DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA
RBT/Consumer Complaint No.113of 2018
Date of institution: 20.02.2018
Date of Decision:07.04.2022
Sanjeev Walia aged about 56 years son of N.P. Walia, resident of 1106-E, Tagore Nagar, Ludhiana 141002.
….Complainant
Versus
United India Insurance Company Limited, Savitri Comm. Complex-I, GT Road, Dholewal, Ludhiana through its authorized signatory.
……..Opposite Party
Complaint under Consumer Protection Act.
Quorum: Shri Ranjit Singh, President.
Mrs. Ranvir Kaur, Member
Present: Sh. M.S. Sethi, Advocate, for complainant
Sh. Rajeev Abhi, Advocate, for OPs
Order dictated by :- Shri Ranjit Singh, President
Order
The present order of ours will dispose of the above complaint filed under Consumer Protection Act, received by way of transfer from District Consumer Disputes Redressal Commission, Ludhiana by the complainant against the Opposite Party on the ground that the complainant and her wife availing services of the opposite party for individual health policy since 25.4.2001. Earlier, the complainant insured upto the sum of Rs.2.50 Lakhs with the opposite party and since 25.4.2013 and the complainant got increased the sum insured every year and accordingly paid the premium yearly on the basis of sum insured against individual Health Insurance Policy. Thereafter, the complainant and her wife hired the services of the opposite party for the period from 25.4.2016 to 24.4.2017 for a sum of Rs.5,00,000/- in continuation of previous policies and paid the premium of Rs.18,257/- to the opposite party. The opposite party also sent policy dated 21.4.2016. Name of the TPA as Rakha TPA P Limited is also disclosed on the first page of the schedule disclosing policy number 201000281P100964301 and plan individual Health Policy and policy sub type as Gold with Dom. Hospital Limit of Rs.50,000/-. Thereafter, next health policy for the period 25.4.2017 to 24.4.2018 for Rs.5,00,000/- in continuation of previous policies and paid the premium of Rs.21,683/- to the opposite party. The opposite party also sent policy dated 11.4.2017. Name of the TPA as Rakha TPA P Limited is also disclosed on the first page of the schedule disclosing policy number 2010002817P101476695 and plan individual Health Policy and policy sub type a Gold with Dom. Hospital Limit of Rs.50,000/-. It is further averred that before admission in the Fortis Escorts Heart Institute, complainant also got CT scan dated 01.12.2017 and thereafter the complainant was remained admitted in the Fortis Escorts Heart Institute, New Delhi for the period from 09.12.2017 to 11.12.2017 during the period of the said policy number 2010002817P101476695 for the period 25.4.2017 to 24.4.2018 as per hospital course etc disclosed in the discharge summary. However, TPA of the opposite party recommended claim Rs.1,75,000/- out of the final hospital bill amount of Rs.2,81,406/- while ignoring medical expenses incurred by the complainant. The aforesaid act of the opposite parties amounts to deficiency in service, unfair trade practice and it has caused mental as well as physical agony and also caused inconvenience to the complainant. Vide instant complaint, the complainant has sought the following reliefs:-
- To pay Rs.1,06,400/- to the complainant along with interest @ 12& per annum
- Any other relief as per facts or circumstances of the case be also allowed if Hon’ble Forum thinks so necessary for the proper disposal of the complaint
2. In reply, the O.P. has challenging the veracity of the complaint on the ground of maintainability. On merits, it is admitted that the complainant obtaining of insurance policies for certain years and enhancement of sum insured w.e.f. 25.4.2013. The complainant has not produced the earlier policies w.e.f. 25.4.2001 to 25.4.2013. The complainant has not intentionally produced the complete copy of the insurance policy and has produced only 1-2 pages of insurance policy without terms and conditions of the insurance policies. The complainant as such is not coming to the Hon’ble Commission with clean hands. It is also admitted that obtaining policy valid w.e.f. 25.4.2016 to 24.4.2017, 25.4.2017 to 24.4.2018 and 25.4.2018 to 24.4.2019 for sum insured of Rs.5,00,000/-, payment of premium and disclosing the name of TPA M/s Raksha Health Insurance TPA Private Limited. The insurance policy is a contract in itself and the parties are bound by the terms and conditions of the insurance policy. It is denied that before admission in the Fortis Escorts Heart Institute, complainant also got CT Scan dated 1.12.2017. It is further stated that the cashless authorization was received from the said hospital which was sanctioned and paid for a sum of Rs.1,75,000/- in full and final settlement of the claim vide letter dated 11.12.2017 in the account of the complainant and accepted by the complainant in full and final settlement of the claim for his treatment in the said hospital from 9.12.2017 to 11.12.2017 under the policy No.2010002817P101476695 valid from 25.4.2017 to 24.4.2018. It is further stated that the TPA had paid a sum of Rs.1,75,000/- in full and final settlement of the claim out of the total bill of Rs.2,81,406/- by deducting Rs.1,06,406/- on the ground that the maximum limit payable for the major surgeries is actual expenses incurred or 70% of the sum insured which is less as per terms and conditions of the policy and the limit beyond Rs.1,75,000/- exhaust for this ailment for which the complainant was treated as the claim is settled for a sum insured of Rs.2.5 Lacks. And there is enhancement in the year 2014-2015 i.e. Rs.3 Lacks and 2015-16 i.e. Rs.4 Lacks and in the year 2016-17 i.e. Rs.5 lacks and as such on account of chronic nature of disease enhanced sum insured of the current year is not applicable. Rest of allegations leveled by the complainant have been denied and prayed for dismissal of the complaint.
- The complainant has tendered certain documents in the shape of evidence On the other hand, the OP has also tendered certain documents in the shape of evidence.
- We have heard learned counsel for the parties at considerable length and have also examined the record of the case.
- Complainant purchased one health policy and policy sub type as Gold with Dom. Hospital Limit of Rs.50,000/-. The complainant renewed the said policy yearly. The complainant got CT Scan on 01.12.2017 and thereafter he was remained admitted in the fortis Escorts Heart Institute, New Delhi for the period 09.12.2017 to 11.12.2017 and during the said period of said policy number 2010002817 P101476695 for the period 25.4.2017 to 24.4.2018. But out of the total amount spent by the complainant on his treatment i.e. Rs.2,81,406/-, the TPA of the opposite party recommended claim of Rs.1,75,000/- while ignoring medical expenses incurred by the complainant. The complainant was paid the premium regularly.
- Opposite party admitted the policy as well as premium paid by complainant. It is also admitted by opposite parties that complainant filed the claim that complainant was diagnosed and admitted in the hospital for the period from 09.12.2017 to 11.12.2017. But the TPA had paid a sum of Rs.1,75,000/- in full and final settlement of the claim out of the total bill of Rs.2,81,406/- by deducting Rs.1,06,406/- on the ground that the maximum limit payable for the major surgeries is actual expenses incurred or 70% of the sum insured which is less as per terms and conditions of the policy and the limit beyond Rs.1,75,000/- exhaust for this ailment for which the complainant was treated as the claim is settled for a sum insured of Rs.2.5 Lacks. And there is enhancement in the year 2014-2015 i.e. Rs.3 Lacks and 2015-16 i.e. Rs.4 Lacks and in the year 2016-17 i.e. Rs.5 lacks and as such on account of chronic nature of disease enhanced sum insured of the current year is not applicable.
- To rebut the above said contention of the learned counsel for the OP, the learned counsel for the complainant has relied upon the law laid down by the Hon’ble Supreme Court of India, in case titled as Galada Power and Telecommunication Limited Vs United India Insurance Company Limited and Another, 2016, 14 SCC 161, in this case, the Hon’ble Supreme Court of India, has held that the insurance company cannot proceed beyond the reasons specified in the repudiation letter. The Hon’ble Apex Court has also held as under:-
. It is evincible, the insurer had taken cognizance of the communication made by the appellant and nominated a surveyor to verify the loss. Once the said exercise has been undertaken, we are disposed to think that the insurer could not have been allowed to take a stand that the claim is hit by the clause pertaining to duration. In the absence of any mention in the letter of repudiation and also from the conduct of the insurer in appointing a surveyor, it can safely be concluded that the insurer had waived the right which was in its favour under the duration clause.
- So, after considering all the facts, documents on file and the law laid down by the Hon’ble Supreme Court of India, present complaint is allowed against opposite party and directed to pay Rs.1,06,460/- alongwith Rs.25,000/- for harassment and Rs.10,000/- as litigation expenses. This order is directed to be complied with within a period of thirty days from the date of receipt of copy of this order. Free certified copies of this order be sent to the parties, as per rules. The files be consigned to record room.
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April 07, 2022
(Ranjit Singh)
President
(Ranvir Kaur)
