complainant as well as counsel for the OP No.1 and also gone through the written argument submitted by counsel for OP No.1 and also scanned the case file very minutely.

7.                After considering the over all circumstances as put before us by respective counsel for the parties, we revealed that the taking of insurance policy by the complainant as well as getting treatment from Patel Hospital, Jalandhar and submitting of insurance claim are admitted fact. The issue arises between the parties which requires interference of this Forum is only whether the OP deducted the amount of Rs.81,677/- is legally as per terms and conditions or not, for that purpose, the learned counsel for the OP make much assertion that the terms and conditions of the policy itself says that the amount whatsoever mentioned in the terms and conditions is liable to be paid to the complainant and accordingly, out of the total insurance claim submitted by the complainant i.e. Rs.1,11,344/- was considered, which was on excessive side and unnecessary amount was added therein and after applying the terms and conditions, the amount of Rs.81,677/- was deducted there-from and the remaining legal amount of Rs.29,667/- was rightly paid to the complainant, which was accepted and as such, there is no negligence, deficiency in service or unfair trade practice on the part of the OP No.1.

8.                To the contrary, the main contention of the complainant is that the terms and conditions was never delivered to the complainant nor made it known to the complainant and the same are not binding upon the complainant and as such, the deduction made by the OP is illegal, whereas the complainant is entitled for the entire amount whatsoever spent by him on his treatment in the Patel Hospital, Jalandhar.

9.                We have sympathetically considered the rival contention and find that the version of the complainant is seems to not a true one because the complainant alleged that he never received the terms and conditions, but copy of the insurance policy Ex.C-1 produced by the complainant himself available on the file, wherein on the second page, it is categorically mentioned as under:-

“The insurance under this policy is subject to conditions, clauses, warranties, endorsements are as per forms attached.”                                This line itself make aware to the complainant that there are some terms and conditions and if the same was not supplied to the complainant at the time of inception of the policy, then it is the duty of the complainant to demand the terms and conditions from the OP, but by filing the instant complaint, the complainant make a pretext only to make his case good one, whereas the documents i.e. Insurance Policy itself shows that the terms and conditions were well within the notice of the complainant. As per natural phenomena, it is the duty of the each insured to abide by the terms and conditions, if so, then he cannot go beyond the terms and conditions and accordingly, we find that the OP has rightly paid the exact amount for whatsoever the complainant is entitled and deduction made from the total amount is also according to terms and conditions. So, we do not find any negligence, deficiency in service on the part of the OPs and further we find no substances in the argument of learned counsel for the complainant, therefore, complaint of the complainant 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.  

10.               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

15.07.2019                              Member                              President