8. On the other hand, ld.counsel for Opposite Parties No.1 and 5 has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that answering opposite parties are neither insurer nor insured. There is no relationship of insurer and insured between answering opposite parties and the complainant. The answering opposite parties have not rendered any service to the complainant of an insurer. The answering opposite parties were to receive claim application with documents as collecting agent of the opposite party no.2 to 4 as per clause 5.5 of the group insurance policy; that being not an insurer, the answering opposite parties are not the necessary parties. The present complaint is bad for mis-joining of opposite parties as parties to the present complaint. Hence present complaint is liable to be dismissed qua answering opposite parties on this score also; that no cause of action arose to complainant against answering opposite parties. The complainant submitted medical claim of his wife Smt.Santosh Kaura for Rs.50,669/- on 26.10.2016 with the opposite party no.1 and opposite party no.1 dispatched the same to opposite party no.5 on the same day i.e. on 26.10.2016. Smt. Santosh Kaura was discharged from the hospital on 12.10.2016. Opposite party no.5 instructed the answering opposite party no.1 for compliance of two queries. Complainant submitted the claim well within time. But there was delay in collecting the claim documents from the office of opposite party no.5 by the representative of Heritage Health Insurance TPA Pvt. Ltd. i.e. opposite party no.3 & 4. The representative of opposite party no.3 and 4 used to collect claim cases/documents from the office of answering opposite party no.5 twice in a month. As per clause 5.5 of group insurance policy, the insured i.e. complainant was required to submit claim documents either with the answering opposite party no.1 & 5 dealing with the claim or with the third party administrator i.e. opposite party no.3 & 4 within 30 days from the date of discharge from the hospital. Thus, the complainant had submitted his claim document with the opposite party no.5 within time. Thus, the complainant had complied with condition of submitting claim within 30 days from the date of discharge from the hospital. Opposite party no.5 received the rejection letter dated 14.03.2017 from opposite party no.3 & 4 on the basis of wrong interpretation of condition no.5.5 of the policy and hence, there is no deficiency in service on the part of opposite party no.1 and 5. On the other hand, none has put in appearance on behalf of the Opposite Parties No. 2, 3 and 4 despite due service and hence preferred to remain exparte in the instant case.
9. The main factum of the case in hand are not denied that complainant is insured under Group Insurance policy of opposite party no.2 and 3, through opposite party no.4. The employment ID of complainant is 7830. The wife of the complainant Smt. Santosh Kaura, sustained fracture of her right arm and she remained hospitalized in Kaura Hospital and Multi-Speciality Centre, G.T. Road, Moga from 5.10.2016 to 12.10.2016. During this period i.e. on 11.10.2016 the complainant informed through e-mail to opposite parties on their e-mail ID No.Ucobank.heritage@bajoria.in in regard to hospitalization of his wife Smt. Santosh Kaura. Thereafter the complainant submitted medical claim of his wife Smt.Santosh Kaura amounting to Rs.50,669/- alongwith claim documents to opposite party no.1 on 26.10.2016 and the opposite party no.1 dispatched the same on the same day i.e. on 26.10.2016 to opposite party no.5 via registered post. The complainant submitted the said medical claim within 30 days from the discharge of his wife from the hospital on 12.10.2016. But opposite party no.3 vide its letter dated 14.03.2017 declined the medical claim of Smt. Santosh Kaura (wife of complainant) on the ground of non submission of claim documents within due time. In the said letter dated 14.03.2017 opposite party no.3 has mentioned that "Please refer your Policy Clause no.5.5 which clearly stated that any claim to be submitted within 30 days after discharge from the hospital". The perusal of clause 5.5 of the said policy clearly shows that in the letter dated 14.03.2017 the opposite parties have not mentioned complete clause 5.5 and concealed the fact that the claim can be submitted to the bank or to TPA within 30 days. In the present case the complainant has given due intimation to the bank and submitted the claim alongwith all relevant documents to the bank within 30 days. In this way, the complainant has made compliance of clause 5.5 of the policy. The opposite party no.2, 3 & 4 wrongly rejected the medical claim of complainant. On the other hand, ld.counsel for the Opposite Parties No.1 and 5 has argued that the complainant submitted medical claim of his wife Smt.Santosh Kaura for Rs.50,669/- on 26.10.2016 with the opposite party no.1 and opposite party no.1 dispatched the same to opposite party no.5 on the same day i.e. on 26.10.2016. Smt. Santosh Kaura was discharged from the hospital on 12.10.2016. Opposite party no.5 instructed the answering opposite party no.1 for compliance of two queries. Complainant submitted the claim well within time. But there was delay in collecting the claim documents from the office of opposite party no.5 by the representative of Heritage Health Insurance TPA Pvt. Ltd. i.e. opposite party no.3 & 4. The representative of opposite party no.3 and 4 used to collect claim cases/documents from the office of answering opposite party no.5 twice in a month. As per clause 5.5 of group insurance policy, the insured i.e. complainant was required to submit claim documents either with the answering opposite party no.1 & 5 dealing with the claim or with the third party administrator i.e. opposite party no.3 & 4 within 30 days from the date of discharge from the hospital. Thus, the complainant had submitted his claim document with the opposite party no.5 within time. Thus, the complainant had complied with condition of submitting claim within 30 days from the date of discharge from the hospital. Opposite party no.5 received the rejection letter dated 14.03.2017 from opposite party no.3 & 4 on the basis of wrong interpretation of condition no.5.5 of the policy and hence, there is no deficiency in service on the part of opposite party no.1 and 5. In this regard, the complainant in his complaint as well as in duly sworn affidavit of the complainant it is vehemently admitted that “the complainant submitted medical claim of his wife Smt.Santosh Kaura amounting to Rs.50,669/- alongwith claim documents to opposite party no.1 on 26.10.2016 and the opposite party no.1 dispatched the same on the same day i.e. on 26.10.2016 to opposite party no.5 via registered post.” Which also corroborated the version and admission of Opposite Parties No.1 and 5 that “the complainant submitted medical claim of his wife Smt.Santosh Kaura for Rs.50,669/- on 26.10.2016 with the opposite party no.1 and opposite party no.1 dispatched the same to opposite party no.5 on the same day i.e. on 26.10.2016.” which fully proves that there is no lapse/ deficiency on the part of Opposite Party No.1 as specifically mentioned by the complainant in his complaint and duly sworn affidavit of the complainant.
10. Ld.counsel for Opposite Parties No.1 and 5 has specifically contended that as admitted by the complainant in his complaint as well as in his duly sworn affidavit that Opposite Party No.1 has forwarded the claim document with Opposite Party No.5 on the same day and hence there is no deficiency in service on the part of Opposite Party No.1, and in this way, the Opposite Party No.1 is wrongly impleaded in the instant case. Furthermore it is contended that Opposite Parties No.1 and 5 are the agent of the Opposite Parties No. 2, 3 and 4 and they have to do nothing, but are only the agent qua the complainant and Opposite Parties No. 2, 3 and 4. In this regard, ld.counsel for Opposite Parties No.1 and 5 have placed on record the citation of Hon’ble National Commission, New Delhi in 2009(2) CPR 143 (NC) tilted as Life Insurance Corporation of India Vs. Smt.Ranjana Misra and Ors. And ruling of Hon’ble Madhya Pradesh State Commission, Bhopal 2009(3) CPR 94 tilled as Snehalata Verma Vs. Life Insurance Corporation of India, in these rulings, it is held that in case of lapse on the part of any agent, then the employer (LIC) is liable for fault if any of the agent and we are fully in agreement with the aforesaid rulings of Hon’ble National Commission, New Delhi.
11. But it is very strange that on the one side, none appeared on behalf of Opposite Parties No. 2, 3 and 4, to defend its case despite due service, but on the other hand, in the letter dated 14.3.2017 issued by Heritage Health TPA Pvt.Limited, it is mentioned that “we are unable to process the claim due to no submission of the claim in due time as per policy terms and conditions.” In this way, the Opposite Parties No. 2, 3 and 4 have failed to confront its case by filing its version through any affidavit of some authorized person, rather preferred to remain exparte with dictatorial manner, rather took objection that there is delay in filing the claim within due time of 30 days from the date of discharge from the hospital. But however, the late submission of the documents, if any, is no ground to decline the genuine claim. Reliance in this connection can be had on National Insurance Company Limited versus Kamal Singhal IV (2010) CPJ297 (NC) wherein the Hon'ble National Consumer Disputes Redressal Commission, New Delhi relying upon various decisions in the matter of (1) National Insurance Company Ltd. v. J. P. Leasing & Finance Pvt. Ltd. (RP No. 643/2005), (2) Punjab Chemical Agency v. National Insurance Company Ltd. (RP No. 2097/2009), (3) New India Assurance Co. Ltd. v. Bahrati Rajiv Bankar, (RP) No. 3294/2009) and (4) National Insurance Company Ltd. v. Jeetmal, (RP No.3366/2009) and also judgment of the Hon'ble Apex Court in the matter of Insurance Company Versus Nitin Khandewal IV (2008) CPJ 1(SC), has held that:
“the appellant Insurance Company is liable to indemnify the owner of the vehicle when the insurer has obtained comprehensive policy to the loss caused to the insurer”.
12. The further contention of the complainant is that in the letter dated 14.03.2017 opposite party no.3 has mentioned that "Please refer your Policy Clause no.5.5 which clearly stated that any claim to be submitted within 30 days after discharge from the hospital". But on the other hand, Opposite Parties No. 2, 3 and 4 have failed to prove on record that they ever mentioned complete clause 5.5 and hence, concealed the fact that the claim can be submitted to the bank or to TPA within 30 days. In this way, no complete clause No.5.5 has ever been submitted to the complainant. Hence, the impugned clause of the insurance cover is not applicable in the case of the complainant because no complete clause was ever supplied to the complainant at the time of obtaining the policy. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.” Moreover, on the other hand, no one appeared on behalf Opposite Parties No. 2, 3 and 4 despite due service for the reasons best known to them and hence they could not produce any evidence to prove that complete clause of the policy was supplied to the complainant, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insruance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the parties, it is clear that Opposite Parties No. 2, 3 and 4 have failed to prove on record that they ever did supply the terms and conditions of the policy to the complainant. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured.
13. It is also an admitted fact that the claim was repudiated vide letter dated 14.03.2017 Ex.C8. The ground on which the claim of the complainant has been repudiated has been that “we are unable to process the claim due to non submission of the claim in due time as per policy terms & conditions.” Perusal of the repudiation letter Ex.C8 shows that it is issued by Heritage Health Insurance TPA Pvt. Limited and it means that on the report of the TPA, Insurance Company has repudiated the claim of the complainant. But recently, our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.1105 of 2014 decided on 25-04-2017, (2017 (3) CLT page 120 in case titled as Sukhdev Singh Nagpal Vs. New Karian Pehalwal Cooperataive Agriculture service Society & Others has held that TPAs have no authority to reject the claim- such power lies, exclusively with the Insurance Companies (Para No.25 to 27). The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same. The claim of the complainant was illegally and arbitrarily rejected by the TPA, against the instructions of the IRDA. In view of this, the repudiation merely on the basis of report of the TPA is not legal.
- It is usual with the insurance company to show all types of green pesters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams 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.5000/- for luxury litigation, being rich.
15. From the aforesaid discussion, it transpires that Opposite Parties No. 2, 3 and 4 have wrongly repudiated the genuine claim of the complainant. Opposite Parties No. 2, 3 and 4 are directed to make the payment of claim of Rs. 50,669/- to the complainant. Opposite Parties No. 2, 3 and 4 are also directed to pay Rs.5,000/- to the complainant on account of compensation besides Rs. 2,000/- as costs of litigation. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 6% p.a from the date of filing of the complaint until full and final recovery. However, complaint against Opposite Parties No.1 and 5 stands dismissed. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
