Punjab

Faridkot

CC/16/85

Shankar Lal Goyal - Complainant(s)

Versus

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

Neeraj Maheshwari

27 Apr 2016

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      85

Date of Institution:  28.03.2016

Date of Decision :   27.04.2016

 

 

Shanker Lal Goyal s/o Sh Maru Ram Goyal, r/o Brij Lal Street, Jaitu, Tehsil Jaitu, District Faridkot.

                                                      ...Complainant

Versus

1. United India Insurance Co. Ltd. Dhanola Road, Barnala through Branch Manager/Manager/Authorised Person.

2. United India Insurance Co. Ltd Registered and Head Office 24, Whites Road, Chennai, through its Managing Director/Director/chairman/Manager/Authorised Person.

3. United India Insurance Company Limited, through Branch Manager/Manager/Authorised Person Kotkapura.

   ....OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Parampal Kaur, Member,

               Sh P Singla, Member.

 

Present: Sh Neeraj Maheshwary, Ld Counsel for complainant,

              Sh Ashok Kumar Monga, Ld Counsel for OPs.

 

 

(Ajit Aggarwal, President)

                                                   The present complaint has been received from the Hon’ble State Commission, Chandigarh as the complaint has been remanded back for decision and the parties were directed to appear in the Forum on 28.03.2013 by order of Hon’ble State Commission Punjab, Chandigarh.

2                                         Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OP seeking directions to OP to make payment of insurance claim amount of Rs.1,50,000/-with interest and for further directing OPs to pay Rs 1,00,000/- as compensation for harassment, inconvenience, mental agony and litigation expenses of Rs 10,000/-.

3                                     Briefly stated, the case of the complainant is that Ops approached complainant for Health Insurance Policy and represented that policy in question is meant for medical treatment of insured in case of need and also explained about fast services of Company for settlement of claim. Detail of authorized hospitals for cashless treatment was also given by Ops to complainant and on assurance of Ops, complainant purchased the policy in question for benefit in future and paid the premium as per terms and conditions of policy. After due enquiry and investigation of everything, Ops gave cover note of policy to complainant and again assured of aforementioned features of the Policy. On 13.06.2011, complainant felt some trouble in his head and forehead and got checked himself from Bharti E.N.T. Clinic, where some tests were conducted upon him. He got conducted his X-ray on same day and also got checked himself for further treatment from Daya Nand Medical College & Hospital, Ludhiana, where his MRI was conducted in Delta Heart Centre. After his check up, Dr Manish Munjal conducted some tests and on 16.06.2011, complainant was admitted in DMC, Ludhiana and he gave due intimation regarding it to Ops. Complainant was discharged on 19.06.2011 and his treat is still continuing with regular intervals. Complainant is regularly taking medicines as prescribed by doctors. After intimation by complainant regarding his illness, Ops have made every investigation and enquiry in the hospital and they assured complainant that his claim would be reimbursed as per insured amount of policy. Complainant gave due intimation to Ops in time and also submitted requisite documents alongwith reports to recover the expenses of medical treatment. Complainant received letter dt 11.07.2011 from Ops requiring him to submit more documents and in response to that, complainant against sent letter on 18.07.2011 and thereafter further sent a letter dt 28.07.2011 alongwith documents. He further sent letter dt 9.08.2011. Thereafter, complainant received confidential letter dt 14.09.2011 demanding more documents to which complainant sent letter dt 28.09.2011 alongwith demanded documents to Ops, but Ops did not make payment of insurance claim to complainant. On 11.11.2011, complainant again sent letter with relevant documents, but they did not make payment of insurance claim. Complainant received a letter dt 24.01.2012, vide which Ops rejected the claim of complainant by giving reason that said illness of complainant is not covered under the insurance policy purchased by complainant during the first two years of its commencement. Complainant made many requests to Ops for payment of insurance claim, but in vain. All this amounts to deficiency in service and trade mal practice on the part of OPs and it has caused harassment and mental agony to complainant for which he has prayed for directions to Ops to pay the insurance claim worth Rs 1,50,000/- and Rs 1,00,000/- as compensation besides Rs.10,000/-as cost of litigation. Hence, the present complaint.

 4                                    On receipt of the notice, OPs filed written statement taking legal objections that complaint is not maintainable in the present form as complainant has concealed the material facts regarding alleged ailment at the time of purchase of policy. Complaint is malafide and has been filed to extract money from Ops. Moreover, it involves complex questions of law and facts, requiring voluminous evidence and it can not be decided by this Forum with limited jurisdiction in limited time span. It is averred that as per exclusion clause no. 4.3 of Insurance Policy, claim of complainant is not maintainable. The alleged ailment i.e Sinusitis and its treatment is excluded for the first two years from the date of purchase of Insurance Policy and the claim sought by complainant is not payable under the policy in question and complaint in hand is liable to be dismissed. It is further averred that claim in question is declined after due enquiry and application of mind as per terms and conditions of policy and there is no deficiency in service and trade mal practice on the part of Ops. However, on merits, Ops have denied all the allegations levelled by complainant being wrong and incorrect and asserted that complainant himself approached Ops with desire to purchase insurance policy and after fully going through the terms and conditions of policy and after fully satisfying himself about its terms and conditions, complainant purchased the said policy. It is further averred that alleged clinical tests and MRI of brain has no concern with alleged disease and it is totally denied that complainant remained admitted in DMC, Ludhiana from 16.06.2011 to 19.06.2011, but as per information supplied and from documents, it is clear that complainant remained under treatment at DMC, Ludhiana for three days from 16.06.2011 to 18.06.2011 and this hospitalization of complainant is not covered under the Insurance Policy in question. Moreover, intimation to Ops was given late and even despite repeated requests and reminders, complainant failed to submit the requisite documents with Ops and did not clear the discrepancies in the medical record as pointed out by Ops. There is no explanation regarding admission and discharge in the medical record. Vide letter dt 24.01.2012, claim of complainant was rightly repudiated with cogent reasons as per exclusion clause 4.3 of the policy and claim was declined after due application of mind and as per terms and conditions of policy. All the other allegations levelled by complainant are denied being wrong and incorrect and it is further reiterated that there is no deficiency in service or unfair trade practice on the part of OPs. The allegations with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                               Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1, and documents Ex C-2 to C-20 and then, closed his evidence.

6                                   In order to rebut the evidence of the complainant, the opposite party tendered in evidence, affidavit of Sh A K Kanojia as Ex R-1 and documents Ex R-2 to 7 and then, closed the evidence on behalf of OPs.

7                                  After remand back of the present complaint, proper opportunity was given to complainant as well as Ops to lead evidence. Both the parties made statement to the effect that they do not want to lead fresh evidence and evidence adduced by them earlier may be read.

8                                  Ld Counsel for complainant vehementally argued that on assurance of Ops complainant purchased Health Insurance Policy for betterment in future. Ops gave detail of all features of insurance policy and assured complainant that there is no                                                                                                                                          hidden feature of expenses of policy and complainant need not worry about medical expenses in case of any need and also gave assurance that OP Company is very fast and renowned for providing best services. As per terms and conditions of said policy, complainant paid premium. The Ops issued only cover note of the Policy, copy of which is Ex C-19. Except the cover note, Ops did not send any policy or its terms and conditions. On 13^th June, 2011, complainant felt some problem in his head and forehead and he got checked himself at Bharti E.N.T Clinic, where some tests were conducted upon him. He got conducted X-ray and chekup for treatment from DMC, Ludhiana. He remained admitted in Daya Nand Medical College & Hospital, Ludhiana from 16.06.2011 to 19.06.2011 and he gave due intimation regarding his illness, admission in hospital and treatment taken, to Ops. Copy of intimation letter is Ex C-2, 3 and copy of claim form is Ex C-7 and after thorough enquiry and investigations, Ops assured complainant that his insurance claim would be reimbursed as per insured amount of policy. Complainant wrote many letters to Ops alongwith relevant documents for recovering his claim amount. Copies of letters are Ex C-8 to C-16. In response to letters of complainant, Ops also issued letter requiring him to send relevant documents, which complainant duly supplied to them. Copies of the letters are Ex C-4, 5, but vide letter dt 24.01.2012, Ops rejected the claim of complainant for reasons completely unknown to him. This act of Ops has caused great harassment and mental agony to complainant. He has prayed for accepting the complaint alongwith compensation and litigation expenses. To prove his case, complainant has stressed on documents Ex C-1 to 20. Document Ex C-2/A is the copy of intimation given by complainant to Ops and Ex C-3 is the copy of mail regarding intimation to Ops.  Ex C-8 to C -16  are the letters  alongwith postal receipt showing correspondence occurred between complainant and Ops regarding requests of complainant to Ops for processing his insurance claim. Ex C-16 is the copy of bill and Ex C-17 are the payment receipts clearing the fact that complainant made payment to Hospital Authorities for taking treatment. Cover note Ex C-19 and 20 prove the fact that complainant was insured with Ops.        

9                                      To controvert the arguments of complainant, ld counsel for Ops averred that as per exclusion clause no. 4.3 of Insurance Policy, claim of complainant is not maintainable. The alleged ailment i.e Sinusitis suffered by complainant and its treatment is excluded for the first two years from the date of purchase of Insurance Policy and the claim sought by complainant is not payable under the policy in question and complaint in hand is liable to be dismissed. It is further averred that claim in question is repudiated after thorough enquiry and application of mind as per terms and conditions of policy and there is no deficiency in service and trade mal practice on the part of Ops. Denying the plea of complainant that he remained admitted in DMC, Ludhiana from 16.06.2011 to 19.06.2011, Ops brought before the Forum that as per information supplied to them and from documents, it is clear that complainant remained under treatment at DMC, Ludhiana for three days from 16.06.2011 to 18.06.2011 and this hospitalization is not covered under the Insurance Policy in question and even intimation to Ops was given late and even despite repeated requests and reminders, complainant failed to submit the relevant documents and also did not clear the discrepancies in the medical record as pointed out by Ops. There is no explanation regarding admission and discharge in the medical record. Vide letter dt 24.01.2012, Ops have rightly repudiated the claim of complainant. Copy of repudiation letter is Ex R-2 and there is no deficiency in service.     

10                                      We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

11                                      After scrutinizing the record placed on file and careful perusal of pleadings and arguments, it is observed that the case of complainant is that he purchased Mediclaim Insurance Policy from OPs, but they sent only Policy Cover Note and did not send any terms and conditions of Policy and policy documents. He renewed the Policy for second year also. During the period of policy, complainant felt some health problem and he got admitted in hospital for treatment and he remained admitted there in the hospital from 15.06.2011 to 19.06.2011. He duly lodged claim before Ops for reimbursement of his medical bills, but Ops illegally and wrongly repudiated his claim.

12                                            In reply OP-2 and 3 argued that disease of complainant does not fall under the Policy. As per exclusion clause, this disease is covered under the policy after first two years. Copy of terms and conditions is Ex R-7. As per terms and conditions of exclusion clause 4.3, this disease does not come under the policy.

13                                            The counsel for complainant argued that at the time of purchase of policy, Ops never disclosed terms and conditions of the policy and exclusion clause to him. Even OPs did not send any terms and conditions and policy document to him. They only sent Policy Cover Note and on it, there was nothing mentioned about exclusion clause. As such, exclusion clause is not binding upon him. In support, he has placed reliance on the citation titled as United India Insurance Co. Ltd & Anr Vs S. M.S. Tele Communications & Anr 2009 (4) Consumer Law Today 145 wherein Hon’ble National Consumer Disputes Redressal Commission, New Delhi held that Consumer Protection Act, 1986 Section 2 (1) (g) - Insurance Act, 1938, Section 114 (A)- Insurance Regulatory and Development Authority (Protection of Policy Holders’ Interest) Regulations, 2002, Regulation 3 – Insurance claim – Exclusion clause – Held that being aware of the existence of the policy is one thing and being aware of the contents and meaning of clauses of the policy is another – Not the case of the petitioner-Insurance Company that the contents and the meaning of the policy were made known to the complainant as the policy was taken by the Bank – Insurance Company had explained the meaning of all the exclusion clauses to the Bank – Findings of the Fora below that exclusion clause not binding on the respondent-complainant upheld. He argued that Ops did not disclose any terms and conditions of exclusion clause at the time of purchase of policy to complainant. Moreover, the disease suffered by complainant is not of such nature which have any pre existing history or symptoms which can be known to a person beforehand. So, the Insurance Company can not deny the claim of complainant on this ground.

  14                                              We have carefully gone through the file and from the above discussion, we come to the conclusion that the OPs did not disclose the terms and conditions and exclusion clause to complainant at the time of purchase of insurance policy and did not send copy of terms and conditions of exclusion clause to complainant. Moreover, the disease of complainant is of such type, which have no pre existing symptoms or history. Therefore, in these circumstances, we are fully convinced with the arguments and case law produced by the complainant and complainant succeeds in proving his case. The act of OPs in repudiating the genuine claim of complainant amounts to deficiency in service and trade mal practice. Present complaint is hereby allowed. OPs are ordered to pay the Mediclaim worth Rs 79,553/-, which is lodged by complainant with them and detail of which is given in Ex R-6 to complainant alongwith interest at the rate of 9% per anum from 24.01.2012 i.e when they repudiated the claim of complainant till final realization. Ops are further directed to pay       Rs.5,000/-as compensation for harassment and mental agony and     Rs.3000/-as litigation expenses to complainant. Compliance of this order be made within one month from the date of 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 order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 27.04.2016                 

 

  Member            Member                   President

                      (P Singla)         (Parampal Kaur)      (Ajit Aggarwal)