DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

 

Complaint Case No : CC/49/2019

Date of Institution : 09.05.2019

Date of Decision : 04.11.2019

Sadhu Ram aged about 66 years S/o Lekh Ram, Resident of Near Gurdwara Village Ghunas, Tehsil Tapa now Resident of Moti Nagar Street No. 4, Tapa Mandi, District Barnala. …Complainant

Versus

1. Oriental Insurance Company, A-25/27, Asaf Ali Road, New Delhi-110002 through its Managing Director/Authorized Signatory.

2. Oriental Insurance Company, 4501, Bank Street, Bathinda through its Managing Director/Authorized Signatory.

3. Punjab National Bank, Branch Tapa Mandi, Tehsil Tapa District Barnala.

4. M/s Raksha TPA Pvt. Ltd., 15/5, Mathura Road, Faridabad-121003.

…Opposite Parties

 

Complaint Under Section 12 of the Consumer Protection Act, 1986

Present: Sh. Gagandeep Garg counsel for complainant.

Sh. Varinder Goyal counsel for opposite parties No. 1 and 2.

Sh. AK Jindal counsel for opposite party No. 3. 

Opposite party No. 4 exparte. 

 

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

3. Smt. Manisha : Member

 (ORDER BY KULJIT SINGH, PRESIDENT):

    The complainant namely Sadhu Ram has filed the present complaint under Section 12 of the Consumer Protection Act 1986 as amended up to date (in short the Act) against Oriental Insurance Company, New Delhi and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that complainant is having one saving account with the opposite party No. 3 who had tied up with the opposite parties No. 1, 2 and 4. It is further alleged that complainant purchased PNB Oriental Royal Mediclaim Policy and opposite parties medically examined the complainant and his wife. Then complainant paid an amount of Rs. 3,320/- on 16.12.2014 to the opposite parties who issued one Policy No. 233200/48/2015/2608 valid from 16.12.2014 to 15.12.2015. The complainant continued the said policy regularly and paid the premium amount for the year 2015-2016 and 2016-2017 and also for 2017-2018 and for the period of 2018 the opposite parties issued policy bearing No. 233200/48/2017/3039 for the complainant and his wife for the period from 24.12.2017 to 23.12.2018 for an amount of Rs. 2 lacs. 

3. It is further alleged that in the month of September 2018 complainant suffered from right eye problem and he went for treatment to Hospital Vasu Eye Institute and Skin Centre, Bathinda where it was diagnosed that he is suffering from Cataract in Right Eye and got admitted for operation from 22.9.2018 to 23.9.2018 and same was done by the doctors. The expenditure charged for the operation was Rs. 14,500/- and Rs. 1,428/- was charged for tests and medicines and follow up so total expenditure of treatment was Rs. 15,928/-. After that complainant submitted all the documents with the opposite parties No. 1, 2 and 4 in the month of September 2018 who assured that the payment will be made by cheques at the residence of the complainant by post. But they have not paid any amount and after many visits of complainant they refused to refund the amount of claim by sending one rejection letter to him, which is deficiency in service on the part of the opposite parties.  Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay the claim amount of Rs. 15,928/- alongwith interest at the rate of 18% per annum from the  date of start of treatment till realization. 

2) To pay Rs. 50,000/- on account of mental tension, agony and  harassment.           

3) To pay Rs. 25,000/- as litigation expenses.  

4) Any other relief this Forum deems fit. 

4. Upon notice of complaint, opposite parties No. 1 and 2 filed written version taking legal objections on the grounds of concealment of true facts, breach of terms of contract of Health Insurance and violation of terms and conditions, no locus standi or cause of action, no jurisdiction and not maintainable. They further objected that number of letters dated 5.11.2018, 20.11.2018, 28.11.2018, 11.12.2018, 10.1.2019 and 17.1.2019 were sent to the complainant to fulfill the required documents but complainant has not completed the required documents for settlement of claim so opposite parties closed the claim of the complainant and there is no deficiency or unfair trade practice on the part of the answering opposite parties. 

5. On merits, it is submitted that the policy was purchased by the complainant through PNB and paid the amount to PNB and answering opposite parties issued the policy to the complainant as per proposal of PNB. Further, as per terms and conditions of the policy no medical check up was conducted by them. Rest of the averments of  complaint are denied by the answering opposite parties. However, it is submitted that opposite party No. 4 issued many letters to the complainant to submit the required documents but he has not submitted the documents as required. Rest of the averments of complaint are also denied by the opposite parties and lastly prayed for the dismissal of the present complaint with special costs. 

6. The opposite party No. 3 also filed written version taking legal objections on the grounds of no locus standi or cause of action to file the present complaint, no jurisdiction, outside the preview of Act and abuse of process of law. Further, the answering opposite party is not in the business of insurance and its role is only of a facilitator/Corporate Agent introducing the parties so they are not liable to pay any amount to the complainant and as per Indian Contract Act an agent can neither sue nor be sued as the answering opposite party is only the corporate agent of the insurance company. 

7. On merits, it is admitted that complainant is having a Saving Account with the answering opposite party. They also admitted that complain purchased the Royal Mediclaim Policy which is valid from 16.12.2014 to 15.12.2015 and continued from 24.12.2016 to 23.12.2017. It is also admitted that complainant paid the premium of Rs. 3,320/- through the answering opposite party to purchase the police from opposite parties No. 1, 2 and 4 so complaint against the answering opposite party is not maintainable. The complainant never approached the answering opposite party for any claim nor he is entitled for any relief from the answering opposite party as it is only an agent of the opposite parties No. 1, 2 and 4. Further, answering opposite party never rejected the claim of the complainant nor they have any concern with the claim of the complainant. Rest of the averments of the complaint are denied by the answering opposite party and lastly prayed for the dismissal of the present complaint with costs. 

8. The opposite party No. 4 not appeared before this Forum despite service so the opposite party No. 4 was proceeded against exparte vide order dated 25.6.2019 by this Forum. 

9. In support of his complaint, the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2, copy of Aadhaar Card Ex.C-3, copy of bill dated 22.9.2018 Ex.C-4, copy of discharge summary Ex.C-5, copy of OPD slip dated 29.9.2018 Ex.C-6, copy of receipt dated 22.9.2018 Ex.C-7, copy of OPD slip dated 5.5.2018 Ex.C-8, copy of ECG payment receipt Ex.C-9, copy of receipt of Rs. 500/- Ex.C-10, copy of bill Ex.C-11, copies of repudiation letters Ex.C-12 and Ex.C-13 and closed the evidence.

10. To rebut the case of the complainant, the opposite parties No. 1  and 2 tendered into evidence affidavit of Ashwani Kumar Ex.OP-1.2/1, copy of policy dated 23.12.2016 Ex.OP-1.2/2, copy of policy dated 23.12.2017 Ex.OP-1.2/3, copy of policy dated 23.12.2018 Ex.OP-1.2/4, copy of terms and conditions Ex.OP-1.2/5, copy of repudiation letter Ex.OP-1.2/6, copies of letters dated 5.11.2018, 20.11.2018, 11.12.2018 Ex.OP-1.2/7 to Ex.OP-1.2/9 and closed the evidence. The opposite party No. 3 tendered in evidence affidavit of Rajesh Kumar Sinha Ex.OP-3/1 and closed the evidence.

11. We have heard counsel for the parties and have gone through the record. Written arguments also filed by complainant and Ops-1 and 2.

12. It is admitted by the opposite party No. 3 that the complainant purchased Royal Mediclaim Policy Ex.C-2 from the opposite parties No. 1, 2 and 4 which was valid from 24.12.2017 to 23.12.2018 for sum assured of Rs. 2,00,000/- for himself and his wife. From the copy of discharge summary of Vasu Eye Institute and Skin Centre, Bathinda Ex.C-5 it is proved on the file that complainant took the treatment from this institute for his right eye from 22.9.2018 to 23.9.2018 within the validity period of the above mentioned insurance policy. From the copies of bills and receipts Ex.C-4, Ex.C-6 to Ex.C-11 it is proved on the file that the complainant spent Rs. 15,928/- on his treatment and tests  with Vasu Eye Institute and Skin Centre, Bathinda. But the opposite parties No. 1 and 2 denied the claim of the complainant vide letter Ex.C-12 on the ground that the complainant has not submitted some documents with the insurance company or TPA within 7 days from the date of discharge from the hospital which are Original Bills, receipts, discharge certificate, medical history of patient, original cash memos, test reports, certificate of nature of operation, any other information and certificate of continuation of policy.

13. To prove his case the complainant relied upon copies of insurance policies Ex.OP-1.2/2 to Ex.OP-1.2/4 which are even exhibited by the insurance company and proved on the file that complainant purchased the Royal Mediclaim Policy for the last three years. Further, the complainant also filed tendered in evidence copy of final bill Ex.C-4, discharge summary Ex.C-5 and copies of bills and receipts Ex.C-6 to Ex.C-11 of the amount which he has claimed from the opposite parties. In this way the complainant proved on the file almost all the documents which were demanded by the opposite parties. Some other documents also demanded by the opposite parties but in our view these documents not necessary to settle the claim of the complainant. Further, in our view if the complainant proved all these documents on the file then he must submitted these documents with the opposite parties but the opposite parties repudiated the claim of the complainant only on the ground of non submission of some unnecessary documents which in our view is deficiency in service and unfair trade practice on the part of the opposite parties. 

14. The Hon'ble Punjab and Haryana High Court at Chandigarh in case titled New India Assurance Company Limited Versus Smt. Usha Yadav and others 2008(3) RCR (Civil) Page-111 held as under.-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All 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 clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs. 5,000/- for luxury litigation being rich.”

This citation is also fully applicable to the facts of present case as in the present matter also the opposite parties earned premium  from the complainant for the last three years but at the time when complainant lodged insurance claim then opposite parties relied upon Clause 5.5 of the terms and conditions of the policy which condition is not communicated to the complainant, so the opposite parties are liable to pay the claim of the complainants. Further, in the present case also insurance company repudiated the claim of the complainant unnecessarily without any strong ground despite his repeated requests which is clear cut deficiency in service and unfair trade practice on their part. 

15. As a result of the above discussion and in view of the above citation of the Hon'ble High Court of Punjab and Haryana at Chandigarh present complaint is allowed against the opposite parties No. 1 and 2. Accordingly, opposite parties No. 1 and 2 are directed to pay Rs. 15,928/- to the complainant on account of insurance claim alongwith interest at the rate of 6% per annum from the date of institution of the present complaint till its actual realization and to pay Rs. 5,000/- to the complainant as consolidated amount of compensation on account of mental tension, harassment and litigation expenses. The opposite parties No. 1 and 2 are also directed to deposit Rs. 3,000/- on account of costs in the Consumer Legal Aid Account maintained by this Forum. Both the opposite parties No. 1 and 2 jointly and severally liable to comply with this order. Compliance of order be made within the period of 30 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance. The file be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN FORUM:

  4th Day of November 2019

 

 

 

            (Kuljit Singh)

            President

 

            (Tejinder Singh Bhangu)

Member

 

(Manisha)

Member