BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 644 of 2018
Date of Institution:28.8.2018
Date of Decision:28.1.2019
Jaswinder Singh S/o Jiwan Singh R/o 524-D/2, Housefed Complex, G.T. Road, Amrtisar 9815397043
Complainant
Versus
Universal Sompo General Insurance Co.Ltd., branch office SCO 113, Ist Floor, Darbara Complex, Near Vishal Mega Mart, Ranjit Avenue, Amritsar through its branch Manager
Opposite Party
Complaint under section 11 & 12 of the Consumer Protection Act, 1986
Present : For the complainant : Sh.R.P.Singh,Advocate
For the opposite party : Sh. P.K.Joshi,Advocate
Coram:
Sh.Charanjit Singh, President
Mr.Anoop Sharma, Member
Ms. Rachna Arora, Member
Order dictated by:
Sh.Charanjit Singh, President
1. Sh.Jaswinder Singh, complainant has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that the complainant got himself medically insured alongwith his family vide policy No. 2825/55527919/1/000 valid from 30.9.2017 to 29.9.2018 for sum assured for Rs. 2,00,000/-. During the period of insurance , Damanpreet Kaur, daughter of the complainant fell ill and was admitted in Floream Hospital on 6.7.2018 and discharged on 11.7.2018. In the said hospital cashless facility was not available, therefore the complainant lodged claim with the opposite party for the reimbursement of Rs. 48,272/- incurred on the treatment of his daughter Damanpreet Kaur. The complainant provided all the documents to the opposite party. Opposite party appointed investigator Mr.Brajesh, who approached the complainant and he was informed regarding the treatment and all the documents were also shown to him. The said investigator told the complainant to write a letter to get the claim in short period and the said letter was dictated by Investigator to the complainant. Thereafter the complainant received a letter dated 16.8.2018 vide which opposite party repudiated the claim of the complainant on the ground that father of the patient has converted the OPD case into IPD. It is worth to mention here that Damanpreet Kaur was taken to hospital and on the advice of the hospital she was admitted in the hospital for the treatment of septecemia with fever and she was treated in the hospital. The investigator dictated the letter in English and the complainant does not know that was got written by him as the complainant is not conversant with the English language perfectly and now the claim has been repudiated on the basis of said letter. The opposite party has wrongly , illegally and unlawfully repudiated the claim of the complainant and the said act of the opposite party amounts to deficiency in service, unfair trade practice which has caused lot of mental tension, pain, agony as well as financial loss to the complainant. Alongwith complaint, complainant has filed his affidavit Ex.C-1, copy of policy Ex.C-2, copy of repudiation letter Ex.C-3, copy of hospital bill Ex.C-4, copy of discharge card Ex.C-5, copy of laboratory bill Ex.C-6, copy of medical bill Ex.C-7, copy of laboratory test report Ex.C-8. Vide instant complaint, complainant has sought for the following reliefs:-
(a) Opposite party be directed to reimburse the claim amount of Rs. 48,272/- alongwith interest @ 18% p.a.
(b) Compensation to the tune of Rs. 25000/- alongwith adequate litigation expenses may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version in which it was denied that Damanpreet daughter of the complainant fell ill and admitted to Florem Hospital on 6.7.3018 and was discharged on 11.7.2018. The opposite party has investigated the claim of the complainant through its Authorized investigator and on scrutiny of the claim documents, it was observed that daughter of the complainant namely Damanpreet Kaur ,6 years femal, covered under CHI health care plus policy, who was admitted for the period from 6.7.2018 to 11..2018 as case of septicemia with fever for which insured treated on conservative management and discharged in medically stable condition. On further scrutiny and investigation, it was found that OPD case is converted into IPD case as per statement of complainant , therefore, on the basis of investigation reports and complete scrutiny of documents the opposite party has rightly repudiated the claim of the complainant vide letter dated 16.8.2018. While denying and controverting other allegations, dismissal of complaint was prayed. Alongwith written version opposite party filed affidavit of the Authorized signatory of opposite party Satnam Singh Ex.OP1, copy of deficiency letter Ex.OP2, copy of repudiation letter Ex.OP3, report of investigator Ex.OP4, letter written by Jaswinder Singh complainant Ex.OP5, claim file Ex.OP6 , terms and conditions Ex.OP7, authority letter Ex.OP8.
3. We have heard the Ld.counsel for the parties and have carefully gone through the record o the file.
4. From the appreciation of the facts and circumstances of the case, it was not denial the fact that the complainant has obtained Health Care Policy Schedule from the opposite party in which complainant himself, his spouse Sukwhinder Kaur and daughter Damanpreet Kaur were fully insured for the sum assured Rs. 2,00,000/-, copy of policy is Ex.C-2 on record. It was the case of the complainant that his daughter Damanpreet Kaur fell ill and was hospitalized in Florem Hospital for the period from 6.7.2018 to 11.7.2018 where diagnosis was recorded as Septecemia with fever and in this regrd complainant has placed on record copy of discharge card Ex.C-5. The complainant incurred an expenditure of Rs. 48,272/- and in this regard complainant has placed on record copy of hospital bill Ex.C-4, copy of laboratory bill Ex.C-6 as well as copy of medicines bill Ex.C-7 on record. However, the claim filed by the complainant was repudiated on the ground that on investigation of the claim documents, it was found that OPD case is converted into IPD case as per patient’s father statement. But we are not agreed with this ground taken by the opposite party as the complainant has produced all the bills of hospital as well as discharge card of the hospital which fully proves that Damanpreet Kaur , daughter of the complainant remained admitted in the hospital for the period from 6.7.2018 to 11.7.2018 . Moreover the opposite party has only relied upon the investigation report made by the investigator who made this ground for repudiating the claim of the complainant. But no affidavit of the investigator , who has submitted his report has been placed on record. In the absence of which no evidentiary value can be made on the report submitted by the surveyor. Reliance in this connection has been placed upon Manikant Vs. New India Assurance Co.Ltd. 1(2012) CPJ 88 (NC) of the Hon’ble National Commission wherein it has been held that the surveyor did not appear in court and subject himself to cross examination nor was any affidavit filed by him to prove his report . Producing a document in court does not by itself constitute proving the document. It has to be backed by credible evidence. In the instant case, no evidence was led to prove the surveyor’s report in the absence of which the surveyor’s report has little evidentiary value.
5. Moreover it is usually seen that insurance companies show green pastures to the insured persons at the time of selling the insurance policy 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 Dharmendra Goel 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. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams 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.
The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
6. From the aforesaid discussion, it transpires that complainant has been able to prove his case and as such the complainant is entitled for the expenses incurred on the treatment of his daughter to the tune of Rs. 48,272/- Opposite party is directed to make payment of Rs. 48,272/- to the complainant . Compliance of this order be made within a period of 30 days from the receipt of copy of this order ; failing which awarded amount shall carry interest @ 9% p.a. from the date of passing of the order until full and final recovery. Cost of litigation are assessed at Rs. 3000/-. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
