BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.26 of 2016

Date of Instt. 12.01.2016

Date of Decision: 30.01.2018

Rekha Gupta aged 54 years W/o Sh. Ashok Kumar Gupta, resident of Village Koopur, PO Adda Kathar, Jalandhar-Hoshiarpur Road, District Jalandhar.

..........Complainant

Versus

1. Universal Sompo General Insurance Company Limited, SCO-4, Second Floor, PUDA Complex, Ladowali Road, Jalandhar through its Branch Manager.

2. M/s EMEDITEK (TPA) Service Limited, Corporate Office: Plot No.577, Udyog Vihar, Phase-V, Gurgaon-122016, Haryana through its Authorized Signatory.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Harvimal Dogra (Member)

Present: Sh. DDS Nayar, Adv Counsel for the Complainant.

Sh. Vikas Kumar Gupta, Adv Counsel for the OP No.1.

OP No.2 exparte.

Order

Karnail Singh (President)

1. This complaint presented by the complainant, wherein stated that her husband Sh. Ashok Kumar Gupta, had taken an IOB-Health Care Plus Policy from the OP No.1 through Indian Overseas Bank, in his name, wherein said Sh. Ashok Kumar Gupta and the complainant were insured persons. The OP No.1 issued a policy No.2817/53680647/01/000 for the period 24.12.2014 to 23.12.2015 to the complainant and her husband, on which premium of Rs.4965/- was paid to the OP No.1. The OP No.1 undertook to indemnify the complainant and her husband for the total sum assured of Rs.2,00,000/-, during the period above mentioned. However, no terms and conditions in respect of the said policy were ever got signed from the complainant and her husband nor the same were ever conveyed/supplied to the complainant and her husband. The OP No.2 is the Third Party Administrator (TPA) of OP No.1 and manages the claim settlement process/affairs of the OP No.1. Hence the complainant is “Consumer” of the OPs and very well falls within the ambit of definition of “Consumer” as provided under the aforesaid act. The complainant remained hospitalized in Dayanand Medical College & Hospital (DMC), Ludhiana from 04.03.2015 to 18.03.2015, during which an amount of Rs.1,90,211/- approximately was spent by the complainant of her own. Thereafter, the claim was lodged with the OPs to claim an amount of Rs.1,90,211/- and requisite claim form was filled and all original bills were submitted by the complainant to the OPs. Thereafter, the claim of the complainant was processed and during processing also, requisite documents were demanded from the complainant and were supplied to the OPs.

2. That on 06.08.2015, an amount of Rs.88,247/- was received in the bank account of husband of the complainant, bearing No.152801000000462 in Indian Overseas Bank, Kathar Branch without any intimation thereof to the complainant or her husband. That on 10.08.2015, the complainant alongwith her husband visited the office of the OP No.1, whereby the complainant enquired about the less credit of Rs.1,01,964/- upon which the complainant was asked to come after few days by saying that the documents are available with the OP No.2 and it would take few days in track the status. That on 03.09.2015, the complainant again visited the office of the OP No.1 and asked about the same, to which the complainant was told to contact the OP No.2 at number 0124-4466666. The complainant had called at the said contact number, but the complainant was not given satisfactory reply about the less credit of Rs.1,01,964/-. Thereafter, the complainant again approached the OP No.1 on 18.09.2015, but the complainant was again put off. When no response was received from the OP No.1, the complainant wrote a regd. Letter dated 07.10.2015 to the OPs calling upon to make the payment of less amount of Rs.1,01,964/- within ten days from the date of receipt of the said letter, but no reply has been given of the said letter and it is clear cut deficiency in service on the part of the OP and accordingly, this complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay a sum of Rs.1,01,964/- as remaining amount out of the total amount of Rs.1,90,211/- and further OPs be directed to pay a compensation for harassment, inconvenience and frustration suffered by the complainant, to the tune of Rs.20,000/- and also be directed to pay Rs.20,000/- as litigation expenses, all the amount be pay with interest @ 12% per annum .

3. Notice of the complaint was given to the OPs, but despite service OP No.2 did not come present and ultimately, OP No.2 proceeded against exparte.

4. OP No.1 appeared through his counsel and filed written reply, whereby contested the complaint by taking preliminary objections that the present complaint is frivolous, vexatious and devoid of merits and hence, the same is liable to be dismissed with cost and further averred that the complainant has not approached the Forum with clean hands and has suppressed the material facts from the Forum. It is further submitted that the cashless claim of the complainant was received by the answering OP and the same has already been paid by the answering OP. It is submitted that the expenses, which were duly covered as per the policy are already paid to the complainant and the details qua the deductions of the expenses is already send to the complainant vide letter dated 12.08.2015, copy of the same is attached herewith and a sum of Rs.88,247/- i.e. claim amount is already paid to the complainant and now nothing is payable as per the terms and conditions of the insurance policy and further submitted that the expenses, which are not under the policy condition, are not payable and further submitted that there is no deficiency in service or negligence or unfair trade practice on the part of the answering OPs. On merits, it is admitted that the insurance policy was issued to the complainant and claim also submitted by the complainant, but claim amount has already been paid and further submitted that the terms and conditions of the policy were duly supplied to the complainant alongwith the copy of insurance and even the terms and conditions were duly intimated to the complainant at the time of signing the proposal form, but the remaining contents of the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

5. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents i.e. Ex.C-1 Insurance Policy, Ex.C-2 Letter dated 13.04.2015, Ex.C-3 Letter to Universal Sompo, Ex.C-4 Letter to Emeditek, Ex.C-5 Bill dated 21.05.2015, Ex.C-6 Receipts and Ex.C-7 Claim Settlement Letter and then closed the evidence.

6. Similarly, counsel for the OP No.1 tendered into evidence affidavit Ex.OP-A alongwith certain documents Ex.OP-1 to Ex.OP8 and further tendered two affidavits Ex.OP-B and Ex.OP-C alongwith one document Ex.OP-9 and closed the evidence on behalf of the OP No.1.

7. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

8. The case of the complainant, to the extent that he purchased Health Care Plus Insurance Policy from OP No.1 and thereafter, the complainant remained admitted in the hospital from 04.03.2015 to 18.03.2015, where she spent an amount of Rs.1,90,211/- and accordingly, she filed an insurance claim and out of the total medical expenditure i.e. Rs.1,90,211/-, the only amount of Rs.88,247/- had been paid by the OP, by transferring the same in the account of the husband of the complainant namely Ashok Kumar Gupta and remaining was declined on the ground that as per terms and conditions, the OP is entitled to deduct some amount from the total claimed amount and up to this, the facts are not in dispute.

9. Now question remains whether the OP has paid less amount of Rs.1,01,964/- to the complainant, for that the complainant is entitled or not. The entitlement of the complainant is declined by the OPs simply on the ground that some deduction have been made for the total claimed amount as per the terms and conditions of the insurance policy and the said terms and conditions have been placed on the file by the OP, which is Ex.OP-9 and further give strength to this factum, the OP has also brought on the file three affidavits of the officials of the OP i.e. Ex.OP-A, Ex.OP-B and Ex.OP-C. We have analyze, this plea of the OP and find that the version of the complainant is that the said terms and conditions in respect of the said policy were never got signed from the complainant or her husband, nor the same were ever supplied to the complainant or her husband and as such, the complainant is not bound by that terms and conditions. We are fully agreed with the version of the complainant that if, the terms and conditions were not supplied or shown to the complainant at the time of inception of the insurance policy, then the said terms and conditions are not binding upon the complainant. When the complainant has took specifically plea in the complaint that the said terms and conditions never shown nor supplied to the complainant or her husband, then duty casted upon the OP to discard this version of the complainant, by bringing on the file cogent and coercive evidence to prove that the said terms and conditions were supplied to the complainant, by bringing on the file some documentary evidence, but apparently in this case, the OP has miserably failed to bring on the file any such type of evidence, where-from we can extract that the terms and conditions were ever supplied to the complainant. So, with these observations, we are of the opinion that the deduction made by the OP on the pretext of the terms and conditions is totally illegal, null and void, rather the complainant is entitled for the entire amount of the expenditure on medical treatment i.e. Rs.1,90,211/- because the insurance of the complainant is upto Rs.2,00,000/-, but the OP had paid a less amount of Rs.1,01,964/-, for that the complainant is entitled to get that less amount from the OP alongwith interest and compensation as well as litigation expenses.

10. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay the remaining amount of Rs.1,01,964/- out of the total amount of Rs.1,90,211/- along with interest @ 9% per annum from the date of filing the complaint, till realization and further OPs are directed to pay compensation for mental harassment to the complainant, to the tune of Rs.10,000/- and also directed to pay litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Harvimal Dogra Karnail Singh

30.01.2018 Member President