BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.
Complaint No.138 of 2014
Instituted On:19.11.2014
Decided On: 12.02.2015
1. Anoop Kumar Goel Son of Sh Jagdish Kumar.
2. Smt. Vanita Goel W/O Anoop Kumar Goel, residents of H.No.455/4, Gill Road, Moga.
……..Complainants
Versus
1. United India Insurance Co. Limited., through its M.D/Secretary/Chairman, Regd. & Head Office at 24, Whites Road, Chennai-600014.
2. Senior Divisional Manager, United India Insurance Co. Limited, Divisional Office at 6-7, Shaheed Bhagat Singh Market, G.T.Road, Moga.
3. Raksha TPA Private Limited, through its M.D./Secretary SCO 122 (Basement) Cabin No.5, Feroze Gandhi Market, Ferozepur Road, Ludhiana.
……… Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
Coram: Sh.S.S.Panesar, President
Smt Vinod Bala, Member
Smt. Bhupinder Kaur ,Member
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Present: Sh.Balraj Kumar Gupta, Advocate counsel for the complainant.
Sh.Jasvinder Singh, Advocate counsel for opposite party No.1
Sh Vijay Sharma Authorised representative for O.P.No.3
ORDER
(S.S.Panesar, President)
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (herein-after referred to as ‘Act’) against United India Insurance Co. Limited., through its M.D/Secretary/Chairman, Regd. & Head Office at 24, Whites Road, Chennai-600014 and others (herein-after referred to as ‘opposite parties’)-OPs directing them to make payment of balance claim amount of Rs.32,602/-, which was spent by the complainant No.2 on her treatment to pay Rs.50,000/- as compensation for causing mental tension and harassment and also grant cost of litigation.
2. Briefly stated, the complainants and their family members had purchased Health Insurance Policy bearing No.201200/48/13/06/00000284 from opposite party Nos. 1 & 2, which was valid w.e.f. 01.01.2014 to 31.12.2014. It was the continuing policy because the complainant had been purchasing the medi claim policies from opposite party Nos.1 & 2 for the last more than six years regularly. During the subsistence of the policy in the month of April 2014, complainant No.2 had undergone an operation due to ‘Rasoli’ and she remained admitted in AMC Bassi Hospital, Ludhiana for the period w.e.f. 04.04.2014 to 07.04.2014. She spent an
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amount of Rs.52,602/- on her treatment. After completion of the treatment from the hospital, complainant No.2 approached opposite party Nos. 1 & 2 and also submitted all the requisite documents and bills for re-imbursement of her medi-claim under the policy. It has been pleaded that the complainant received a letter dated 16.07.2014 from opposite party No.3 vide which, the latter sanctioned a sum of Rs.20,000/- only instead of Rs. 52,602/- on false and baseless ground. The complainants have received the sanctioned amount under protest. Complainants allege that the opposite parties have deducted Rs.24,158/- on the ground that the complainants did not supply the terms and conditions of the policy besides Rs.6500/- were deducted as photocopy bill non payable, whereas, all the original bills were submitted to the opposite parties. However, the terms and conditions of the policy were not supplied to the complainants. Due to the negligent act of the opposite parties, the complainants are suffering from mental and physical harassment and economic loss. Hence the present complaint.
3. Notice of the complaint was given to the opposite parties. Opposite party Nos.1 & 2 appeared through their counsel Sh. Jasvinder Singh Advocate and filed written reply contesting the same. They took up preliminary objections that the complaint is not maintainable; that the complainant has got no locus-standi; that there is no deficiency in service on the part of the opposite parties; that a complicated question of law and facts are involved in the present complaint; that the complainant has not approached this Forum with clean hands; that the complaint is not
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maintainable as per report dated 18.12.2014 of the Raksha TPA opposite party No.3 who was observed as under:-
“ As per policy terms and conditions Hystrectomy payable is 20% of sum insured, therefore, 20% of Rs.1,00,000/- is Rs.20,000/-. Complainant No.2 admitted in AIMC Bassi Hospital, Ludhiana and was treated surgically with total Lap, Hystrectomy. As per United Family Floater Plicy Hystrectomy payable is 20% of sum insured, which has already been paid to the complainants in lieu of medi- claim policy bearing No.201200/48/13/06/00000284.
On merits, opposite party Nos.1 & 2 took almost the same and similar pleas as taken up in the preliminary objections. All the allegations made in the complaint were specifically denied being incorrect and it is stated that the complaint deserves to be dismissed.
4. Opposite party No.3 appeared through his authorized representative Sh. Vijay Sharma and filed its written reply on the similar lines written reply as filed by opposite party Nos.1 & 2, therefore, there is no gain saying in repeating the allegations.
5. In order to prove his case, the complainant tendered in evidence his affidavits Ex.C-1 & Ex.C-2 and copies of documents Ex.C-3 to Ex.C-18 and closed his evidence.
6. To rebut the evidence of the complainant, the opposite party Nos.1 & 2 tendered affidavit Ex.OP1& 2/1 of Sh.Sudesh Kumar Phulay Senior Divisional Manager and copies of documents Ex.OP1& 2/2 to
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OP1&2/5 and closed his evidence. Opposite party No.3 tendered affidavit of Sh Vinay Batra, General Manager, Ex. O.P.No.3/1 and copies of documents Ex.OP3/2 & Ex.OP3/3 and closed his evidence.
7. We have heard the learned counsel for the complainant, opposite party Nos. 1 & 2 and authorized representative of opposite party No.3 and have also carefully gone through the record.
8. On the basis of the evidence on record, the learned counsel for the complainants has vehemently contended that complainant No.2 was operated upon operation for ‘Rasoli’ at AMC Bassi Hospital, Ludhiana. She remained admitted there in the hospital w.e.f. 04.04.2014 to 07.04.2014. The complainants have produced medical bill on record, which is Ex.C-12 while details of expenses accounts for Ex.C-10. Complainant No.2 had to spend an amount of Rs. 52,602/- on her treatment. It is not disputed that the complainants and her family members were having medi claim policy, which was operative with effect from 01.01.2014 to 31.12.2014. Copy whereof is Ex.C-8. It is also admitted case of the parties that the complainants and her family were getting medi claim policies for the last six years continuously. Copies of insurance policies account for Ex.C-3 to Ex.C-8. After discharge from the hospital, the complainants applied for getting the medical expenses disbursed under the insurance policy in dispute. But, however, vide letter, copy whereof is Ex. C-14, the opposite parties allowed the claim to the extent of Rs.20,000/- only while the remaining claim was repudiated on the ground that under the terms and
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conditions of the insurance policy, claim amount was payable to the extent of 20% only against the insured amount. Even, if the case of the opposite parties is admitted to be correct for the sake of arguments, even then he assured amount under the current policy being Rs.3,00,000/-, the claim was allowable to the extent of Rs.60,000/-, whereas, the complainant has claimed a sum of Rs.52,602/- only. The opposite parties have reduced the claim of the complainant on false and flimsy grounds. The reason assigned for not allowing the claim in full is neither legal nor valid. It is, contended that the claim of the complainant for the balance amount of Rs.32,602/- alongwith compensation & costs to be assessed by this Forum is required to be allowed.
9. On the other hand, the learned counsel for the opposite parties has vehemently contended that as per terms and conditions of United Family Floater policy, 20% of the assured amount was payable in case the claimant suffers from hysterectomy as per Clause 1.2. While as per Clause 4.1 and 4.3, the claim was not payable, in case of hysterectomy, during the first two years of the operation of the policy. It is further contended by the opposite parties that although under the insurance policy Ex.C-8, no insurance amount was payable, as per Clause 4.1. & 4.3, the policy being less than 24 months in operation, yet under the policy for the year 2011-2012, a sum of Rs.20,000/- was paid. Sum assured under that policy was Rs.1 lac. only. The payable amount under the insurance policy has already been disbursed to the complainants. Instant complaint is nothing, but an
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abuse of process of law. The complainants are not entitled to the amount claimed vide instant complaint and the same is liable to be dismissed.
10 We have given thoughtful consideration to rival contentions.
11. There is no denying the fact that the insured complainant No.2 was under the cover of medi claim insurance policy w.e.f. from 01.01.2014 to 31.12.2014 vide insurance cover Ex.C-8. The insured sum in the said policy was to the extent of Rs.3,00,000/- in relation to complainant No.2. There is no denying the fact that complainant No.2 under went hysterectomy operation and remained admitted in the hospital w.e.f. 04.04.2014 to 07.04.2014. It is also not disputed that complainant No.2 incurred an expenses of Rs.52,602/- on her treatment. Bill of the hospital as well as details of expenses account for Ex.C-10 and Ex.C-12 respectively. Only dispute, inter se parties pertain to the fact as to whether complainant No.2 was entitled to the balance amount of Rs.32,602/- or not.? A perusal of repudiation letter Ex.C-14 would reveal that the complainant No.2 was awarded the claim amount on the basis of the insurance policy bearing No. 201200/48/13/06/00000284, which is current policy under that policy, complainant No.2 has been insured for an amount of Rs.3,00,000/-. Even, if the hidden clauses of insurance policy i.e. Clauses No. 4.1 & 4.3 are taken into consideration, the claimant could get medi claim to the extent of Rs.60,000/-. However, in the case in hand, the complainants have claimed Rs.52,602/- only as medi claim, out of which Rs.20,000/- have already been paid to complainant No.2, which the complainant has accepted under
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protest. In such a situation, the complainants are entitled to recover Rs.32,602/- from the opposite parties. The opposite parties have made a lame excuses to deny the claim in full. If the complainant No.2 has been awarded the claim under the current insurance policy, the insured amount cannot be taken to be Rs.1,00,000/- by any stretch of imagination. We hold that opposite parties are deficient in service. As such, we are constrained to hold that the complainant No.2 is entitled to recover balance sum of Rs.32,602/- from opposite party Nos.1 to 3 with interest @9% per annum from the date of filing of the complaint until full and final recovery. The complainants are also entitled to recover Rs.2,000/- (Rs. Two thousand) as litigation expenses. The complaint stands allowed accordingly. Compliance of this order be made within a period of thirty days from the date of receipt its copy. The opposite parties are jointly, severally & co-extensively liable to make the payment. Copies of the order be sent to the parties free of cost immediately and thereafter the file be consigned to the record room.
(Bhupinder Kaur) (Vinod Bala) (S.S.Panesar)
Member Member President
Announced in Open Forum.
Dated:12.02.2015.
