Order by:
Sh.Amrinder Singh Sidhu, President
1. This Consumer Complaint has been received by transfer vide order dated 26.11.2021 of Hon’ble President, State Consumer Disputes Redressal Commission, Punjab at Chandigarh under section 48 of CPA Act, vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 from District Consumer Commission, Ludhiana to District Consumer Commission, Moga to decide the same in Camp Court at Ludhiana and said order was ordered to be affected from 14th March, 2022.
2. The complainant has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now section 35 of Consumer Protection Act, 2019) on the allegations that earlier, the complainant had purchased the medical policy in the year 2014 i.e. Family First Silver 5 lacs+ 15 lacks Plan under the Health Insurance Policy offered by the Opposite Parties which was lateron continued as per the assurances of the Opposite Parties for better services and accordingly, policy bearing No.30371398201501 was issued valid for the period 7.11.2015 to 6.11.2016 on payment of premium of Rs.24,129/-. At the time of purchasing the policy in question till 2016, the complainant was duly medically checked up and there was no disease and was healthy. Subsequent to the medical investigation carried upon the complainant, it transpired in the MRI scan report that LT Kidney shows a 9*8*6 cm exophytic mass lesion from lower pole anteriorly with extension into anterior pararenal space. The complainant was accordingly advised by his doctor to further undergo certain medical tests from where it revealed that he had renal cell Carcinoma. The complainant was referred to Action Cancer Hospital, New Delhi on 17.04.2016 for the treatment of his RCC problem where he remained admitted from 18.04.2016 till 27.04.2016, where the complainant spent Rs.3,68,979/- for the said treatment of his RCC problem and in this regard, the complainant informed the Opposite Party for the payment to the hospital, but the Opposite Party delayed and the complainant was forced to readmit in the hospital inspite of having been discharged due to non payment of medical charges and was forced to pay extra charges of Rs.7100/-. Thereafter, the complainant lodged the claim for the reimbursement of his medical expenses, but the Opposite Party only reimbursed Rs.2,74,538/- by making illegal deductions as such provide negligent in providing efficiency service to the complainant by paying the entire amount. Again the complainant remained admitted in Doctor Ved Gupta Hospital from 04.08.2016 to 07.10.2016 where he spent Rs.4,91,589/- and further remained admitted in Dr.Pritpal Singh Mokha where he spent Rs.1,73,888/- on his treatment. After discharge, the complainant lodged all this claims, and completed all the formalities, but the Opposite Parties did not pay any heed to make the imbursement of his medical expenses inspite of serving legal notice and as such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.
a) The Opposite Parties may be directed to reimburse the amount of Rs.6,65,477/- and also to pay Rs.50,000/- on account of compensation due to mental tension and harassment caused by the complainant, Rs.22,000/- as costs of litigation or any other relief to which this District Consumer Commission may deem fit be also granted.
3. Opposite Parties appeared through counsel and contested the complaint by filing the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission. It is submitted that the policy in question Family First Silver was issued by the Opposite Party to the complainant on the basis of information provided by the Assured in the proposal form and the Opposite Party has acted strictly as per the policy terms and conditions. The present complaint is liable to be dismissed on the ground that under the policy, no benefit is payable for the averments mentioned in complaint with regard to the treatment of the complainant in Doctor Ved Gupta Hospital and from Dr.Pritpal Singh. The complainant till date has not submitted the claim intimation-claimant’s statement form or any pre-authorization request for the alleged claims of treatment at Doctor Ved Gupta Hospital and from Dr.Pritpal Singh nor he has submitted any requisite documents (medical and other), hence it is impossible for the Opposite Party to assess the case of the complainant and to put it under the process of payment without the knowledge of the claim or without receiving any document from the complainant. Whenever any claim is submitted a thorough investigation has to be done regarding the same, the identity of the claimant has to be verified, the genuineness of the claim has to be verified, the status of the policy has to be checked and if it is in accordance with the policy terms and conditions then only the claim can be processed and as such, the complaint is not maintainable before this District Consumer Commission. Further the complainant has submitted the claim for treatment at Action Cancer Hospital, New Delhi and he received the amount of Rs.2,74,538/- from the Opposite Party, then what stopped the complainant from filing the claim with the Opposite Party for the other two alleged claims. On merits, the Opposite Party took up almost the same and similar pleas as taken up by them in the preliminary objections and hence, the complaint may be dismissed.
4. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents Ex.C1 to Ex.C77 and closed the evidence on behalf of the complainant.
5. On the other hand, to rebut the evidence of the complainant, Opposite Parties also tendered into evidence the affidavit Ex.RA alongwith copies of documents Ex.OP1/1 to OP1/6 closed the evidence.
6. We have heard the ld.counsel for the parties, perused the written submission of the Opposite Party and also gone through the documents placed on record.
7. Ld.counsel for the Complainant as well as Opposite Party have mainly reiterated the facts as narrated in the complaint as well as in the written statement and we have perused the rival contentions of the parties. Ld.counsel for the Complainant has mainly reiterated the facts as narrated in the complaint and contended that despite lodgin the claim for the reimbursement and on completing all the formalities, the Opposite Parties did not pay any heed to make the reimbursement of his claim and rather some part of the claim has been paid and retained the remaining amount of his medical expenses. On the other hand, ld.counsel for the Opposite Party has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that the complainant till date has not submitted the claim intimation-claimant’s statement form or any pre-authorization request for the alleged claims of treatment at Doctor Ved Gupta Hospital and from Dr.Pritpal Singh nor he has submitted any requisite documents (medical and other), hence it is impossible for the Opposite Party to assess the case of the complainant and to put it under the process of payment without the knowledge of the claim or without receiving any document from the complainant. Whenever any claim is submitted a thorough investigation has to be done regarding the same, the identity of the claimant has to be verified, the genuineness of the claim has to be verified, the status of the policy has to be checked and if it is in accordance with the policy terms and conditions then only the claim can be processed and as such, the complaint is not maintainable before this District Consumer Commission. Further the complainant has submitted the claim for treatment at Action Cancer Hospital, New Delhi and he received the amount of Rs.2,74,538/- from the Opposite Party, then what stopped the complainant from filing the claim with the Opposite Party for the other two alleged claims. But we do not agree with the aforesaid contention of the Opposite Party because all the relevant documents and bills and all related documents have already been placed by the complainant on official file from the last about years. Moreover, when the complainant has lodged first claim (the part amount against said bill has already been made by the Opposite Party), then what was the hitch for the complainant to lodge the remaining claims. It is unbelievable that anybody knowingly will delay his own claim by not lodging the claim. It is pertinent to mention over here that the copies of these documents/ claim etc. have duly been supplied to the Opposite Parties by this District Consumer Commission at the time of serving the notice of complaint at its initial stage which have duly been received by the Opposite Party and during this period, the Opposite Parties could process the claim of the complainant, but despite of lapse of sufficient time i.e. about five year from the date of required documents/ information, the Opposite Party kept mum for the reasons best known to their concerning officials and due to non settlement of the claim, the complainant is suffering badly and he has already spent hefty amount on his treatment.
8. In such a situation the repudiation made by the Opposite Parties-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, 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.
9. In view of the above discussion, we hold that all the Opposite Parties have wrongly and illegally not settled the remaining claim of the complainant.
10. Now come to the quantum of compensation. In his complaint, the complainant prayed for the reimbursement of the amount of Rs.6,65,477/- alongwith interest and this amount spent by the complainant on his treatment has nowhere denied by the Opposite Party by filing any cogent and convincing evidence on record and hence we allow the complaint upto that extent.
11. In view of the aforesaid facts and circumstances of the case, we allow the complaint of the Complainant and direct Opposite Party to reimburse the remaining medical bills of the complainant amounting to Rs.6,65,477/- (Rupees six lakh sixty five thousands four hundred seventy seven only) alongwith interest @ 8% per annum from the date of filing the complaint i.e. 17.10.2017 till its realization. The compliance of this order be made by Opposite Party within 60 days from the date of receipt of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Commission. Copies of the order be furnished to the parties free of cost by District Consumer Commission, Ludhiana and thereafter, the file be consigned to record room after compliance.
12. Reason for delay in deciding the complaint.
This Consumer Complaint was originally filed at District Consumer Disputes Redressal Forum (Now Commission) at Ludhiana and it keep pending over there until Hon’ble State Consumer Disputes Redressal Commission, Punjab vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 has transferred the instant Consumer Complaint alongwith Other Complaints to District Consumer Commission, Moga with directions to work on this file onward from 14th March, 2022 and accordingly District Consumer Commission, Moga has decided the present complaint at Camp Court, Ludhiana, as early as possible as it could decide the same
Announced in Open Commission at Camp Court, Ludhiana.
