Punjab

Ludhiana

CC/14/523

Satinder Singh - Complainant(s)

Versus

United India Ins.Co.Ltd - Opp.Party(s)

19 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 523 of 28.07.2014

                                                                                                                    Date of Decision: 19.02.2015

                                                                                                                   

Satwinder Singh s/o Late S.Devinder Singh age 47 years r/o House no.3814, Shivaji Nagar, Gali no.8, Ludhiana.

……Complainant

Versus 

1. United India Insurance Compnay Ltd., through its Branch Manager, Industrial Area- B, Above Allahabad Bank, Near Partap Chowk, Ludhiana.

2. M/s Raksha TPA Pvt. Ltd., through its Managing Director, SCO-122, (Basement), Cabin no.5, Feroze Gandhi Market, Ludhiana.

 

…..Opposite party 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member

                   Smt.Babita, Member

 

Present:       Sh.S.S.Heer, Advocate for complainant.

                   Sh.M.S.Jassal, Advocate for OPs.

 

 

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Satwinder Singh s/o Late S.Devinder Singh age 47 years r/o House no.3814, Shivaji Nagar, Gali no.8, Ludhiana (herein-after in short to be referred as ‘complainant’) against United India Insurance Compnay Ltd., through its Branch Manager, Industrial Area- B, Above Allahabad Bank, Near Partap Chowk, Ludhiana and other (herein-after in short to be referred as ‘OP’)- directing them to pay Rs.1,80,000/- (insured amount Rs.2,50,000/-  -  Rs.70,000/-) as medicalim reimbursement amount as per the insured value mentioned under the insurance policy no.201003/48/13/06/00000208 valid from 23.8.13 to 22.8.14 alongwith interest @ 24% p.a. from 31.5.14 till the realization. Further Ops be directed to pay Rs.1.00 lac as compensation for mental pain and agony alongwith cost alongwith any other relief as this Forum deems fit.

2.                Brief facts of the complaint are that complainant had purchased a Individual Health Insurance policy for the first time in the year 2002 and the same was further renewed upto the period 23.08.13 to 22.08.14, vide policy no.201003/48/13/06/00000208 and a sum of Rs.6751/- was paid as premium, which was received by OP1, vide receipt dated 16.8.13. The said policy is known as Family Medicare Policy. In the aforesaid policy the following persons are covered:-

1. Satwinder Singh 45 years self

2. Smt.Rajinder Kaur age 43 Spouse

3. Ms.Puneet Kaur age 19 years Daughter

4. Master Jaspreet Singh 15 years Son

5. Ms.Inderpreet Kaur 12 year Daughter

 

          The sum of insured opted Rs.2,50,000/-. Suddenly the complainant suffered a problem of Coronary Artery Disease- TVD, Unstable Angina, LV Dysfunction and COPD and he got himself admitted in the CMC and Hospital for the treatment of said disease and he remained admitted from 1.5.14 to 19.5.14. The information regarding the admission of complainant in the hospital was given to OP1 by the brother of the complainant, vide letter dated 5.5.14. The complainant spent Rs.3,08,850/- for the treatment of aforesaid disease. The said charges were paid by the complainant to the said hospital. After his discharge from the hospital complainant has submitted a medical claim of Rs.3,08,850/- with OP1 on 31.5.14 alongwith original bills and receipts in respect of the medical expenses incurred for the treatment of the complainant. After the submission of mediclaim to the OP1, the complainant contacted them a number of times in respect of reimbursement of mediclaim of Rs.3,08,850/- under the Family Medicare Policy, but the Ops unilaterally reimbursed the amount the amount of Rs.70,000/- to the complainant and the said amount was transferred to the account of the complainant. Claiming the above act as deficiency in service on the part of the Ops, the complainant has filed this complaint.

3.                On notice of the complaint, OPs appeared through their counsel and filed written statement taking preliminary objections that present complaint is not maintainable; the complainant has taken the Individual Health Insurance Policy for the period from 23.8.08 to 22.08.09 from OP1 and sum insured was Rs.1.00 lac, which was further extended for the period 23.08.13 to 22.08.14, where the sum Insured was Rs.2,50,000/-. Complainant remained admitted in CMC and Hospital, Ludhiana from 1.5.14 to 19.5.14 for his treatment. Thereafter after receiving all the requisite documents from the complainant, OP1 sent all the papers to OP2 and claim of the complainant was duly considered and from discharge summary of the complainant, it was found that the complainant was having chest pain and breathlessness since 2007 accordingly 70% of the sum insured on Rs.1.00 lac for the policy 23.8.08 to 22.8.09. On merits, admitting the contents of paras no.1 to 8 submitted that Rs.70,000/-, which was found to be allowable as per the individual health insurance policy for the period 23.8.08 to 22.8.09 was paid directly to the complainant. Since the patient was having pre-existing disease in the year 2007 as mentioned for the discharge summary of the hospital. The intention of the complainant was to renew the policies from 2008 upto 2014 for the purpose to increase insured sum to get the mediclaim benefit from the OPs after his treatment.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Satwinder Singh Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C38. On the other hand, Ld. counsel for OPs has adduced the evidence by way of duly sworn affidavit of Sh.Satnam Singh Basra, Deputy Manager, United India Insurance Company Ltd. D.O. No.IV, Savitri Commercial Complex, G.T.Road, Dholewal, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and also attached documents Ex.R1 to Ex.R38.

5.                Case was fixed for arguments. Ld. counsel for complainant filed written arguments averring that complainant had purchased a Individual Health Insurance policy for the first time in the year 2002 and the same was further renewed upto the period 22.08.08. The said policy was renewed by the OPs under policy no. 201003/48/08/97/00000181 valid from 23.8.08 to 22.08.09. The said policy continuously renewed upto 22.8.13, vide various policies. The said policy lastly renewed on 16.8.13, vide policy no.201003/48/13/06/00000208 valid from 23.08.13 to 22.08.14,and a sum of Rs.6751/- was paid as premium, which was received by OP1, vide receipt dated 16.8.13. The said policy is known as Family Medicare Policy. In the said policy, inception date of the insured has been mentioned 23.08.02 and a sum of insured opted Rs.2,50,000/-. Suddenly the complainant suffered a problem of Coronary Artery Disease- TVD, Unstable Angina, LV Dysfunction and COPD and he got himself admitted in the CMC and Hospital for the treatment of said disease and he remained admitted from 1.5.14 to 19.5.14. The information regarding the admission of complainant in the hospital was given to OP1 by the brother of the complainant, vide letter dated 5.5.14. The complainant spent Rs.3,08,850/- for the treatment of aforesaid disease. After his discharge from the hospital complainant has submitted a medical claim of Rs.3,08,850/- with OP1 on 31.5.14 alongwith original bills and receipts in respect of the medical expenses incurred for the treatment of the complainant. But the Ops reimbursed the amount of Rs.70,000/- to the complainant and the said amount was transferred to the account of the complainant without assigning any reason regarding the deduction of Rs.1,80,000/- from the claim amount.

6.                Refuting the allegations leveled by the complainant, Ld. counsel for OPs argued that no doubt the policy was extended upto the period 23.08.13 to 22.08.14 and the value of the sum insured was Rs.2,50,000/-. But the demand of the complainant is that the claim should be satisfied to the extent of 70% of the insured value for the period 23.08.13 to 22.08.14, which comes out to Rs.1,75,000/- instead of value of the sum insured of the policy 2008, is not agreeable. Further Ld. counsel for OPs has relied upon the clause 5.14 of the policy, which is as follow:-

“5.14 Enhancement of Sum Insured- The insured may seek enhancement of Sum Insured in writing at or before payment of premium for renewal, which may be granted at the discretion of the Company. However, notwithstanding enhancement, for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding policy period, liability of the company shall be only to the extent of the Sum Insured under the policy in force at the time when it was contracted or suffered during the currency of such renewed policy or any subsequent renewal thereof.”

                   OPs further argued that the complainant was having pre-existing disease of breathlessness as mentioned in the discharge summary Ex.C7, the relevant part of which is reproduced as below:-

“Patient Mr.Satwinder Singh- 47 years old male was admitted with c/o chest pain and breathlessness X one day and Past H/o MI in 2007 for further treatment and management. CAG was done which showed triple vessel disease. Patient was put on IABP for ongoing hypotension and ischemia and raised PA pressure.

The Options of treatment were discussed in details with the patient and her relatives and they opted for surgery. Patient was taken up for CABG on 8^th May, 2014.”

 

                        Further averred that the intention of the complainant was to get higher compensation on the basis of the latest policy for the period 23.08.13 to 22.08.14 for which he went on extending the policies and got the treatment during this period.

7.                We have gone through the pleadings, written arguments submitted on behalf of complainant as well as defence taken by the OPs and have also perused the entire record placed on file and also gone through the case law relied on by the complainant and the OPs.

8.                It is evident that the complainant availed the policies continuously for the years 2002 to 2008, which was further extended from 23.8.08 to 22.8.09 and lastly renewed on 16.8.13, vide policy no.201003/48/13/06/00000208 valid for the period 23.8.13 to 22.8.14. It is correct that discharge summary of the hospital shows that he was having chest pain and breathlessness since the year 2007. As such, the payment of Rs.70,000/- was paid on the basis of the policy of the year 2008, wherein the insured value was Rs.1.00 lac. But if the claim is to be settled on the sums insured in the previous year’s policies what was the fun of enhancing the sum in the current year while the complainant paid higher premium on the enhanced sum insured. Ld. counsel for complainant has also relied upon the judgements, which is as follows:-

“Dharmendra Goel Vs Oriental Insurance Co. Ltd.-2008 (3) CPC 264 passed by Hon’ble Supreme Court of India, wherein, it is held that it is often seen that insurance company disowns the figure of accepted value of insured goods on one pretext or other which is a bad attitude. Company should be bound by value of vehicle which they determined at the time of renewal of policy. In the present case, vehicle was used for seven months as such reduction value of Rs.10,000/- is justified. Company directed to pay Rs.3,44,000/- after this reduction and also to pay interest. Further relied on the case New India Assurance Co. Ltd. Vs Bhagar Singh-2009(1) CPC 426 passed by Hon’ble National Commission, wherein, it is held that the officer of Rs.40,000/- was not accepted by the petitioner. As premium was accepted on Rs.2 lacs insurer cannot be allowed to limit the claim upto Rs.40,000/- only. Insurer directed to pay full insured claim of Rs.1,62,370/- with 9% p.a. interest. Alternative offer of repair charges cannot be accepted after lapse of 6 years. Order of District Forum upheld and further relied upon case P.C Chacko and another Vs Chairman Life Insurance Corporation of India and others-2008 (3) CPC 248 passed by Supreme Court of India, wherein, it was held that Section 45- Insurance Corporation is a State within the meaning of Article 12 of Constitution. Action of Corporation in settlement of claim must be fair, just and equitable.

 

          The abovesaid judgements are very much relevant. As such the present case is covered in these similar case laws. However, it is not tenable that the patient would go on lingering his treatment only to get mediclaim benefit of the insurance policy and it is also not tenable that the person would be awaiting for 6 years to get the treatment and put his life in risk for such a long time. If the OPs had decided to pay 70% of the insured value then it should have been paid for the last policy valid from 23.8.13 to 22.8.14. As such, OPs are found to be deficient in service.

9.                Sequel to the above discussion, the present complaint is allowed and the OPs are directed to re-consider the claim according to the last policy for the period 23.08.13 to 22.08.14 and to settle and pay the claim of the complainant @ 70% of the sum insured of the last above mentioned policy. Further OPs are directed to pay Rs.5000/-(Five thousand only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days of receipt of the copy of the order, which be made available to the parties, free of costs. File be consigned to record room.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.

Dated:19.02.2015 

Hardeep Singh