O R D E R
K.S. MOHI, PRESIDENT
The complainant has filed the present complaint against the O.P u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken Health Insurance Policy No.040200/48/09/97/00002259, covering himself and his family members from O.P which was valid for the period from 16.10.2009 to 15.10.2010. On 20.09.2010 daughter of the complainant got admitted in the Sunder Lal Jain Hospital, Ashok Vihar. She remained in the hospital till 22.09.2010 and the complainant spent about Rs.17,000/- on account of treatment of his daughter. It is alleged that all the documents along with the medical bills have been filed by the complainant within time. Complainant filed claim with O.P for reimbursement of the amount which was repudiated by the O.P vide its letter dated 27.11.2010. It is further alleged that repudiation of claim by O.P was illegal and unjustified. It is alleged that the complainant has made various requests and reminders to the O.P for reimbursement of the claim of complainant but all in vain. It further alleged that vide order dated 24.04.2014 this Hon’ble Forum was pleased to direct the complainant to send the comments to the O.P in compliance to the letter dated 27.11.2010. The operative part is as follows: Para…5, “In view of these facts and circumstances we are of the considered opinion that the ends of the justice will be met if complainant is directed to send his comments to the OP as requested by the TPA vide his letter dated 27.11.2010 along with all the relevant records in connection with the claim of the complainant. On receipt of the comments of the complainant and all the relevant documents from the complainant the O.P shall consider the claim of the complainant and deicide one way or the other the claim of the complainant, within a period of 30 days in accordance with terms and conditions of the policy. In the fact and circumstances of the case, parties are left to bear their own cost. Complaint is disposed of accordingly.” It is alleged that in compliance of order dated 24.04.2014 passed by this Hon’ble Forum the complainant filed the written comments with the O.P on 20.05.2014 along with documents. It is further alleged that complainant went to the office of the O.P on 24.06.2014, 10.07.2014, 25.07.2014 and 08.08.2014. On 08.08.2014 the complainant was informed by O.P that the claims have been approved and the complainant will have to approach the TPA at Gurgaon Office. It is alleged that on 22.08.2014 the complainant approached the TPA along with relevant documents and submitted the same. The O.P arbitrarily and without informing the complainant credited an amount of Rs.9,968/- on 23.08.2014 directly in the account of the complainant. It is further alleged that no letter/ intimation whatsoever was issued to the complainant by the O.P for the deduction of amount claimed by the complainant. On these facts complainants pray that O.P be directed to pay Rs.7,015/- along with interest @ 12% per annum, apart from cost and compensation as claimed.
2. O.P appeared and filed the written statement. In its written statement O.P has not disputed that complainant had taken policy referred to above. It is alleged that earlier the complainant had filed one complaint bearing No.323/2012 before this Hon’ble Forum regarding the same cause of action as alleged in the present complaint. It is further alleged that this Hon’ble Forum disposed off the said complaint vide order dated 24.04.2014 and both parties were given certain direction in the aforesaid order dated 24.04.2014, the O.P i.e. United India Insurance Co. Ltd. is ready to pay the claim of the complainant as per terms and conditions of the policy but the complainant is not accepting the claim amount and he is demanding much more money above the claim which cannot be considered as per the terms and conditions of the policy. It is alleged that the complainant has submitted the claim dated 07.10.2010 for total sum of Rs.16,983/-. It is further alleged as per terms and conditions of the policy the sum insured for the complainant’s daughter in the medical policy was Rs.1,25,000/-, therefore, she was only entitled for accommodation/ room of Rs.1,250/- per day (1% of the sum insured) but the complainant took the accommodation/ room of Rs.3,200/- per day. It is alleged that complainant’s daughter was admitted in the hospital for two days and the complainant calculated the total amount for accommodation/ room Rs.6,400/- but actually the complainant’s daughter was entitled for accommodation/ room Rs.2,500/- for two days. It is further alleged that as per terms and conditions of the policy, the TPA legally deducted the access amount for accommodation/ room and other charges as per the terms and conditions of the policy and the permissible as per terms and conditions of the policy and same has been credited in the account of the complainant, but the complainant is adamant to take much more amount from the answering O.P which is not permissible under the law. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit in evidence testifying all the facts as alleged in the complaint. On the other hand Sh. Hemant Kumar Pal, Asstt. Manager has filed his affidavit in evidence testifying all the facts as alleged in the written statement. Written submissions have also been filed by both the parties.
4. We have carefully gone through the record of the case and have heard submissions of Ld. Counsels for the parties.
5. In the instant case the complainant had filed previous complaint bearing No.323/2012 and the forum by disposing of the said complaint in Para 5 of the judgment directed the complainant to furnish all the relevant records in connection with the claim to O.P. The case of complainant is that even after furnishing all the relevant documents the O.P did not make entire payment of the medical claim but arbitrarily credited an amount of Rs.9,968/- on 23.08.2014 directly in the account of the complainant leaving an amount of Rs.7,015/- which according to O.P has been deducted as per terms and conditions of the policy. It is relevant to mention here that counsel for the O.P had brought cheque in the sum of Rs.3,115/- for complainant which was not acceptable by the counsel for the complainant for the ground that even with this amount the complainant has not been paid full amount of the complainant. Now the question arises whether the complainant is entitled to the remaining amount or not. Admittedly the complainant that sought roughly Rs.17,000/- towards medical claim and the O.P carried out certain deduction while applying the terms and conditions. It is shocking that the O.P has not placed on record any documents regarding terms and conditions. Even if it is presumed that there were terms and conditions for deduction on the medical bill submitted by the complainant, even then the O.P cannot be permitted to do so firstly because the said so called terms and conditions do not form part of the policy and that there is no record as to how these terms and conditions were supplied to the complainant. It is now well settled law that until and unless the terms and conditions were supplied to the complainant they cannot be relied upon by the O.P. In case titled IV (2014) CPJ 14A (CL) HAR. Oriental Insurance Co. Ltd. Vs Vivek Rekhan, the claim filed on the basis of mediclaim policy was repudiated by the insurance company on the basis of exclusion clause. The court held that the insurance company vaguely denied without pointing out as to in which manner and on which date terms and condition were supplied to the complainant. Therefore, unless terms and condition have been supplied to the complainant before taking a policy, exclusion clause cannot be enforced.
6. Keeping in view the discussion above the O.P rejected the claim on whimsical reasons, therefore, deficiency in service. We direct the O.P to pay a sum of Rs.7,015/- to the complainant. No interest is payable because the part payment has already been paid by the O.P during course of proceedings and there was no delay on the part of the O.P. Furthermore it is the complainant himself who declined to accept other cheque of Rs.3,115/- tendered by O.P in the court on 11.03.2016 which conveys that it is intention of the complainant to cause more delay, to claim more towards interest which is not the spirit of the Consumer Protection Act, because while dealing with complaint under the Act, the forum is expected of granting adequate award/ compensation to the consumer rather than to enrich them. However, in the facts and circumstances the O.P is further sadder with compensation of Rs.1,500/- to the complainant towards harassment and litigation expenses.
Copy of this order be sent to the parties as per rules.
Announced this 11th day of March, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
A.G.
