BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

      Complaint No.78 of 2019

      Date of Instt. 13.03.2019

      Date of Decision: 25.09.2024

Anuj Wasan, aged 26 years, son of Vijay Kumar Wasan, resident of 29-30 Vijay Nagar, Jalandhar.

..........Complainant

Versus

United India Insurance Company Limited, Sayal House, Lajpat Nagar Market, Jalandhar, Punjab-144001.

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)

Present:       Sh. Kunwar Sood, Adv. Counsel for Complainant.

                   Sh. K. L. Dua, Adv. Counsel for OP.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant availed health insurance policy and got himself insured vide policy No.2013002817P115182019 from 20.01.2018 to 19.01.2019 and to that effect the detailed insurance policy was also issued. A total sum assured for the policy was Rs.3,00,000/- and most importantly the complainant had been getting himself insured since 20.01.2014 regularly. During the subsistence of the said insurance policy, the complainant suffered from medical ailment of Bankart lesion right with slap tear and for the said medical ailment the complainant had to undergo extensive medical treatment at Guardian Hospital, Jalandhar and the complainant was admitted on 12.01.2019 and underwent treatment till 15.01.2019. The ailment was suffered during the subsistence of the policy and the OP was bound to remit the claim to the complainant. The complainant had to incur total expenses of Rs.1,95,294/- and the medical record to that effect has already been on the record. The complainant immediately intimated the OP about the claim which was lodged with the OP vide No.UIC 5451442520 and all the necessary and required detail had been provided and supplied to the OP, while the OP has been showing resistance to the genuine claim of the complainant. The complainant has received an email from the OP and an amount of Rs.1,16,083/- has been credited in the account of the complainant and the said amount is not only deficient, but is also against the insurance policy itself. The OP has wrongly made deductions in the claim amount unilaterally against the terms and conditions of the insurance policy itself which is totally unjustified and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OP be directed to pay claim amount of Rs.79,211/- with interest @ 12% per annum. Further OP be directed to pay a compensation of Rs.10,000/- for causing mental tension and harassment to the complainant and Rs.15,000/- as litigation expenses.

2.                Notice of the complaint was given to the OP, who filed reply and contested the complaint by taking preliminary objections that non cause of action  arose to the complainant to file the present false and frivolous complaint. It is further averred that the present complaint is not maintainable and the complainant has not disclosed the true and material facts and has concealed the material facts and has tried to mislead the Forum by concealment of the material facts and as such is not entitled for the grant of any relief.

3.                Rejoinder not filed by the complainant.

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

5.                We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.

6.                It is admitted that the complainant has availed the health insurance policy from the OP which was valid from 20.01.2018 to 19.01.2019. The same has been proved as Ex.C-1. It is also admitted that the total sum assured was Rs.3,00,000/-. It is also admitted that during the subsistence of the policy, the complainant suffered from medical ailment of ‘Bankart lesion right with slap tear’. It is also not disputed that he had to undergo medical treatment at Guardian Hospital, Jalandhar and was admitted in the hospital on 12.01.2019 and discharged on 15.01.2019. It is also not disputed that the complainant incurred Rs.1,95,294/- as expenses. It is also not disputed that he informed the OP immediately about the claim, which was lodged by the complainant with the OP. The complainant has proved that the OP has approved his claim of Rs.1,16,083/- and the same was received by the complainant. The email received by the complainant has been proved by the complainant as Ex.C-3. Though, the complainant has challenged vide this complaint that the deductions made by the OP of Rs.79,211/- are illegal, wrong and against the terms and conditions of the insurance policy. It has been alleged by the complainant that there are no such terms and conditions in the policy for which the deductions have been made by the OP.

7.                The OP has alleged that the complainant has been given the amount of Rs.1,16,083/- as per terms and conditions of the policy. The deductions have been made as per the terms and conditions of the policy. No illegal deductions have been made by the OP.

8.                The complainant has proved all the documents including the medical record policy claim and settlement letter. Similarly, the OP has also proved on record all these documents. All these documents have been admitted and are not disputed. The controversy in the present case is regarding the deductions made by the OP. As per settlement voucher and as per the letter Ex.C3/OP1 produced on record by the OP in the Commission shows that out of Rs.1,16,083/-, the amount of Rs.44,000/- was paid as per reasonable customary rate as rates compared with Patel Hospital, Jalandhar, Rs.64,050/- of implants was paid and Rs.8033 was paid for pre-post hospitalization expenses. As per this letter and Ex.C-3/OP-1, Rs.2500/- were deducted for admission charges, Rs.1500/- were deducted as per room rent capping and Rs.36,159/- were deducted as per room reasonable and customary charges. Rs.17,943/- were deducted as per room rent capping and Rs.6091/- were deducted for non-payable items.

9.                As per terms and conditions of the insurance policy, there is no such condition that the amount shall be settled or paid after comparing the rates with other hospitals. There is no such terms and conditions that the rates applicable to other hospitals shall be given to the complainant for the same problem. Even otherwise this policy of the OPs is wrong and illegal on the face of it. Similarly, the deductions made by the OP as per room rent capping and customary charges are wrong and illegal. Nothing has been explained by the OP in the terms and conditions of the insurance policy that how the entitlement of room is fixed by the OP. All the deductions have been made by the OP as per room capping. So far as the deductions made by the OP of Rs.6091/- for non-payable items are there, these deductions can be considered to be genuine as these are convenience items which were used as per bill. Out of Rs.27,923/-, Rs.21,832/- have been approved by the OP and Rs.6091/- have been deducted for convenience charges and all other medication charges have been given. The terms and conditions about the room entitlement and room rent capping have not been explained to the complainant at the time of issuing the policy in simple words nor this fact has been proved by the OP that all the terms and conditions regarding the entitlement of room or room rent capping or customary charges as comparable with the other hospital have been explained to the complainant and after admitting the same, the complainant has purchased the policy. No terms and conditions have been filed on record by the OP to show that these terms and conditions were well within the knowledge of the complainant, whereas the complainant has alleged that he was never supplied with any terms and conditions. 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. . It has been held by the Hon’ble Punjab & Haryana High Court, in Civil Revision No.2318 of 2008, decided on 22.04.2008, titled as “New India Assurance Company Limited Vs. Smt. Usha Yadav & Others”, 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’. Thus, the deficiency in service has been proved. The deductions made by the OP except Rs.6901/- are wrong and illegal.

                   So, from the overall circumstances and in view of the law, the complainant is entitled for the relief.

10.              In view of the above detailed discussion, the complaint of the complainant is partly allowed and OP is directed to pay Rs.72,311/- with interest @ 9% per annum from the date of filing complaint till its realization. Further, OP is directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.8000/- as litigation expenses. 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.

11.              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     

25.09.2024         Member                          Member           President