| ORDER | Complainant Vinod Kansra through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the opposite parties be directed to make the payment of Rs.1,75,000/- i.e. balance insurance claim along with interest @ 18% p.a. He has also claimed Rs.50,000/- as damages for illegal harassment, deficiency in services and mental agony and Rs.20,000/- as litigation expenses, all in the interest of justice. - The case of the complainant in brief is that he purchased a health insurance policy from the opposite parties vide policy No.111100/48/13/97/00000380 covering the period from 15.3.2014 to 14.3.2015 for a sum of Rs.5,50,000/- which was issued by the opposite party no.3 in which complainant, his wife Poonam Kansra and his daughter Miss Akanksha was covered for sum of Rs.2,50,000/-, Rs.1,50,000/- and Rs.1,50,000/- respectively and complainant paid Rs.12085/- as premium for the same and as such he is consumer of the opposite parties. It was pleaded that complainant himself and his family got insured with the opposite parties for the last about 20 years through health insurance policies and never got any claim against those policies and even again got health insurance policy for future. It was pleaded that complainant got some problem in his knees and he was operated himself for change of both the knees from Fortis Escorts Hospital, Amritsar which is in the list of scheduled hospitals of insurance company and he remained admitted in the said hospital from 14.10.2014 to 21.10.2014. It was further pleaded that complainant spent more than Rs.3,50,000/- for the said operation of total knee replacement and back up treatment and operation was done on 15.10.2014. It was also pleaded that complainant submitted all the requisite documents including medical bills with the opposite parties and demanded Rs.2,50,000/- i.e. sum assured as insurance claim but complainant was surprised when opposite parties transferred Rs.75,000/- only in his saving account on 9.2.2015 without mentioning any reason of giving a meager amount instead of Rs.2,50,000/- i.e. sum assured. Opposite party no.4 is also sister concern company of opposite parties no.1 to 3 and it also deals in insurance claims. It was next pleaded that complainant was harassed by the opposite parties by forcing him running pillar to post on flimsy ground and asking for documents time and again even before transferring above said amount in his account. Complainant time and again approached the opposite parties personally as well as through correspondence and requested them to pay his full insurance claim but of no use. He also got issued a legal notice dated 13.2.2015 to the opposite parties in which he demanded Rs.1,75,000/- i.e. balance insurance claim alongwith interest @ 18 % p.a. and also demanded Rs.50,000/- as damaged for illegal harassment and mental agony but till date neither reply was given nor any payment was made by the opposite parties to the complainant, hence this complaint.
3. Upon notice, the opposite parties have appeared through their counsel and filed the written reply stating there in that it was denied that complainant himself and his family got insured with the opposite parties for the last about 20 years through Health insurance policies and he remained admitted in the Fortis Escorts Hospital Amritsar. It was admitted that complainant submitted all the documents and demanded Rs.2,50,000/- along with medical bills but it was denied that opposite parties made the payment of Rs.75,000/- as insurance claim amount in the savings account of the complainant on 9.2.2015 without any reason. It was stated that complainant had a history of pain in his both knees since one year which was clear from the pre authorization form dated 25.1.2013 submitted by M/s Fortis Escorts Hospital Amritsar for availing cashless benefit. It was further stated that complainant was suffering from this ailment since last one year i.e. since January, 2012 and during the period of January, 2012 complainant was having a mediclaim policy bearing no.111100/48/18/97/00000696 effecting from 15.3.2011 to 14.3.2012 for a sum assured of Rs.75,000/- and as such complainant was rightly compensated with the amount of Rs.75,000/-. It was denied that there is any deficiency in service on the part of the opposite parties. All other averments made in the complaint have been denied. Lastly, the complaint has been prayed to be dismissed with costs. - Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1 alongwith other documents Ex.C2 to Ex.C11 and closed the evidence on behalf of complainant.
- Counsel for opposite parties tendered into evidence affidavit of Pardeep Singh Branch Manager Ex.OP-1, affidavit of Sandeep Singh Technical Support Executive Ex.OP-7 alongwith other documents Ex.OP-2 to Ex.OP6 and Ex.OP8 to Ex.OP14 and closed the evidence on behalf of opposite parties.
6. We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for some documents that have been somehow ignored to be produced by the contesting litigants. We observe that the OP insurers have apparently settled the med-insurance claim with the Policy SI (Sum Insured) determined at an amount of Rs.75,000/- (paragraph ‘5’ of the written reply & paragraph ‘3’ & ‘2’ of the OP Affidavits Ex.OP1 & Ex.OP7) for of the one prime reason that the patient complainant had contracted the ‘knee-joint-pain’ in both his knees in January’ 2012 when the applicable in-force policy # 48/18/97/000000696 (valid from 15.03.2011 to 14.03.2012) was for an SI (Sum Insured) of Rs 75,000/- only and thus the impugned claim was settled and paid in full (on 09.02.2015) for Rs.75,000/- as per the complainant’s entitlement in terms of the then SI of the Policy. However, the OP insurers have failed to produce any cogent evidence proving that the complainant had contracted the ‘ailment’ in question in January’2012 and in its absence the allegation has been just a ‘bald’ statement. The OP insurers have stated in its reply (in own words) as: “In fact, the complainant Vinod Khansra had a history of pain in his both knees since one year which was revealed as per the pre-authorization Form dated 25.01.2013 submitted by M/s Fortis Escorts Hospital, Amritsar for availing cashless benefit. ..… Hence the complainant was rightly compensated with the amount of Rs.75,000/- because as per condition 5.12 of Gold Policy – enhancement of Sum Insured – it is clearly stated that - The insured for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding policy period (in present case January 2012), then liability of the company shall be only to the extent of 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 -. Therefore, the claim was settled correctly for Rs.75,000/-.” We are unable to agree with this clarifying contention put forth by the OP Insurers since there has been no pre-authorization Form of 25.01.2013 produced on record (alleged to have been submitted by M/s Fortis Escorts Hospital, Amritsar) for availing cashless benefit and there was no occasion for the prompt of the same as the complainant was admitted to this hospital only on 14.10.2014 as is evident from the Ex.OP8, the Fortis’ request for cashless Hospitalization for medical insurance policy and it also mentions clearly as: Pain Both Knees 1½ years and difficulty in walking: 07 months and that indicates the alleged contraction incurring somewhat around April’2013 when the said Policy with SI as Rs.75,000/- was not in force and instead the fresher Policy with the SI of Rs.2.50 Lac has been in force. We find the OP insurer’s present settlement of claim as callous (sans application of fair mind) and ‘deficient in service’ causing much delay and harassment to the complainant and that holds them liable to an adverse award under the Act. 7. In the light of the all above, we partly allow the present complaint and thus ORDER the OP insurers to settle and pay the impugned Claim in question as per the applicable Policy Ex.OP2 (valid from 15.03.2014 to 14.03.2015) for an SI (Sum Insured) of Rs.2,50,000/- to the complainant besides to pay him Rs.5,000/- as compensation (inclusive of cost of litigation) within 30 days of the receipt of the copy of these orders otherwise the full awarded amount shall attract simple interest @ 9% PA form the date of orders till actual payment. 8. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record. (Naveen Puri) President. ANNOUNCED: (Jagdeep Kaur) March 11, 2016 Member. *YP* | |
