Haryana

Fatehabad

CC/390/2018

Harmesh Kumar - Complainant(s)

Versus

United India Insurance Company - Opp.Party(s)

K.R Jangra

06 Jul 2023

ORDER

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                      Sh.Rajbir Singh, President.                                                         Sh.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                                Complaint Case No.: 390 of 2018.

                                             Date of Institution:    13.11.2018

                                                        Date of order:            06.07.2023           

 

Harmesh Kumar son of Shri Rup Chand resident of Jagan Nath Colony, Jakhal Tehsil Tohana District Fatehabad.

                                                                          ….. Complainant.

                                       

                                                      Versus  

 

1.Branch Manager, United India Insurance Company Limited, Government High School Road, Main Road, Khanori Mandi, District Sangrur.

 

2.Arun Gupta, Agent United Insurance Company Limited, c/o Gupta Computer, Centre near Aggarsain Chowk, Jakhal Tehisl Tohana District Fatehabad.

 

….Opposite parties.

 

Complaint U/s 35 of the Consumer Protection Act

                                                                                

Present:          Shri K.R.Jangra, Advocate for the complainant.

                  Shri N.D.Mittal, Advocate for the OP No.1.                                              Op No.2 exparte vide order dated 18.12.2018.

 

ORDER

SH.RAJBIR SINGH, PRESIDENT

                   Brief facts of the present complaint are that the complainant had purchased a FAMILY MEDICARE POLICY 2014 bearing No. 1117872817P- 107643950 under RAKSHA HEALTH INSURANCE PLAN by making insurance premium of Rs.23051/-,  for sum assured of Rs.5 lacs from the OPs, having validity from 30.08.2017 to 29.08.2018; that the complainant felt ill in the month of November, 2017 and took treatment from Dayanand Medical College and Hospital Management society, Civil Line, Ludhiana; that the complainant spent Rs.2,79,419/- on his treatment besides taking treatment from Rajan Heart Care after spending a sum of Rs.15,000/- and Rs.18,000/- on account of hospital charges and medicines etc.; that the insurance company had only paid Rs.1,07,894/- to the hospitals and the complainant had to pay Rs.2,04,525/- being rest of the payment; that the Ops had to pay the complete bills as it all happened during the subsistence of the policy;  that the complainant requested the Ops number of times besides serving legal notices upon them to release the balance amount but to no avail; that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice. Hence, this complaint.   

2.                On notice Op No.1 appeared and filed its written statement whereas Op No.2 did not turn up despite issuance of notice through registered post. Hence, Op No.2 was proceeded against exparte vide order 18.12.2018. Op No.1 in its reply has taken preliminary objections such as non-joinder of necessary parties, complainant has no locus standi to file the present complaint being false and frivolous; that the claim of the complainant was processed and settled by the TPA after considering the all relevant terms and conditions; that the complainant had obtained policy for Rs.2 laks since 30.08.2012 which was further enhanced upto Rs.5 lakhs w.e.f.  30.08.2017; that as per claim settlement Rs.1,07,894/- has already been paid to the hospital and in token thereof son of the complainant had given his consent by signing on the declaration, therefore, there is no deficiency in service and unfair trade practice on the part of replying Op. Other contentions have been controverted and in the end, a submission was made for dismissal of the complaint.

4.                In evidence, the complainant has tendered his affidavit Annexure C1 besides documents Annexure C2 to Annexure C5. On the other hand, the Op No.1 has tendered into evidence affidavit of Sh.Surender Kumar, Assistant Annexure R1 and documents Annexure R2 to Annexure R7.

5.                We have heard learned counsel for the parties and with their kind assistance, the material available on the case file, have been perused and examined.

6.                The fact regarding obtaining the health policy (Annexure C3) by the complainant from the Ops and his falling ill during the subsistence of the policy (Annexure C4 & Annexure C5) is not disputed. The grievance of the complainant is that the Op No.1 had to pay the billed amount spent by him for his hospitalization and medicines etc. i.e Rs.2,79,419/-  during the currency of the policy but the Op No.1 had only part payment of Rs.1,07,894/- and therefore, he had to pay the rest of the amount through his own pocket.

7.                Per contra it has been submitted that the complainant is not entitled for the benefit upto Rs.5 lakh as the policy was enhanced from Rs.2 lakh to Rs.5 lakh for the year 2018-2019 (Annexure R5 & Annexure R6), therefore, the claim was settled and paid keeping in view sun insured of Rs.2 lakh. In support of his contentions learned counsel for the Op No.1 drew the attention of this Commission towards clause 5.14 of the terms and condition of the policy (Annexure R7),which is reproduced as under :

The insured may seek enhancement of sum insured in writing at or before payment of premium for renewal, which may be granted at the discretion of the company. However, notwithstanding  enhancement, for claims arising in respect of ailment disease or injury contracted or suffered during a preceding policy period, liability of the company shall be only to the extent of the sum insured under the policy in-force at the time when it was contracted or suffered during the currency of such renewed policy or any subsequent renewal thereof.

8.                          Perusal of the Annexure C4/C5 reveals that the complainant had fallen ill in the month of November, 2017 and he remained hospitalized from 09.11.2017 to 21.11.2017.  In Annexure R6, the policy No.1117872818P106988426 issued to the complainant for the period from 30.08.2017 to 29.08.2018 has been shown for sum insured of Rs.5,00,000/- therefore, the stand taken by the Ops for releasing the amount keeping in view the Rs.2,00,000/- as sum assured under the policy in question does not survive any more.  It is not the case of the Op that the premium for enhancement of the policy cover from Rs.2 lac to Rs.5 lac has not been by the insurance company.  Further, it is worthwhile to mention here that the insurance company by using its discretion has issued the policy for enhanced sum insured i.e. from Rs.2 lac to Rs.5 lac for the period 30.08.2017 to 29.08.2018 (Annexure R6) after charging requisite premium, therefore, at this stage, the insurance company cannot raise this plea. At the time of ailment, the policy cover was upto Rs.5 lac as is mentioned in Annexure R6, therefore, clause 5.14 of the terms and conditions is not applicable in the case in hand.

9.                          It is also relevant to mention here that Section 19 of the General Insurance Business Nationalization Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of claim is utterly arbitrary on the grounds which are not justifiable. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. What brought insurance into being was popular concern for future uncertainty. Man wanted to protect their hard earned property from uncertainty and this simple requirement was given a shape with the innovation and improvement of insurance policy. The only principle was to make good the loss. In our country, the insurance sector was nationalized with an objective to reach the corners of this country with insurance network, mobilize a huge resources and lend our shoulders in the nation building and in similar way the Insurance Companies also should not shirk their liabilities in case of genuine claims, like the present one, made under the insurance policies. Rather the act and conduct of the Op/insurance company shows that it has misrepresented the benefits, advantages, conditions, or terms of the policy to the complainant. Undisputedly, the Op has already made the payment to the tune of Rs.1,07,894/- after deducting the TDs as mentioned in the Annexure R2.

10.                        Thus, as a sequel to our above discussion, we accept the present complaint and direct the Ops to pay the amount of Rs.1,59,534/-  after deducting the TDS as per terms and conditions alongwith interest @ 6% per annum from the date of filing of present complaint till actual realization. We also direct the Ops to further pay a sum of Rs.11,000/- for mental agony and harassment including litigation expenses to the complainant.  The order be complied within a period of 45 days from today.

11.                        In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.