Order by:

Sh.Amrinder Singh Sidhu, President

1.       This Consumer Complaint has been received by transfer vide order dated 26.11.2021 of Hon’ble President, State Consumer Disputes Redressal Commission, Punjab at Chandigarh under section 48 of CPA Act, vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 from District Consumer Commission, Ludhiana to District Consumer Commission, Moga to decide the same in Camp Court at Ludhiana and said order was ordered to be affected from 14^th March, 2022.

2.       The  complainant  has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now section 35 of Consumer Protection Act, 2019) on the allegations that he has been purchasing the medi claim policies for himself as well as his wife Smt.Neelam Kumar since the year 2013, the detail of which as under:-

Further alleges, that during the policy period,  the complainant developed some problem of chest pain, hypertension, CAD-Angina & OSA and was admitted in Dayanand Medical College & Hospital, Ludhiana from 02.02.2017 to 03.02.2017. Thereafter,  the complainant  also remained in SPS Hospital, Ludhiana  on 03.02.2017 to 07.02.2017. In all, the complainant spent Rs.1,65,000/- on his medical treatment. At the time of admission in the hospitals, the complainant immeidately informed the Opposite Parties that since the policy in question was cashless, to process the claim of the complainant as cashless, but the Opposite Parties did not pay any heed to the request of the complainant and as such, the complainant was compelled to pay all the expenses from his own pocket. After that, the complainant lodged the claim of his medical reimbursement with the Opposite Parties, but the Opposite Parties flatly refused to admit the rightful claim of the complainant and as such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.

a)       The Opposite Parties may be directed to release the insurance claim of Rs.2 lakhs and also to pay Rs.5 lakhs  on account of compensation due to mental tension and harassment caused by the complainant besides costs of litigation  and also to pay any other relief to which this District Consumer Commission may deem fit.

3.       Opposite Parties  appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission. It is submitted that the complainant has only lodged the claim with respect to hospitalization at Dayanand Medical College & Hospital, Ludhiana  and out of that  claim amount, the  payable amount was worked out at Rs.11000/- vide discharge voucher cum consent letter dated 16.08.2017 and besides this, the complainant is not entitled to any further amount.  Moreover, the complainant has not lodged any other claim with respect to his hospitalisation at SPS Hospital, Ludhiana if any and due to no submitting his claim, said claim could not be processed and as such, the complaint filed by the complainant is false and  frivolous and the same deserves dismissal.   On merits, the Opposite Parties took up almost same and similar pleas as taken up by them in the preliminary objections    and the complaint may be dismissed with costs.  

4.       In order to  prove  her  case, the complainants tendered into  evidence his affidavit Ex.C-A alongwith copies of documents Ex.C1 to Ex.C10 and mark A to Mark G and closed the evidence on behalf of the complainant.

5.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties also tendered into evidence the affidavit Ex.RA   alongwith copies of documents Ex.R1 to Ex.R5 and  closed the evidence.

6.       We have heard the ld.counsel for the parties and also  gone through the documents placed  on record.

7.       During the course of arguments,  the complainant was present himself alongwith his counsel and stated that he  is serving as ERS/SS in Northern Railway posted at Ludhiana and when the Opposite Parties have failed to make the reimbursement of his medical claim, he has opted to chose  to get the medical bills reimbursement from his department of his remaining claim and as such, the has already got reimbursement  of his medical bills from his department. He has further submitted that his only grievance is that he is purchasing the policies from the Opposite Parties since the year 2013 without any break and when he was a dire need of assistance of Opposite Parties at the time of admission in the hospital, the Opposite Parties did not pay any heed to his grievance because the policy so purchased by him was cashless and in such a situation, he suffered great mental tension and harassment because the officials of the Opposite Parties  flatly refused to process his claim with regard to cashless treatment in the hospitals concerned and as such, there is great lapse on the part of the Opposite Parties. For this, he prayed before this District Consumer Commission to direct the Opposite Parties to pay Rs.5 Lakhs on account of compensation due to mental tension and harassment caused by the complainant besides costs of litigation. Hence, we are of the view that due to non processing of the cashless treatment of the complainant, the complainant must have suffered loss. In such a situation, non processing of the genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pesters 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 Dharmendra Goel 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.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seems 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.

8.       But at the moment, we are of view also, that the claim for compensation to the tune of Rs.5 lakhs appears to be exorbitant and excessive. The rationale behind grant of compensation has been to compensate a party of the loss occasioned by it. It is none of the intention of the legislature while legislating the Consumer Protection Act to enrich a particular party at the cost of the other. The compensation has to be awarded in commensuration with the loss occasioned to the complainant. In our considered view, ends of justice would  be fully met if the complainant is awarded lump-sum compensation to the tune of Rs.25,000/- and we award the same accordingly.

9.       In view of the aforesaid facts and circumstances of the case, we partly allow the complaint of the complainant against  Opposite Parties and Opposite Parties are directed to pay lump sum compensation of Rs.25,000/- (Rupees twenty five thousands only) alongwith interest  @ 8% per annum from the date of filing of this complaint i.e. 22.11.2017 till its actual realization. The compliance of this order be made by the Opposite Parties within  60 days from the date of receipt of the copy of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of District Consumer Commission, Ludhiana.  Copies of the order be furnished to the parties free of cost by District Consumer Commission, Ludhiana and thereafter, the file be consigned to record room after compliance.

10.     Reason for delay in deciding the complaint.

This Consumer Complaint was originally filed at District Consumer Disputes Redressal Forum (Now Commission) at Ludhiana and it keep pending over there until Hon’ble State Consumer Disputes Redressal Commission, Punjab vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 has transferred the instant Consumer Complaint alongwith Other Complaints to District Consumer Commission, Moga with directions to work on this file onward from 14^th March, 2022 and accordingly District Consumer Commission, Moga has decided the present complaint at Camp Court, Ludhiana, as early as possible as it could decide the same.

Announced in Open Commission at Camp Court, Ludhiana.