Punjab

Moga

CC/17/39

Parveen Kumar Bansal - Complainant(s)

Versus

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

Kulbir Singh Brar

02 Aug 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                      CC No. 39 of 2017

                                                                                      Instituted on: 18.04.2017

                                                                                      Decided on: 02.08.2017 

 

Parveen Kumar Bansal aged about 57 years, son of Shiv Charan Dass, resident of House no.186, Friends Colony, G.T. Road, Moga, Tehsil & District Moga.

 

                                                                                ……… Complainant

 

Versus

1.       The Oriental Insurance Company Limited, through its Branch Manager, having its office at opposite Chhabra Hospital, Above Fine Furniture, Bus Stand Road, Ludhiana.

 

2.       The Oriental Insurance Company Limited, through its Branch Manager, having its office at Amolak Bhawan, G.T.Road, Moga, Tehsil & District Moga.

 

3.       Dr. Lalita Kansal, Kansal Hospital, Gandhi Road, Moga, Tehsil & District Moga.   

 

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Kulbir Singh Brar, Advocate Cl. for complainant.

                   Sh. Pawan Kumar Sharma, Advocate Cl. for opposite party nos.1 & 2.

                   Opposite party no.3 ex-parte.

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against The Oriental Insurance Company Limited, through its Branch Manager, having its office at opposite Chhabra Hospital, Above Fine Furniture, Bus Stand Road, Ludhiana and others (hereinafter referred to as the opposite parties) directing them to pay a sum of Rs.57,947/- to complainant jointly and severally on account of medical insurance claim, which was illegally repudiated by opposite party nos.1 & 2 with interest @ 12% per annum w.e.f. 24.10.2016 till the date of realization. Further opposite parties may be directed to pay Rs.50,000/- on account of mental tension, agony and harassment and Rs.11,000/- as litigation expenses to the complainant or any other relief which this Forum may deem fit and proper be granted.

2.                Briefly stated the facts of the case are that the complainant had taken a PNB- Oriental Royal Mediclaim policy bearing no.233902/48/2016/5052 for himself, through Punjab National Bank, Partap Road, Moga for the period 18.01.2016 to 17.01.2017 from The Oriental Insurance Company. During the policy period, the complainant fell ill due to Dengue Fever and got admitted in the hospital of opposite party no.3 for the period 7.10.2016 to 17.10.2016 for his treatment. The complainant spent Rs.57,947/- on his treatment. On 08.10.2016, the brother of the complainant duly informed the opposite party no.2 regarding the admission of the complainant in the hospital. After getting discharge from the hospital, the complainant approached opposite party no.2 for his medical insurance claim. Opposite party no.2 advised the complainant to fill the claim form and also directed to enclose the original discharge card of the hospital alongwith bills, receipts and cash memos from the hospital/Chemist, receipts and pathological test reports from pathologist. As per advise given by opposite party no.2, the complainant submitted the duly filled claim form dated 24.10.2016 in the office of opposite party no.2 alongwith other relevant documents in original. In the week of November, 2016 the complainant received a letter dated 22.11.2016 from opposite party no.2 regarding submission of some more documents as required by TPA. After receiving the said letter, the complainant immediately submitted the required documents in original with opposite party no.2 and complainant was told that the claim amount will be directly transferred in the bank account of the complainant within 15 days, if no more documents required by TPA. After passing of 15 days period, the complainant did not receive any payment from the opposite parties. The complainant went to the office of opposite party no.2 and enquired about the payment. The concerned officer of opposite party no.2 told the complainant that they did not receive the final report from TPA and after receiving the final report, they will transfer the claim amount in the account of the complainant. But nothing was done. Thereafter, complainant several times visited the office of opposite party no.2 and always received the same answer. Thereafter, the complainant received a letter from the opposite party no.1 vide which the claim of the complainant was repudiated. After receiving the said letter, the complainant immediately approached at the office of opposite party no.2 and met with the branch manager, but all in vain. Due to the acts of opposite parties, the complainant has suffered a great harassment, financial loss and irreparable loss. Hence this complaint.

3.                Upon notice, opposite party nos.1 & 2 appeared through counsel and filed written reply taking certain preliminary objections that the complaint is not maintainable; that the complainant is stopped by his own act and conduct; that the complainant has not complied with the terms and conditions of insurance policy; that no cause of action arose to the complainant against the answering opposite parties; that there is no deficiency in service on the part of opposite party nos.1 & 2; that the complainant has not come to the Forum with clean hands. He has concealed, suppressed and misstated the material facts from this Forum. Infact, true facts are that the complainant Parveen Kumar Bansal had taken PNB-Oriental Royal Mediclaim Policy bearing no.233902/48/2016/5052 for the period 18.01.2016 to 17.01.2017. It is alleged by Sh.Parveen Kumar Bansal/complainant that he fell ill due to dengue fever and was admitted in Kansal Hospital, Moga from 7.10.2016 to 17.10.2016. The complainant filed the claim form with answering opposite parties on 24.10.2016 and after receiving the claim form, the opposite parties investigated the claim and wrote letter dated 22.11.2016 to complainant requesting him to furnish the documents. After receiving the claim form and after investigating and on perusal of all the relevant documents, it was observed that as per medical opinion NS1 antigen is non specific and lgM and lgG dengue are negative, admission not needed and can be treated as OPD, platelet count was well above one lakh. Admission not indicated. Since OPD expenses for medicines and diagnostic purposes are not admissible under the policy, the claim stands repudiated under exclusion clause 4.10. Hence the claim is not admissible. On merits, it is admitted to the extent that complainant submitted claim form dated 24.10.2016. All the documents were not filed with the claim form. The answering opposite parties requested for other documents vide letter dated 22.11.2016. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with special costs has been made.

4.                Notice issued for the service of opposite party no.3 duly served. But despite that none had appeared on behalf of opposite party no.3. As such, opposite party no.3 was proceeded against ex-parte.

5.                In order to prove the case, complainant tendered in evidence his duly sworn affidavit Ex. C-1 alongwith copies of documents Ex.C-2 to Ex.C-38 and closed the evidence. 

6.                On the other hand, opposite party nos.1 & 2 tendered in evidence duly sworn affidavit of Sh.Sanjeev Kumar, Manager, Oriental Insurance Company Ltd. Ex.OP-1, 2/1 alongwith copies of documents Ex.OP-1, 2/2 to Ex.OP-1, 2/5 and closed the evidence.

7.                We have heard ld. counsel for the parties and have very carefully gone through record placed on file.

8.                Ld. counsel for the complainant argued that the complainant purchased a Mediclaim policy from opposite party nos.1 & 2. During the policy period, complainant fell ill due to Dengue Fever and got admitted in the hospital of opposite party no.3 for the period 7.10.2016 to 17.10.2016 for his treatment, where he spent Rs.57,947/- on his treatment and due intimation regarding his admission was duly given to opposite parties. After getting discharge from the hospital, the complainant lodged the claim with opposite parties and also submitted the claim form alongwith all the relevant documents in original with them. The opposite parties assured the complainant that claim amount will be directly transferred in his bank account. But the complainant has not received any payment. However opposite parties repudiated the claim of the complainant. In reply, opposite parties admitted that the complainant had taken Mediclaim Policy from them. It has also admitted that complainant fell ill due to dengue fever and was admitted in Kansal Hospital, Moga and he filed claim form with answering opposite parties. They submitted that after receiving the claim form, they investigated the matter and after investigating and on perusal of all the relevant documents, it was observed that as per medical opinion NS1 antigen is non specific and lgM and lgG dengue are negative, admission not needed and can be treated as OPD, platelet count was well above one lakh. Admission not indicated. Since OPD expenses for medicines and diagnostic purposes are not admissible under the policy, the claim stands repudiated under exclusion clause 4.10. Hence the claim is not admissible.

9.                We have thoroughly gone through the file, evidence and arguments led by ld. Counsel for both the parties. It is admitted case of the parties that the complainant purchased mediclaim policy from opposite parties and it is further admitted that the complainant remained hospitalized during the policy period for his treatment and after discharge from the hospital, he lodged the claim for the reimbursement of medical expenses alongwith all other required documents with opposite parties. In order to prove his version that complainant has produced his discharge slip and medical record as Ex.C-8 and Ex.C-23 to Ex.C-38. In order to prove that he spent Rs. 57,947/- for his treatment, he produced copies of bills and receipts Ex.C13 to Ex.C-22. From these documents it is proved that the complainant remained hospitalized for the treatment of dengue and he spent Rs. 57,947/- for his treatment. The only plea of the opposite parties is that after receiving the claim from the complainant it was referred to TPA for their opinion and observation, but said TPA repudiated the claim of the complainant on the ground that the treatment taken by the complainant does not require hospitalization and moreover it does not come under daycare procedure and the same is OPD basis treatment and does not require hospitalization. So, the claim of the complainant was repudiated. There is no doubt that attending and treating doctor is the best judge to decide whether the patient requires hospitalization for his treatment or not. The alleged expert who gave opinion only from the documents i.e. too who is appointed by the Insurance Company and paid by them cannot decide whether any patient requires hospitalization or not for his treatment. It is general tendency that a person reports in favour of the party, who engages him and paid him. So, we cannot rely upon the opinion of alleged expert appointed by Insurance Company.  It is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. On this point, Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Ors 2008 (3) RCR (Civil) Page 111 has held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which generally are hidden need to be simplified so that these are easily understood by a person at the time of buying any Policy. The Insurance Companies in such cases, rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy.   Further Hon'ble Apex Court in case titled as M/s Modern Insulators Ltd. Vs The Oriental Insurance Company Ltd. - 2000(1) CPR 93 (Supreme Court) 242 held that clauses which are not explained to complainant are not binding upon the Insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims.   Further Hon'ble Punjab and Haryana High Court in case tilted as IFFCO TOKYO General Insurance company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others - 2012 (1) RCR(Civil) 901 held that  Contract Act, 1872 – Insurance Act, 1938 – contract among unequal – Validity – Medicalim Policy – Exclusion clause – Pre existing disease – Exclusion clause is standard form of contracts – When bargaining power of the party is unequal and consumer has no real freedom to contract – Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

10.              In view of above discussion, we are of considered opinion that opposite parties have wrongly and illegally repudiated the claim of complainant which amounts to deficiency in service and trade mal practice. Hence, present complaint in hand is hereby allowed with direction to opposite parties to pay Rs.57,947/- as insurance claim to complainant alongwith interest at the rate of 9 % per annum from 20.03.2017, when they repudiated the claim of complainant till final realization. Opposite parties are further directed to pay Rs.3000/-(Three thousand only) as  litigation expenses to the complainant. Compliance of this order be made within one month from the receipt of the copy of the order, failing which complainant shall be entitled to proceed under section 25 and 27 of the Consumer Protection Act. Copy of the order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated: 02.08.2017

                                                  (Bhupinder Kaur)                    (Ajit Aggarwal)

                                                       Member                                           President