BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.210 of 2016

Date of Instt. 11.05.2016

Date of Decision : 4.10.2016

Vijay Kumar aged about 59 years son of Raunki Ram C/o Radhe Krishna Auto Pvt. Ltd., Circular Road, Kapurthala.

..........Complainant

Versus

United India Insurance Co.Ltd., 19, GT Road, Jalandhar through its Branch Manager/Divisional Manager.

.........Opposite party

Complaint Under The Consumer Protection Act.

Before: S. Bhupinder Singh (President)

Sh.Parminder Sharma (Member)

Present: Sh.Rakesh Gupta Adv., counsel for the complainant.

Sh.RS Arora Adv., counsel for opposite party.

Order

Bhupinder Singh (President)

1. The complainant has filed the present complaint under 'The Consumer Protection Act' against the opposite party (hereinafter called as OP) in which the complainant has submitted that he obtained Family Medicare Policy No.200500281P10927 9191 for himself and his wife with sum insured Rs.5 Lakhs for the period from 31.1.2015 to 30.1.2016 from the OP. The complainant pleaded that he has been regularly getting his aforesaid policy renewed w.e.f 25.1.2003 from the OP and Oriental Insurance Company Limited, Kapurthala. The complainant got insurance policy from the OP in the year 2003 vide cover note No.661088 and continuously renewed the policy upto the year 2009 from the OP. Thereafter, the complainant got insurance policy renewed from Oriental Insurance Company Limited, Kapurthala w.e.f 25.1.2009 to 24.1.2010 with sum insured Rs.4 Lakhs vide cover note No.363870 dated 21.1.2009 and continuously got his policy renewed upto the year 2012 from Oriental Insurance Company Limited, Kapurthala. Thereafter, a portable scheme was launched by IRDA and under the scheme the complainant got his policy transferred from Oriental Insurance Company Limited, Kapurthala to OP i.e. United India Insurance Company Limited, Jalandhar and under the aforesaid portability scheme, the complainant obtained the medicare policy for himself and his wife with sum insured Rs.5 Lakhs vide cover note No.597820 dated 23.1.2012 for the period from 25.1.2012 to 24.1.2013 on payment of premium to the OP. The fact of portability has been clearly mentioned in the cover note dated 23.1.2012. Thereafter, the complainant continued renewing the policy from the OP without any break from OP. The complainant fell ill and was taken to Patel Hospital, Jalandhar where he remained admitted from 7.9.2015 to 12.9.2015 and he spent Rs.1,35,000/- on his treatment. Thereafter, the complainant was shifted to Medanta, The Medicity, Gurgaon and he remained admitted there from 13.9.2015 to 22.9.2015 and spent an amount of Rs.2,20,000/- on his treatment. Then again the complainant was admitted in Medanta The Medicity, Gurgaon on 25.9.2015 and discharged on 13.10.2015 and he spent about Rs.7 Lakhs on his treatment during this period. Thereafter, the complainant lodged three different claims bearing Nos.54551516149864, 54551516244545, 54551516261728 for the aforesaid respective three periods. However, the OP passed an amount of Rs.1,81,980/- in favour of the complainant and rejected the remaining amount of Rs.3 Lakhs on the ground that total entitlement of the claim amount is Rs.2 Lakhs only and not Rs.5 Lakhs. The OP also failed to supply the repudiation letter to the complainant and the complainant came to know about this rejection of his remaining claims from the official website of the third party administrator namely Raksha TPA Pvt Ltd. The Complainat submitted that all this amounts to deficiency of service on the part of opposite party. The complainant submitted that earlier opposite party repudiated the claim of Rs. 53978/- and also in the year 2013but ultimately the op on the order of Consumer Forum in complaint case No: 438 of 2013, decided on 2.4.2014. As the opposite parties unnecessarily harassing the complainant, therefore opposite parties be directed to pay the balance claim of Rs. 3 Lakhs to the complainant alongwith interest @ 18% from the date of filing the complaint till its realization. The complaint is also entitled to compensation to the tune of Rs. 50000/- and Rs. 25000/- as litigation expenses.

2. Upon notice, OP appeared through counsel and filed a written reply pleaded that the insurance of the complainant for a sum of Rs.5 Lakhs was incepted for the first time from 25.1.2012 and prior to it, the sum insured was Rs.2 Lakhs only. Therefore, upper limit for payment was to be limited by the insurance company to Rs.2 Lakhs as the insured had not completed 48 months of insurance from 25.1.2012 before claiming the reimbursement of the expenses incurred on the treatment during admission in hospitals dated 7.9.2015, 13.9.2015 and 25.9.2015. The period of 48 months was to conclude on 24.1.2016. So what was only to be taken into account, was the sum insured for the period 25.1.2011 to 24.1.2012 which was Rs.2 Lakhs. There is obtained enhancement in insurance from Rs.2 Lakhs to Rs.5 Lakhs could even be asked for more, in anticipation of the disease, demanding still higher expenses. To keep a check over such motives taking shape, the insurance company has laid down the exclusion clause of elapsing of 48 months for the reason that those proponents who apprehended gravity of their disease aggravating and there being every possibility of incurring heavy expenses on the treatment as in the case of complainant who is a chronic patient of multiple diseases, might shift an enlarged burden on the insurance company under the enhanced limit for his imminent grave disease. Therefore, the insured must run a period of 48 months from the date of inception of the raised sum insured before claiming entitlement under the raised sum insured, otherwise the insured would go in for enhancement of the sum insured in one jump multifold to meet the anticipated high expenses for their immediate foreseeable treatment at the cost of insurance company and it is checked under the provisions of this clause as a public policy. Earlier, the complainant filed consumer complaint in the year 2013 and the OP made the payment as per decision of this Forum dated 2.4.2014 ex.C20 and the OP made the payment as per decision of this Forum amounting to Rs.53,978/- but the facts of that decided complaint were quite different and issues were also different. In the said complaint, it was never the issue over the inception of the sum insured Rs.5 Lakhs. Whereas in the present case the issue is whether the sum insured Rs.5 Lakhs could be taken as such when 48 months had not elapsed from 25.1.2012 i.e. from the date of inception of the insurance for Rs.5 Lakhs whereas the claims have arisen on 7.9.2015, 13.9.2015 and 25.9.2015. According to the provisions in the insurance policy of 48 months lapsing from the inception of the liability undertaken of Rs.5 Lakhs which come before 24.1.2016 i.e. 48 months from 25.1.2012, could not fall under the provision of the limit of Rs.5 Lakhs. Learned counsel for the OP submitted that as the sum insured for the policy 2011-12 was Rs.2 Lakhs and the present claims of the complainant fall within 48 months from 25.1.2012, so, the OP had taken and settled the largest claim bill of Rs.6,98,593/- of which the amount payable to the complainant under the terms and conditions of the policy, came out Rs.1,81,980/- which was paid to the complainant. The opposite party paid an amount of Rs. 53978/- to the complainant as a result of order of the consumer Forum dated 2.4.2014 but facts of that case were quite different and issues variant in that complaint. It was never issue over the inception of the sum insured, whereas in the present case issue is whether the sum insured of Rs. 5 Lakhs could be passed as such when 48 months has elapsed on 25.1.2012 i.e from the date of inception of the insurance of Rs. 5 Lakhs and the claims have arisen on 7.9.2015, 13.9.2015 and 25.9.2015. Op therefore submitted that there is no deficiency in the service on the part of the OP.

3. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C23 and closed his evidence.

4. On the other hand, learned counsel for the OP has tendered into evidence affidavit Ex.OA alongwith copy of document Ex.O1 and closed evidence.

5. We have heard the Ld. counsel for the parties, minutely gone through the record and have appreciated the evidence produced on record by both the parties with the valuable assistance of Ld. counsels for the parties.

From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that the complainant obtained Family Medicare Policy No.200500281P10927 9191 for himself and his wife with sum insured Rs.5 Lakhs for the period from 31.1.2015 to 30.1.2016 from the OP. The complainant submitted that he has been regularly getting his aforesaid policy renewedw.e.f 25.1.2003 renewed from the OP and Oriental Insurance Company Limited, Kapurthala. The complainant got insurance policy from the OP in the year 2003 vide cover note No.661088 and continuously renewed the policy upto the year 2009 from the OP. Thereafter, the complainant got insurance policy renewed from Oriental Insurance Company Limited, Kapurthala w.e.f 25.1.2009 to 24.1.2010 with sum insured Rs.4 Lakhs vide cover note No.363870 dated 21.1.2009 and continuously got his policy renewed upto the year 2012 from Oriental Insurance Company Limited, Kapurthala. Thereafter, a portable scheme was launched by IRDA and under the scheme the complainant got his policy transferred from Oriental Insurance Company Limited, Kapurthala to OP i.e. United India Insurance Company Limited, Jalandhar and under the aforesaid portability scheme, the complainant obtained the medicare policy for himself and his wife with sum insured Rs.5 Lakhs vide cover note No.597820 dated 23.1.2012 for the period from 25.1.2012 to 24.1.2013 on payment of premium to the OP.

6 The fact of portability has been clearly mentioned in the cover note dated 23.1.2012 Ex.C10. Thereafter, the complainant continued renewing the policy from the OP without any break from OP. The complainant fell ill and was taken to Patel Hospital, Jalandhar where he remained admitted from 7.9.2015 to 12.9.2015 and he spent Rs.1,35,000/- on his treatment. Thereafter, the complainant was shifted to Medanta The Medicity, Gurgaon and he remained admitted there from 13.9.2015 to 22.9.2015 and spent an amount of Rs.2,20,000/- on his treatment. Then again the complainant was admitted in Medanta The Medicity, Gurgaon on 25.9.2015 and discharged on 13.10.2015 and he spent about Rs.7 Lakhs on his treatment during this period. Thereafter, the complainant lodged three different claims bearing Nos.54551516149864, 54551516244545, 54551516261728 for the aforesaid respective three periods. However, the OP passed an amount of Rs.1,81,980/- in favour of the complainant and rejected the remaining amount of Rs.3 Lakhs on the ground that total entitlement of the claim amount is Rs.2 Lakhs only and not Rs.5 Lakhs. The OP also failed to supply the repudiation letter to the complainant and the complainant came to know about this rejection of his remaining claims from the official website of the third party administrator namely Raksha TPA Pvt Ltd. Learned counsel for the complainant submitted that all this amounts to deficiency of service on the part of the OP qua the complainant.

7. Whereas the case of the OP is that the insurance of the complainant for a sum of Rs.5 Lakhs was incepted for the first time from 25.1.2012 and prior to it, the sum insured was Rs.2 Lakhs only. Therefore, upper limit for payment was to be limited by the insurance company to Rs.2 Lakhs as the insured had not completed 48 months of insurance from 25.1.2012 before claiming the reimbursement of the expenses incurred on the treatment during admission in hospitals dated 7.9.2015, 13.9.2015 and 25.9.2015. The period of 48 months was to conclude on 24.1.2016. So what was only to be taken into account, was the sum insured for the period 25.1.2011 to 24.1.2012 which was Rs.2 Lakhs. There is obtained enhancement in insurance from Rs.2 Lakhs to Rs.5 Lakhs could even be asked for more, in anticipation of the disease, demanding still higher expenses. To keep a check over such motives taking shape, the insurance company has laid down the exclusion clause of elapsing of 48 months for the reason that those proponents who apprehended gravity of their disease aggravating and there being every possibility of incurring heavy expenses on the treatment as in the case of complainant who is a chronic patient of multiple diseases, might shift an enlarged burden on the insurance company under the enhanced limit for his imminent grave disease. Therefore, the insured must run a period of 48 months from the date of inception of the raised sum insured before claiming entitlement under the raised sum insured, otherwise the insured would go in for enhancement of the sum insured in one jump multifold to meet the anticipated high expenses for their immediate foreseeable treatment at the cost of insurance company and it is checked under the provisions of this clause as a public policy. Earlier, the complainant filed consumer complaint in the year 2013 and the OP made the payment as per decision of this Forum dated 2.4.2014 ex.C20 and the OP made the payment as per decision of this Forum amounting to Rs.53,978/- but the facts of that decided complaint were quite different and issues were also different. In the said complaint, it was never the issue over the inception of the sum insured Rs.5 Lakhs. Whereas in the present case the issue is whether the sum insured Rs.5 Lakhs could be taken as such when 48 months had not elapsed from 25.1.2012 i.e. from the date of inception of the insurance for Rs.5 Lakhs whereas the claims have arisen on 7.9.2015, 13.9.2015 and 25.9.2015. According to the provisions in the insurance policy of 48 months lapsing from the inception of the liability undertaken of Rs.5 Lakhs which come before 24.1.2016 i.e. 48 months from 25.1.2012, could not fall under the provision of the limit of Rs.5 Lakhs. Learned counsel for the OP submitted that as the sum insured for the policy 2011-12 was Rs.2 Lakhs and the present claims of the complainant fall within 48 months from 25.1.2012, so, the OP had taken and settled the largest claim bill of Rs.6,98,593/- of which the amount payable to the complainant under the terms and conditions of the policy, came out Rs.1,81,980/- which was paid to the complainant as detailed in Ex.C18. The remaining amount was not payable to the complainant. Learned counsel for the OP submitted that under these circumstances, there is no deficiency of service on the part of the OP qua the complainant.

8. From the entire above discussion, we have come to the conclusion that the complainant obtained Family Medicare Policy No.200500281P10927 9191 for himself and his wife with the sum assured of Rs. 5 Lakhs for the period from 31.1.2015 to 30.1.2016 from the OP. The complainant has been regularly getting his policy renewed from the Opposite Party and Oriental Insurance Company Limited, Kapurthala w.e.f. 25.1.2003. The Complainant got insurance policy from the OP in the year 2003 and continuously renewed the policy upto year 2009 from the OP. Thereafter, the complainant got insurance policy from the Oriental Insurance Company Limited, Kapurthala w.e.f 25.1.2009 to 24.1.2010 vide cover note dated 21.01.2010 and continuously up to the year 2012 from Oriental Insurance Company Limited, Kapurthala. Thereafter, a portable scheme was launched by the IRDA and under the scheme, the complainant got his family transferred from Insurance Company Limited, Kapurthala to the OP i.e United India Insurance Company Limited, Jalandhar. Under the aforesaid portable scheme the complainant obtained Medicare policy for himself and his wife with the sum assured of Rs. 5 Lakhs vide cover note No.597820 dated 23.1.2012 for the period from 25.01.2012 to 24.01.2013. Thereafter, the complainant continuously has been renewing the policy without any break from the OP. The complainant fell ill and was admitted in Patel Hospital, Jalandhar from the period 07.09.2013 to 12.09.2015 and he spent Rs. 1,35,000/- on his treatment. Thereafter, the complainant was shifted to Medanta The Medicity, Gurgaon and he remained admitted there from 13.9.2015 to 22.9.2015 and he spent amount of Rs.2,20,000/- on his treatment. But again the complainant was admitted in Medanta The Medicity, Gurgaon on 25.09.2015 and discharged on 13.10.2015 and he spent Rs. 6,98,593/- on his treatment during this period. The complainant lodged three different claims bearing Nos.54551516149864, 54551516244545, 54551516261728 for the aforesaid respective three periods. The OP passed an amount of Rs.1,81,980/- in favour of complainant and rejected the remaining claim of the complainant on the ground that the entitlement of the claim amount is Rs. 2 Lakhs only and not Rs. 5 Lakhs. Opposite party proved on record that insurance of the complainant for the sum of Rs. 5 Lakhs was incepted for the first time on 25.01.2012 and prior to it the sum assured was Rs. 2 Lakhs only. Therefore, upper limit for payment was limited by the insurance company to Rs. 2 Lakhs. As the insured had not completed 48 months insurance from 25.01.2012 before claiming reimbursement of the expenses incurred on the treatment during the admission in the hospitals on 07.09.2015, 13.09.2015 and 25.09.2015. The period of 48 months was to be calculated on 24.01.2016. So, what was to be taken into account was the sum assured for the period from 25.1.2011 to 24.01.2012 which was Rs. 2 Lakhs. No doubt the complainant obtained enhanced amount insurance amount of Rs. 2 Lakhs to Rs. 5 Lakhs for the first time from 25.01.2012 vide cover note No. 597820 Ex-C10. Prior to that, sum assured was Rs. 2 Lakhs. So, as per the policy in question, the complainant was entitled to the sum assured which was period of 48 months i.e amount assured for the policy period 25.01.2011 to 24.01.2012 which was Rs. 2 Lakhs. According to the provisions of insurance policy in question period of 48 months lapsing from the inception of liability undertaken of Rs. 5 Lakhs which comes before 24.01.2016 i.e. 48 months from 25.01.2012 could not fall under the provisions of limit of Rs. 5 Lakhs. So, the OP has rightly treated /settled the claim of complainant and the sum assured of Rs. 2 Lakhs under the policy for the period from 20.11.2012 Ex-C9. However OP had taken and settled the largest claim Bill of Rs. 6,98,593/- out of which amount payable to the complainant under the terms and conditions of the policy comes out Rs. 1,81,980/- which was paid to the complainant as detailed in the Ex C18. But the OP did not settle the remaining two bills of the complainant, as the complainant was entitled to the tune of Rs. 2 Lakhs i.e. the sum assured under the policy which was prevalent 48 months prior to the admission /treatment i.e in the year 2012. As such is entitled to the balance amount of insurance of Rs. 18,020/-. But OP failed to settle the other two bills Ex.C-16 and Ex. C-17 for this balance amount of Rs. 18,020/-. Consequently we hold that OP is certainly deficient in service in not settling the claim of the complainant for the other two bills Ex.C-16 and Ex. C-17 for the balance insurance amount of Rs. 18,020/-. Resultantly we hold that the complainant is entitled to this balance amount of Rs. 18,020/- against the bills Ex.C-16 of Rs. 2,18,065/- and Ex. C-17 for Rs. 1,32,278/- submitted by the complainant to the opposite party. Resultantly we partly allow this complaint with cost and OP is directed to pay balance insurance amount of Rs. 18,020/- to the complainant. The opposite party is also directed to pay compensation to the tune of Rs. 25,000/-. The OP is also directed to pay cost of litigation Rs. 5,000/-. Compliance be made by the OP within a period of one month from the receipt of this order. Copies of the order be sent to the parties free of cost, under rules. File be consigned to the record room.

Dated Parminder Sharma Bhupinder Singh

04.10.2016 Member President