BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

                                                                   Complaint No.34 of 2016

                                                               New CC No.165 of 2020

                                                               (Remanded Back) 11.02.2020

                                                                   Date of Inst. 19.05.2020

                                                                   Date of Decision: 07.06.2024

Sunil Kohli son of M. R. Kohli resident of 948 Urban Estate Phase-II, Jalandhar.

..........Complainant

Versus

1.       United India Insurance Co. Ltd., Branch Office Phagwara        through its Branch Manager.

2.       Medsave Health Care (TPA), Chandigarh, SCO 66, IInd Floor,         Sector 40-C, Chandigarh through its Director.

3.       United India Insurance Co. Ltd., Divisional Office, Syal House,        Lajpat Nagar, Jalandhar. Through its Senior Divisional Manager.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:         Smt. Harveen Bhardwaj          (President)

 Smt. Jyotsna                           (Member)                                  Sh. Jaswant Singh Dhillon       (Member)

Present:        Smt. Harleen Kaur, Adv. & Miss. Anchita, Adv. Counsels                              for the Complainant.

                    Sh. K. L. Dua, Adv Counsel for the OP No.1 & 3.

                    OP No.2 exparte.

Order

Dr.Harveen Bhardwaj (President)

1.                    The instant complaint has been remanded back by the Hon’ble State Commission, vide order dated 11.02.2020, whereby the order of this Commission dated 28.11.2018 had been set-aside and further, a direction was given to this Commission to decide afresh after affording opportunity to lead further evidence to both the parties.

2.                Brief facts of the complaint are that complainant obtained individual health insurance policy covering risk of reimburse/indemnify expenses to the insured persons, expenses incurred for hospitalization and for medical/surgical treatment at any hospital/nursing home and for any disease or suffer from any illness/ailments, disease or injury sustained from OP No.1 through its authorized agent for the period stated in the policy schedule by renewal effective from 03.03.2015 to 02.03.2016. The complainant has been continuously and un-interruptly insured himself and his wife Meera Kohli since year 2006 without any gap/break and policy number is 115012814P110449475.

3.                That insured person covered by Health Insurance Policy for Medical benefit are complainant and his wife Meera Kohli as under:-

4.                That cover note and policy schedule of the policy was issued in the name of the complainant. The total amount of renewal premium of Rs.14,905/- was paid to the OP No.1 through its authorized agent. The product name was individual health insurance policy-2010 for hospitalization benefit. The policy document was not issued/delivered to the complainant by OP No.1 during the whole of the period of the policy. It is mandatory and obligatory upon OP No.1 to have issued policy document along with the terms and conditions and exclusion clauses if there is any.

5.                Meera Kohli, wife of the complainant, co-insured with the OP No.1, complained of decreased vision in bright light eye and on examination was diagnosed to have immature senile cataract (PSC) in both eye. She was advised cataract surgery with IOLI in both eyes (right eye first) at the earliest for her safety by Thind Eye Hospital, Jalandhar. She was operated upon left eye for cataract with Phacoemulsification with multifocal intra Ocular lens implantation on 13.04.2015 in Thind Eye Hospital Jalandhar, by Dr. J. S. Thind, Surgeon, who performed contract eye surgery. After discharge from hospital, the complainant made a claim for amount of Rs.62,992/- for medical and surgical expenses incurred by the complainant for reimbursement for hospitalization and treatment for left eye cataract surgery to OPs. All the required documents i.e. claim form, bills receipts and discharge certificate along with clinical tests report etc. were submitted to OP No.1. The complainant has also completed all the requirements, whichever were asked for the settlement of mediclaim of Rs.62,992/- and accordingly, the complainant was informed that his claim had been registered by the OP No.2, but to the utter surprise and dismay of the complainant unilaterally, oppressively and arbitrarily on whims and fency drastically reduced medi claim reimbursement of claim for amount to Rs.35,972/- and remitted the aforesaid amount through NEFT to the banker of the complainant, but after deduction of Rs.27,020/- from medi-claim amount of Rs.62,992/- of the complainant on the purported grounds and deductions whatsoever, any made are strictly as per the terms and conditions of health insurance policy issued to the complainant by OP No.1 without stating any such conditions and exclusion clause and without providing details of such purported deductions. The OPs are guilty of rendering deficient service, negligent and adopted unfair trade practice by reducing the claim amount drastically without any reason and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse balance medi claim amount of Rs.27,020/- deducted from claim amount of Rs.62,992/- as mentioned in the claim settlement memo dated 27.05.2015 with interest @ 12% per annum from the date of lodgment of the claim upto date of actual payment and further OPs be directed to pay compensation to the complainant, to the tune of Rs.50,000/- and litigation expense of Rs.10,000/-.

6.                Notice of the complaint was given to the OPs and accordingly, OP No.2 duly served, but despite service, OP No.2 failed to appear and ultimately, OP No.2 was proceeded against exparte. OP No.1 and 3 appeared through its counsel and filed joint reply, whereby contested the complaint by taking preliminary objections that no cause of action arose to the complainant to file the present complaint and further averred that the complainant is barred by his act and conduct from filing the present complaint. The complainant has accepted the payment without any protest and as such, he is barred by his act and conduct from filing the present complaint and further averred that the present complaint is the misuse of the process of Forum and further submitted that there is no deficiency or negligence in the performance of the services or any illegal trade practice on the part of the OPs and even the complaint of the complainant false and frivolous and the same is liable to be dismissed with cost and further alleged that the complainant was paid full and final amount due and admissible under the rules as per the directives of the OP No.2. The charges, which were not supported by the documentary evidence and the amount which was not legally permissible was deducted and the remaining amount of the claim was paid to the complainant. So, the present complaint is not maintainable and the same is liable to be dismissed. On merits, it is admitted that the complainant got insurance policy for himself as well as for his wife and it is also admitted that the complainant submitted a medi claim and part payment of the said claim has been already made. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

7.                In order to prove their respective versions, both the parties have produced on the file their respective evidence.

8.                We have heard the learned counsel for the respective parties and also gone through the case file as well as written arguments submitted by counsel for the complainant very minutely.

9.                The present complaint has been remanded back by the Hon’ble State Commission to decide a fresh after affording opportunity to lead further evidence to both the parties. Earlier the District Commission dismissed the complaint of the complainant on two grounds. The first ground considered by the District Commission was that there is legal infirmity in the complaint on the ground that Meera Kohli is only the consumer to file the complaint, whereas the complaint has been filed by her husband, who is not consumer and the complaint was dismissed being not maintainable. Another ground considered by the District Commission was that once the complainant has accepted the amount and after 8 months, the complainant cannot
allege that the amount is on lesser side. On these two grounds, the complaint was dismissed by the District Commission.

10.              Appeal was filed. The Hon’ble State Commission has observed that the District Forum cannot review its own order. The Hon’ble State Commission has further observed that as per the law laid down by the Hon’ble Apex Court in the judgment 2011 (9) SCC 544, titled as ‘Rajeev Hitendra Pathak and Others Vs. Achyut Kashinath Karekar and Anr.’ and another judgment report in 2015(11) SCC 661 ‘Kamlesh Aggarwal Vs. Narain Singh Dabbas and anr.’, wherein it has been held that ‘the District Forum as well as State Commission have not been given powers to review its own order.’ Meaning thereby that the order passed by the District Commission observing that this Commission has no jurisdiction, was set-aside. Perusal of the record shows that the complaint was filed by the complainant on 19.01.2016 and after hearing the complainant, the District Commission concluded that the complaint is within limitation and this Forum has pecuniary as well as territorial jurisdiction to proceed with the complaint. As per the observation of the Hon’ble State Commission, once the complaint has been admitted by the District Forum considering it to be within limitation and having pecuniary as well as territorial jurisdiction, the same cannot be dismissed on this ground by reviewing its own order without furnishing any document in support of the contention raised by the OP that the complaint is not within limitation and the District Forum has no jurisdiction.

11.              The complainant has alleged that the wife of the complainant/co-insured suffered eye problem and she was operated upon left eye for cataract with Phacoemulsification with multifocal intra Ocular lens implantation on 13.04.2015 in Thind Eye Hospital. A claim was lodged by the complainant with the OP alongwith documents, receipts and discharge certificate. All the documents were supplied to the OP vide letter dated 20.05.2015 and the OP deducted the amount of Rs.27,020/- from mediclaim amount of Rs.62,992/-. There was a correspondence between the complainant and the OPs, but the OPs did not pay the entire amount to the complainant. The claim deductions letter Ex.C-1 shows that the claim deductions were made and the complainant was informed vide letter dated 03.06.2015 and the present complaint was filed on 18.01.2016, which is well within the limitation.

12.              The complainant has alleged that no policy documents alongwith terms and conditions were ever supplied to the complainant, which is the duty of the OP. It has been held in a case titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Rajwant Kaur and Other”, 2021 (3) CLT 540 (CHD) that ‘the onus is on the appellant insurance company to prove that it provided the terms and conditions of the policy to the complainant and the same were in her knowledge’. It has been held in a case titled as “National Insurance Co. Ltd. & Ors Vs. M/s Saraya Industries Ltd”, 2020 (1) CLT 278 (NC) that ‘it is the duty of the insurance company to supply all the terms and conditions of an insurance policy to the policy holder-there cannot be any presumption under law on the terms and conditions’.

13.               Perusal of the Ex.C-1 shows that the letter of the deductions of the claim has been issued by the Medsave Healthcare (TPA) Ltd., Chandigarh. The Hon’ble State Commission has held the letter Ex.C-1 as not valid as TPA cannot repudiate the claim only the insurance company is competent to repudiate the claim on the report of the TPA as OP No.2 has no privity of contract with the complainant. No evidence has been led by both the parties after remand of the case. Deduction letter Ex.C-1 has been held to be invalid as such in view of the above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to pay the balance mediclaim amount of Rs.27,020/- deducted from the claim amount of Rs.62,992/- in claim settlement memo dated 27.05.2015 with interest @ 6% per annum from the date of lodgment of the claim, till its realization. Further, OPs are directed to pay a compensation of Rs.15,000/- as compensation for causing mental tension and harassment to the complainant and litigation expenses of Rs.5000/-. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

14.              Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

07.06.2024         Member                          Member             President