Charanjit Singh, President;
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11 and 12 against the opposite party on the allegations that the complainant had purchased Family Medicare Policy in the year 2014 from the opposite party for himself and his family i.e. his wife Smt. Shilpi Bhandari and his minor son namely Palksh Bhandari in the year 2015, the complainant blessed with a son namely Hiyansh Bhandari, After few months, the complainant had inserted his second minor son in the list of insured along with his wife and his son. The complainant had paid the premium amount and the opposite party had issued only the cover note and never issued any document containing terms and conditions alongwith cover note. The policy was obtained/ purchased by the complainant from the opposite party namely Family Medicare Policy,2014 bearing Policy No.2002012816P117229905 dated 14.12.2016 till 13.12.2017 for which premium of Rs.6,205/- was paid by him. During the validity of the aforesaid policy, on 16.03.2017, the son of the complainant namely Hiyansh Bhandari suffered from cough and cold and was got admitted in Dr. Naresh Grover Hospital at Majitha Road, Amritsar. The O.P. was duly informed about the admission of his son in the hospital by the complainant. They admitted the son of the complainant and started his treatment. The son of the complainant remained admitted in hospital for 7 days and on 22.03.2017 he was discharged from the Hospital. The complainant spend an amount of Rs.75,730/- on account of treatment of his son. Accordingly in order to get the claim from the opposite party regarding the expenses incurred by the complainant on the treatment of his son, he approached the opposite party, submitted claim from alongwith all the relevant documents to them and requested them to make the payment of said amount Rs.75,730/- covered under the said policy and he was assured for the reimbursement by the opposite party. He visited the office of the opposite party number of times for the reimbursement of his claim amount but they put off the matter on one pretext to other. Ultimately they illegally, malafidely, unlawfully, and arbitrary repudiated the claim of the complainant by issuing a repudiation E-mail dated 02/07/2017 on the flimsy grounds which is as follows:-
As per discharge card, patient is diagnosed with NBA with moderate to severe Exacerbation of RAD since birth and as per the records available, insured is covered since 14.12.2015 while DOB is 14.08.2015. As disease is pre-existing, hence claim is not admissible under clause 4.1/UIC family Medicare policy. But till today the complainant had not received any document containing terms and conditions.
The repudiation of the claim of the complainant on the part of the opposite party wants to grab the huge amount of the insurance claim of the complainant which he had incurred and paid for the treatment of his son. So far as the terms and conditions of the policy in question are concerned, the opposite party did not issue any documents alongwith the policy which contained the terms and conditions and rather, they issued the cover note to the complainant and as such, the alleged terms and conditions contained in the repudiation letter are not at all applicable to this case nor the complainant is bound by the same. Even till date they have not supplied the terms and conditions of the policy in question to the complainant. The complainant has prayed that the present complaint may be allowed and the following reliefs may be granted to the complainant.
- The opposite party may be directed to make the payment of Rs. 75,730/- being the claim amount which he had incurred on treatment of his son and paid to the hospital alongwith interest on it @ 18% p.a. from the date of payment to hospital till reason.
- Compensation of Rs. 10,000/- may be awarded to him on account of suffering mental pain, agony, harassment, inconvenience at their hands due to deficiency in service.
- Costs of the proceedings of Rs. 10,000/-
3 After formal admission of the complaint, notice was issued to Opposite Party and opposite party appeared through counsel and filed written version and contested the complaint by interalia pleadings that the present complaint is not legally maintainable as the amount claimed is not within the insurance coverage obtained by the complainant from the opposite party much less there is no deficiency in service and unfair trade practice on the part of opposite party. The complainant purchased Family Medicare policy from the opposite party for himself and his family i.e. his wife and his minor son namely Palkash Bhandari. The complainant had added the name of second son in the said policy on 14.12.2015. The son of the complainant got admitted in the hospital on 16.03.2017 and discharged on 22.3.2017. As per terms and conditions of the said policy as general exclusion under exclusion clause 4.1, which are reproduced as under:-
4.1 All pre existing disease( whether treated/untreated, declare or not declare in the proposal form) which are excluded up to 48 month the policy being enforced. Pre existing disease shall be covered only after the policy has been continuously enforce for 48 months.
And as such in the present case as per discharge card patient is diagnosed with NBA with Moderate to severe exacerbation of RAD since Birth and congenital and as per records available, insured is covered since 14.12.2015 while DOB is 14/08/2015. As disease is pre existing/congenital hence claim is not admissible under clause 4.1 /UIC-Family Medicare Policy. The complainant has not adduced any cogent and convincing material in order to substantiate the please as alleged in the complaint especially when the insurance coverage is only as per the insurance policy schedule and its terms and conditions and even otherwise it is not open to the complainant to defeat the rights of the opposite party by way of rising concocted and afterthought pleas as the claim is to be dealt within the insurance coverage only. The complainant has not come to this Commission with clean hands and has concealed material facts from the Commission and as such the present complaint merits dismissal on this simple score only. The present complaint is an abuse of process of court and is simply filed just with a view to get wrongful gain and to cause wrongful loss to the opposite party because the complainant was well aware of the terms and conditions of the insurance policy because he was taking the said policy since 2014. No consumer dispute survives between the parties much less any cause of action has arisen in favour of the complainant. There is no deficiency in service on the part of the opposite party. After receiving the information regarding the admission of the son of the complainant the opposite party immediately informed its TPA Vipual medcort insurance TPA Pvt. Ltd and the said TPA after due investigation regarding the treatment given to the son of the complainant as per terms and conditions of the policy. After receiving the information regarding the admission of the son of the complainant the opposite party deputed its TPA for the settlement of the claim, The opposite party has rightly repudiated the claim of the complainant because the same was not covered under the term and conditions of the policy issued to the complainant. The complainant is taking the said policy since 2014 and he as well aware of the terms and conditions has been issued to the complainant at the time of issuing the policy to the complainant. The opposite party has denied the other contents of the complaint and prayed for dismissal of the same.
4 To prove his case, Ld. counsel for the complainant has tendered in evidence affidavit of complainant Ex. C-1, copy of e mail of repudiation letter Ex. C-2, copy of the policy Ex. C-3, copy of the letters Ex. C-4 and C-5, copy of the consent letter Ex. C-6, copy of birth certificate Ex. C-7, copies of letters Ex. C-8 to C-10, copy of discharge slip Ex. C-11, copy of the hospital Bill Ex. C-12, copy of the medicine bill Ex. C-13, copy of report of the laboratory Ex. C-14, copy of payment receipts Ex. C-15 to Ex. C-19 and closed the evidence. Ld. counsel for the opposite party tendered evidence affidavit of Surinder Singh, Sr. Divisional Manager Ex. OP-1, attested copy of policy Ex. OP-2, discharge slip Ex. OP-3, copy of letter dated 14.2.2018 Ex. OP-4 and closed the evidence.
5 We have heard the Ld. counsel for the parties and have gone through the record on the file.
6 From the combined and harmonious reading of documents and pleadings on record it is going to prove that the complainant purchased one policy from the opposite party namely Family Medicare Policy,2014 bearing Policy No.2002012816P117229905 dated 14.12.2016 till 13.12.2017 for which premium of Rs.6,205/- was paid by him. The complainant blessed with son namely Hiyansh Bhandari and after few months the name of the son was inserted in the list of insured alongwith his wife and his son. During the validity of the aforesaid policy, on 16.03.2017, the son of the complainant namely Hiyansh Bhandari suffered from cough and cold and he was got admitted in Hospital for 7 days and was discharged on 22.3.2017. The total expenses incurred upon the treatment was to the tune of Rs. 75,730/-. Thereafter the complainant lodged the claim alongwith all relevant documents with the opposite party but the same was repudiated by the opposite party on flimsy ground which is as follows:-
As per discharge card, patient is diagnosed with NBA with moderate to severe Exacerbation of RAD since birth and as per the records available, insured is covered since 14.12.2015 while DOB is 14.08.2015. As disease is pre-existing, hence claim is not admissible under clause 4.1/UIC family Medicare policy. But till today the complainant had not received any document containing terms and conditions.
The opposite party has raised this contention from discharge slip of Hiyansh son of Udhit Bhandari which belongs to Dr. Naresh Grover Hospital. It is pertinent to mention here that the patient i.e. Hiyansh was admitted in the hospital on 16.3.2017 whereas his name was inserted in the Policy in the year 2015 and from the year 2015 onwards. No treatment record is placed on record regarding the said disease of the patient. The patient was never treated for the said disease and opposite party has not placed any record which shows that Hiyansh was suffering from the said disease since his birth. These contentions raised by the opposite party disproved from the cross examination of Dr. Naresh Grover who is M.D. Paediatric who treated the patient i.e. Hiyansh who in the cross examination has admitted that the rough history was prepared by my assistant and further he admitted that he has seen Ex. CY and same does not bear my signature. Further he has admitted in the cross examination that no previous record regarding the major illness of the patient was shown to us by the parents, the patient never visited us before he was admitted in the Hospital. Further he admitted in the cross examination that most of the child suffer from the repeated cough and cold in first 2-3 years of life and it is common problem. So it is very much clear from the statement of the said doctor that there is no previous record regarding the illness of the patient i.e. Hiyansh and the patient never visited their hospital before admitting in the hospital. Secondly, it is very much clear from the statement that most of the child suffered from repeated cough and cold for initial 2-3 years and it is a common problem. So it is very much clear from the statement of doctor that cough and cold is a common problem and it cannot be considered as pre-existing disease. One more witness was examined by the opposite party namely Sh. Rajesh Sidana, Manager, Dr. Naresh Grover Hospital, Majitha Road Amritsar and he admitted that the patient namely was suffering from repeated episode of cough and cold after every 15-20 days interval and was diagnosed as NBA with Mod to severe exacerbation of RAD and he also admitted in his cross examination that there is no any such record in my file from where it is verified that Hiyansh was treated in our hospital earlier. Further he stated that he admitted that it is correct that there might be clerical error while writing the disease since birth on document Ex. OP-3. There is no previous record of any disease. No prescription slip was submitted by the attendant of the patient. Further he also admitted that cough and cold is not a disease but I am not medical expert as I am working with Dr. Naresh as clinical assistant.
7 From the above discussion it is very much clear that the patient i.e. Hiyansh was never treated for the said disease. There is no record present on the record which shows that earlier to this, he was admitted in the hospital and he was taking some treatment for the said disease. So we are not agreed with the opposite party on the plea that the patient has history of pre-existing disease. Secondly in the repudiation letter the claim was repudiated as it is not admissible under clause 4.1 UIC –Family Medicare policy but the complainant has categorically stated that he has not received terms and conditions of the said policy and opposite party has failed to prove on record any evidence that same was explained and supplied to the complainant. Reliance has been placed on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, It is usual with the insurance company to show all types of green pastures 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 DharmendraGoel 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.UshaYadav& 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.
By holding the genuine claim of the complainant and by repudiating the claim of complainant, the opposite party is deficient in service and unfair trade practice.
8 In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Party is directed to make the payment of Rs. 75,730/- to the complainant. The complainant has been harassed by the opposite party unnecessarily for a long time. The complainant is are also entitled to Rs. 10,000/- ( Rs. Ten Thousand only) as compensation on account of harassment and mental agony and Rs 7,500/-( Rs. Seven Thousand Five Hundred only) as litigation expenses. Opposite party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
21.10.2022
