Punjab

Faridkot

CC/17/288

Harjit Singh Kalsi - Complainant(s)

Versus

MD India Health care centre Pvt. Ltd - Opp.Party(s)

Harjit Singh Kalsi

22 Jan 2019

ORDER

      DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      288 of 2017

Date of Institution:   1.09.2017

Date of Decision :    22.01.2019

 

Harjit Singh Kalsi Advocate aged about 66 years, Faridkot, District Courts, Faridkot.

...Complainant

Versus

1. M D India, Health Care Centre, (TPA) Pvt Ltd, Phase-I, Plot No. 138, Mohali.
2. The Oriental Insurance Company Ltd, Oriental House, Asaf Ali road, A-25/27, New Delhi.
3. Branch Office, the Oriental Insurance Company Ltd, Near Jublie Cinema, Faridkot, District Faridkot.                                         

 .....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt. Param Pal Kaur, Member.

 

Present: Sh  Harjit Singh, Ld Counsel for complainant,

              Sh Vinod Monga, Ld Counsel for OPs.

 

ORDER

(Ajit Aggarwal, President)

                                      Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of balance amount of Rs.3,000/- on account of Mediclaim of complainant and for further directing OPs to pay Rs.50,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.5,000/-.

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2                               Briefly stated, the case of the complainant is that complainant retired as a Senior Assistant from D C Office, Faridkot and he was insured under the Punjab Government Employees and Pensioners Health Insurance Scheme launched by Government. He got conducted the surgery of his right eye from Guru Gobind Singh Medical College and Hospital, Faridkot. He remained admitted in hospital from 19.09.2016 to 20.09.2016 and in treatment, a lens was fitted in his right eye and he spent Rs.9000/-on his treatment. On lodging the claim with OPs, they cleared the claim for Rs.6000/-and did not clear the claim for remaining amount of Rs.3000/-which amounts to deficiency in service and trade mal practice on the part of Ops. Despite repeated requests, OPs have not cleared the claim for remaining amount of Rs.3000/-. Legal notice served to OPs also served no purpose. Action of Ops in withholding the remaining amount of Rs.3,000/-out of total amount incurred by him on his treatment, amounts to deficiency in service. Due to non payment of entire insurance claim by OPs, complainant has been suffering great economic loss and hardships. This act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. Hence, the present complaint.

3                                       The counsel for complainant was heard with regard to admission of the complaint and vide order dated 7.09.2017,

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complaint was admitted and notice was ordered to be issued to the opposite parties.

4       On receipt of the notice, OPs                                                                                                                                                                             filed written statement taking legal objections that complaint filed by complainant is not maintainable in the present form and is liable to be dismissed as claim of complainant has already been passed. It is submitted that complainant submitted non cashless claim for Rs.9000/-, which was considered and processed as per PGEPHIS rates and amount of Rs.6000/-already stands paid to complainant for his cataract surgery. Thus, there is no deficiency in service on their part. However, on merits it is admitted that complainant was insured under the policy in question and he lodged claim for Rs.9000/-for amount incurred by him on treatment of his eye surgery. Claim of complainant was passed for Rs.6000/-as per package amount for cataract surgery as per PGEPHIS rates and nothing is due to be paid to complainant. It is reiterated that there is no deficiency in service on the part of Ops and prayed for dismissal of complaint with costs.

5                                        Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to 11 and then, closed his evidence.

6                               In order to rebut the evidence given by complainant, the ld Counsel for OPs tendered in evidence, affidavit of Ashwani

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Kumar as Ex OP-1 and document Ex OP-2 and then, closed the same on behalf of OPs.

7                                              We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

8                                       The case of complainant is that he  was insured under the Policy in question and during the period of insurance, complainant got conducted the cataract surgery of his right eye from Guru Gobind Singh Medical College and Hospital, Faridkot and spent Rs.9000/-on his treatment. He lodged the claim for Rs.9000/-with Ops, but they passed the claim only for Rs.6000/-and did not clear the remaining amount of Rs.3000/-spent by him on his eye surgery. Grievance of complainant is that despite repeated requests and even issuance of legal notice to OPs, they did not pass his remaining claim amount of Rs.3000/-, which amounts to deficiency in service and has caused great harassment and mental agony to him for which he has prayed for accepting the present complaint alongwith compensation and litigation expenses besides the main relief. On the other hand, plea taken by Ops is that they have already cleared the claim amount for Rs.6000/-as per package rates for cataract surgery for Punjab Government Employees and Pensioners Health Insurance Scheme and now nothing is due or payable towards them on account of insurance claim. OPs have already paid the amount covered under policy in question and claim

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sought by complainant for remaining amount is not permissible. There is no deficiency in service on the part of Ops and have prayed for dismissal of complaint with costs.

9                                 To prove his case complainant has relied upon documents Ex C-8 and C-10 which are copies of letters wherein complainant made requests to Ops to clear his claim for remaining amount of Rs.3000/-under policy in question and Ex C-9 and Ex C-11 are original postal receipts placed on record by complainant to prove his pleadings that he made requests to OPs for clearing his claim for remaining amount. Ex C-3 is the copy of legal notice dated 31.07.2017 served by complainant to OPs. Through his affidavit Ex C-1, complainant has reiterated his grievance.

10                         There is no iota of doubt that during the subsistence of mediclaim insurance policy in question, complainant suffered from some problem and being insured under the said policy, he was entitled to get insurance claim on account of expenses incurred by him on his treatment.

11                                                From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that he was insured with them as per Punjab Government Employees and Pensioners Health Insurance Scheme and got treatment of his right eye. OPs argued

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that as per policy terms and conditions and scheduled rate for the treatment under policy in question, the complainant is entitled only for Rs.6,000/- as insurance claim for his treatment for cataract surgery at Guru Gobind Singh Medical College and  Hospital, Faridkot and as per scheduled rates, he is not entitled for any other amount than this and this amount has already been paid to complainant and now, he is not entitled for anything else. It is observed that out of total amount of Rs.9,000/- spent by complainant on his treatment, OPs made payment of Rs.6,000/-and illegally withheld the remaining insurance claim amount of Rs.3,000/-, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement that how they calculated this amount on their own. Admittedly, the complainant spent Rs.9,000/- for his treatment and paid this amount to hospital authorities, the Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the person.

11                                                            Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001 (1) CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are

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required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The 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 the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy.

12                                         From the above discussion and case law produced by the complainant, we are of considered opinion that OPs have wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy out of entire amount, spent on treatment by complainant, which was covered under the Mediclaim insurance policy. The present complaint is hereby accepted. OPs are directed to pay the remaining claim amount of Rs.3,000/-to complainant, which was wrongly deducted by them out of amount spent by him on his treatment alongwith interest at the rate of 9 % per anum from the date when they made less payment to complainant till final realization. They are further directed to pay Rs.2,000/-to complainant as consolidated compensation for harassment and mental agony suffered by him including litigation

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expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 22.01.2019         

          (Param Pal Kaur)              (Ajit Aggarwal)

                                         Member                              President