Punjab

Sangrur

CC/593/2020

Ramesh Kumar - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

Sh. Darshan Gupta

04 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR, PUNJAB.

 

          Complaint Case No       : CC/593/2020

                                              Date of Institution                   : 02.12.2020

          Date of Decision            : 04.07.2024

Ramesh Kumar aged 58 years son of Late Sh. Chhaju Ram C/o R.K. Marble Industry, Patiala Road, Sangrur, Tehsil and District Sangrur.    

                                                                                        …Complainant

                                              Versus

1. United India Insurance Company Limited, Railway Road, Sangrur through its Divisional Manager.   

2. United India Insurance Company Limited, 24 Whites Road, Chennai 600014 through its Managing Director.

                                                                                         ...Opposite Parties.

Complaint under section 35 of the Consumer Protection Act, 2019

Present:       Sh. Darshan Gupta counsel for complainant.

                   Sh. M.P. Singh Pahwa counsel for opposite parties.

Quorum.-

1. Sh. Jot Naranjan Singh Gill                    : President

2. Smt. Sarita Garg                           : Member
3. Sh. Kanwaljeet Singh                    : Member   

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

 

1.                The complainant namely Ramesh Kumar has filed the present complaint under Section 35 of the Consumer Protection Act 2019, (amended upto date) against United India Insurance Company Limited and others (in short the opposite parties).

2.                The facts leading to the present complaint as stated by the complainant are that the complainant had remained the customer of the opposite parties and regularly purchased the Family Medicare Policy 2014 from the opposite party No. 2 since long and now the complainant renewed his family policy from opposite party No. 1 vide policy No. 2019002820P102004353 for the period of 14.6.2020 to 13.6.2021. The complainant paid Rs. 29,745/- to opposite party No. 2 towards the premium of his Family Medicare Policy 2014 and the opposite party told the complainant that as per this policy, the treatment from the company’s network hospitals will always be cashless and therefore, there will be no need to pay any amount to the hospital authorities, if any type of medical treatment taken from the hospital. It is further alleged that in this policy the complainant and his wife Smt. Usha Rani are insured for the sum of Rs. 5 lacs. The opposite party No. 1 has sent insurance policy for the all the insured and except these documents nothing has been supplied to the complainant with regard to the family health policy, which was purchased by the complainant. The opposite parties never supplied the terms and conditions alongwith said policy till date and since the year 2014 till July 2020, no medical claim was ever lodged by the complainant with the opposite parties for himself and for his spouse insured under this policy. It is further alleged that on 24^th of June 2020, the complainant had fever and cough and after waiting for three days when the body temperature did not came down and no recovery from cough and fever then the local doctors advised that there seems to be symptoms of Covid-19 then the complainant on 29^th June 2020 admitted in the Fortis Hospital, Ludhiana and on the same day the hospital authority intimated to the opposite parties to the cashless request for the patient as the hospital was listed as network hospital for cashless treatment as per the list of network hospital of the opposite parties. The doctors of the hospital after various clinical and lab tests found the complainant Covid-19 positive and started the treatment of the complainant. The complainant remained admitted in the above said hospital from 29^th June 2020 to 8^th July 2020. The hospital authority gave a discount of Rs. 25,000/- to the complainant and after deduction of discount the hospital claimed a total bill of Rs. 2,25,229/- for the treatment of complainant. But the opposite parties arbitrarily and unlawfully made the deductions i.e. 1. Not covered Administrative Expenses Rs. 7200/-, 2. Not covered consumable Rs. 21,889/-, 3. Hospital Discount Rs. 25,050/-, 4. Room Rent Limit Exceed Rs. 38,750/- , 5. Proportionate Deduction as per Room Rent Rs. 50,647/- and the total deduction is Rs. 1, 43,536/-. It is further alleged that at that time the complainant having no sufficient means of funds to deposit with the hospital authority and had to borrow the same. The opposite parties denied the cashless treatment at that time and the complainant has to pay Rs. 1,43,536/- for his treatment and the complainant has to face mental tension, agony and harassment due to the conduct of the opposite parties. The complainant sent a letter dated 17.8.2020 to the opposite party No. 1 for supplying the copies of terms and conditions but till today, opposite parties did not supply the same to the complainant. Thus, there is deficiency in service and unfair trade practice on the part of the opposite parties. Hence, the present complaint is filed seeking the following reliefs.-

1. The opposite parties may be directed to pay the amount of Rs. 1,43,536/- alongwith interest @ 18% per annum from the date of discharge from hospital till realization.
2. To pay Rs. 1,00,000/- for mental agony and harassment inconvenience and Rs. 33,000/- as litigation expenses.  

3.                Upon notice of this complaint, the opposite parties appeared and filed written reply by taking preliminary objections interalia on the grounds that complainant has no locus standi and cause of action to file the present complaint. The complaint is not filed in proper form and therefore the same is not maintainable. The complainant has not complied with the terms and conditions of the insurance policy. The complaint is bad for non-joinder of necessary party. This Commission has no jurisdiction to entertain and try this complaint. An intricate question of facts and law are involved in this matter and same cannot be decided by summary procedure. The complainant has not come with clean hands etc.

4.                On merits, it is admitted to the extent that the complainant purchased the Family Medicare Policy 2014 from the opposite parties effective from 14.6.2020 to 13.6.2021 on payment of requisite premium by opting sum insured as 5.00 Lac. The complainant has concealed the fact that he was supplied with detailed terms and conditions of the policy and the policy was subject to terms and conditions detailed in the policy. The complainant has been paid due amount payable to him as per terms and conditions of the policy which includes IRDA (Health Insurance Regulation) 2013 and IRDA (Protection of policy holder’s interest) Regulations 2002 and the deductions were also made as per terms and conditions of the policy. The cashless treatment was also denied as per terms and conditions of the policy. Therefore, there is no deficiency in service and unfair trade practice on the part of the opposite parties and prayed for the dismissal of complaint with costs.

5.                In order to prove the case the complainant tendered into evidence copy of policy Ex.C-1, copy of medical bill Ex.C-2, copy of deduction of bill Ex.C-3, copy of legal notice Ex.C-4, copy of postal receipts Ex.C-5 & Ex.C-6, copy of OPD slip Ex.C-7, copy of self attested affidavit Ex.C-8, copy of letter Ex.C-9 and closed the evidence.

6.                To rebut the case the opposite parties tendered into evidence self attested affidavit Ex.O.Ps1/1 and closed the evidence.

7.                We have heard the learned counsel for the parties and have gone through the record on the file.

8.                In order to prove his case the complainant has placed on record copy of insurance policy Ex.C-1 which shows that the complainant has purchased Family Medicare Policy 2014 and the complainant regularly renewed the above said insurance policy and the same was valid from 14.6.2020 to midnight on 13.6.2021. The policy further shows that the complainant Ramesh Kumar and his wife Smt. Usha Rani were insured under the said policy. From the policy it also shows that the sum insured opted Rs. 5,00,000/-. The complainant has also placed on record copy of Inpatient Detail Running Bill Ex.C-2 which shows the Net Bill Amount Rs. 2,25,229.13 and Medsave Healthcare (TPA) Limited paid Rs. 1,06718.00 to the hospital and the Patient Share Rs. 1,18,511.13 and Net Payable Amount shows as Rs. 1,13,511.13. Ex.C-3 is the copy of Deduction Bill which shows as under:-

Sr. No. Deduction                                                          Amount

1. Not Covered- Administrative Expenses           7200

2. Not Covered- Consumable                               21889

3. Hospital Discount                                            25050

4. Room Rent Limit Exceed                                 38750

5. Proportionate Deduction as per Room Rent    50647

Total Deduction Amount                                     1,43,536

The complainant also placed on record letter dated 17.8.2020 Ex.C-3 which was written by the complainant to the Branch Manager, United India Insurance Co. Railway Road, Sangrur vide which the complainant submitted that the total amount of bill paid to Hospital for Rs. 2,25,229.13 only 1,06,718.00 have been paid by the company and reasons of deduction of such amount may be intimated to him and on this letter the opposite parties have given note that we have given the Detail of Deductions made by TPA Medsave. Ex.C-4 is the copy of legal notice dated 24.8.2020 and Ex.C-5 & Ex.C-6 are the postal receipts. Ex.C-8 is the detailed affidavit of complaint vide which he reiterated the averments as mentioned in the complaint.

9.                On the other hand, the opposite parties in order to rebut the case of the complainant have placed on record affidavit of Manmohan Singh Deputy Manager of opposite party No.1 Ex.O.Ps1/1 alongwith Annexure R1the calculations alongwith deductions and apart from this the opposite parties have not placed on record any document.

10.               It is admitted fact between the parties that the complainant has purchased the Family Medicare Policy 2014 from the opposite parties effective from 14.6.2020 to 13.6.2021 on payment of requisite premium by opting sum insured as 5.00 Lac. It is also not disputed between the parties that the complainant remained admitted in the above said hospital from 29^th June 2020 to 8^th July 2020 and after deduction of discount the hospital claimed a total bill of Rs. 2,25,229/- for the treatment of complainant.

11.              The allegation of the complainant is that out of the above said total bill of Rs. 2,25,229/- the opposite parties have paid only Rs. 1,06,718/- to the hospital and the remaining amount of Rs. 1,18,511.13/- has been paid by the complainant to the hospital. However, the complainant was insured for an amount of Rs. 5,00,000/- as per policy (Ex.C-1). On this the opposite parties have submitted that they have paid the above said amount of Rs. 1,06,718/- to the hospital as per policy terms and conditions, but the opposite parties have failed to place on record the terms and conditions of the policy. Even, the opposite parties have also failed to place on record any evidence that they have supplied the terms and conditions of the policy to the complainant alongwith the policy. Moreover, the opposite parties have added the amount of Rs. 25,050/- the hospital discount in the deduction which was given to the complainant by the hospital. So, we are of the view that the opposite parties have failed to rebut the allegations of the complainant by producing any cogent, reliable and trustworthy evidence on record. Therefore, it proves that the claim of the complainant was genuine one and there was clear cut deficiency in service on the part of the opposite parties and the complainant is entitled for the remaining amount of Rs. 1,18,511.13/- (as per bill Ex.C-2) which was paid by the complainant to the hospital as the complainant was insured for an amount of Rs. 5,00,000/- (as per policy Ex.C-1).

12.              Learned Counsel for complainant placed reliance 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.

13.               Ld. Counsel for the complainant has also relied upon the judgment of the Hon’ble National Consumer Disputes Redressal Commission, New Delhi 2021 DNJ 335:2021 (4) C.P.R. 336: 2021 NCJ 944: 2021 (4) C.P.J. 85 in case titled M/s Anjaneya Jewellery Vs New India Assurance Co. Ltd. and ors. vide which in Para No. 26 the Hon’ble National Commission held that there is no material on Record to establish that the Opposite Party Insurance Company had given the Terms and Conditions of the Special Package Insurance Policy or at any point of time or ever informed the Complainant about the same. Thus, the Exclusion Clause on the basis of which the Opposite Party Insurance Company had repudiated the Insurance Claim of the Complainant cannot be sustained as the Opposite Party Insurance Company could not rely upon the same. The Repudiation letter is, therefore, set aside.

14.               In view of our above discussion, we partly allow the present complaint against the opposite parties and directed the opposite parties to pay an amount of Rs. 1,18,511.13/- to the complainant along with interest @ 7% per annum from the date of filing of the present complaint till realization. We further directed the opposite parties to pay an amount of Rs. 5,000/- in lieu of compensation on account of mental agony and harassment suffered by the complainant as well as an amount of Rs. 5,000/- on account of litigation expenses to the complainant.

15.              This order be complied with within a period of sixty days of receipt of copy of this order.

16.              The complaint could not be decided within the statutory time period due to heavy pendency of cases.

17.              Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.

                                Announced.

 

                                July 04, 2023.

 

 

        (Kanwaljeet Singh)    (Sarita Garg)     (Jot Naranjan Singh Gill)

                 Member           Member                 President