DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA.

 

Consumer Complaint No. : CC/33/2018 

Date of Institution : 22.03.2018

Date of Decision : 19.08.2019

 

Amritpal Singh, aged about 38 years, son of Hazara Singh, resident of # C-532, Aaki Patti, VPO Sanghera, Tehsil and District Barnala.

...Complainant

Versus

1. Medi Assist India TPA Private Ltd., SCO 19, 2nd Floor, Cabin No. 207, C, Sector 7-C, Chandigarh-160019 through its Area Manager.

2. The Oriental Insurance Co. Ltd., Divisional Office 4501, Bank Street Bathinda through its Divisional Manager.

3. Punjab National Bank, Branch Sanghera, District Barnala through its Branch Manager.

4. Punjab National Bank, Circle Office Model Town, Phase-1, Bathinda through its Manager CRM.

…Opposite parties

 

(Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.KULJIT SINGH, PRESIDENT

SH. TEJINDER SINGH BHANGU MEMBER 

SMT. MANISHA MEMBER 

COUNSEL FOR THE PARTIES:

For complainant : Sh. Jasvir Singh Bhangu Advocate 

For OP-1 : Exparte\

For OP-2 : Sh. Varinder Kumar Goyal Advocate

For Ops-3 and 4 : Sh. Vinod Kumar Goyal Advocate

Per KULJIT SINGH, PRESIDENT 

1. The present complaint has filed under Section 12 of the Consumer Protection Act, 1986 against the OPs on the averments that he has a saving account no.3478000101049553 with OP no.3 and he purchased one PNB-Oriental Royal Mediclaim Policy No. 233200/48/2014/4006 from OP no.2 through OP no.3, who is authorized agent of OPs no.1 and 2 after making the necessary payment from his aforesaid account and said policy was renewed from time to time and policy no. 233200/48/2016/3293 was issued to complainant by OP no.2 through OP no.3. The said policy was valid from 11.02.2016 to 10.02.2017 covering the risk of complainant, his wife Aprinder Kaur, daughter Prabhnoor Kaur and son Taranveer Singh No terms and conditions were supplied to him at the time of issuing the said policy. As per the said policy, complainant along with his family members are entitled to get free treatment for any ailment suffered by them. The complainant fell sick and as such he has been under treatment of Gastroenterology Department Dayanand Medical College and Hospital Ludhiana as outdoor patient for the period 16.02.2016 to 14.09.2016 and during that period, he spent Rs.67,834/- for his treatment. The complainant submitted the claim with the opposite party No. 4 and made repeated requests to OPs to refund the amount spent by him on his treatment, but of no use. Therefore, he has filed the present complaint and prayed that OPs be directed to pay Rs.67,834/- along with interest @ 12% per annum from the date of payment till realization, besides to pay Rs.1,00,000/- as compensation for mental harassment and Rs.15,000/- as litigation expenses.

2. OP no.1 was proceeded against exparte by this Forum, vide order dated 13.07.2018.

3. OP no.2 filed its separate written reply and contested the complaint of the complainant with certain preliminary objections that the complainant has not come to the Forum with clean hands and has concealed the true facts from this Forum. The complainant is guilty of breach of terms of the contract of Health Insurance. The complainant has no locus standi to file the complaint. On merits, it was averred that policy issued to complainant renewed from time to time and the said policy was valid from 11.02.2016 to 10.02.2017. The said policy covered the risk of complainant and his family members. It was denied that complainant was assured regarding refund of any amount spent on his treatment. It is submitted that as per terms of the policy no outdoor treatment shall be payable, which is within the knowledge of the complainant. Rest of the averments of the complainant were denied by complainant by OP no.2 and it prayed for dismissal of the complaint.

4. OPs no.3 and 4 appeared and filed their separate written reply and contested the complaint of the complainant by averring that complaint is not maintainable. The complaint is estopped by his act and conduct from filing the complaint. This fact was admitted by OPs no.3 and 4 that PNB Oriental Medi Claim Policy was obtained from OP no.2 through OP no.1 by making payment of premium from his account with PNB Sanghera and said policy was valid from 11.02.2016 to 10.02.2017. Rest of the averments of the complainant were denied by OPs no.3 and 4 and they prayed for dismissal of the complaint. 

5. The complainant has tendered in evidence his affidavit Ex.C-16 along with copies of documents Ex.C-1 to Ex.C-15 and closed the evidence. As against it; OP no.2 tendered in evidence affidavit of Roop Lal Baleem Sr. Divisional Manager as Ex.OP-2/1, affidavit of Ashwani Kumar as Ex.OP-2/2 and terms and conditions of the policy as Ex.OP-2/3 and closed the evidence. The opposite parties No. 3 and 4 tendered in evidence affidavit of Vijay Kumar Meena as Ex.OP-3.4/1 and closed their evidence.

6. We have heard learned counsel for the parties and have also examined the record of the case very carefully. Written arguments of the parties have also been gone through.

7. The complainant tendered his affidavit Ex.C-16 in support of his case. He deposed in his deposition that he obtained insurance policy from OP no.2 through Op no.3 and same was valid from 11.02.2016 to 10.02.2017. He admitted in the hospital from 16.02.2016 to 14.09.2016 and he spent Rs.67,834/- on his treatment. He averred that OPs are not ready to refund his amount, which he spent on his treatment. He alleged deficiency in service and unfair trade practice on the part of OPs. Ex.C-1 is copy of pass book issued by PNB in the name of complainant. Ex.C-2 is policy schedule. Ex.C-3 is self declaration given by complainant. Ex.C-4 is authorization letter to MEDI Assist India Pvt. Ltd. Ex.C-8 is medical certificate of OPD Case. Ex.C-9 is legal notice dated 05.02.2018 served upon OPs. Ex.C-10 to Ex.C-13 are postal receipts thereof. Ex.C-15 is reply to notice. 

8. To refute this evidence of complainant, OP no.2 tendered in evidence affidavit of Roop Lal Baleem Sr. Divisional Manager as Ex.OP-2/1, affidavit of Ashwani Kumar as Ex.OP-2/2 and terms and conditions of the policy as Ex.OP-2/3. The opposite parties No. 3 and 4 to rebut the case of the complainant also tendered in evidence affidavit of Vijay Kumar Meena as Ex.OP-3.4/1. 

9. From perusal of entire record, evidence, written arguments and hearing respective pleadings of the parties, we find that it is an established fact that the complainant was under the treatment of the hospital Dayanand Medical College and Hospital, Ludhiana from the period from 16.02.2016 to 14.09.2016 for treatment of Gastroenterology DMC College and Hospital and this fact was admitted by OPs without any hesitation. As per clause 3.6 and 3.7 of the terms and conditions of the policy Ex.OP-2/3 that medical expenses are incurred for the same condition for which the insured persons hospitalization was required and hospitalization claim for such hospitalization is admissible by the insurance company. 

10. The complainant obtained the insurance policy from OP no.2 through OP no.3 who is authorized agent of the OPs no.1 and 2 after making necessary payment and formalities. Due to fell sick, the complainant under the treatment of Gastroenterology Department DMC Ludhiana as out door patient for the period from 16.02.2016 to 14.09.2016 and during that period, he spent Rs.67,834/- on his treatment. The above said policy valid from 11.02.2016 to 10.02.2017 covering the risk of complainant alongwith his family members. Thus, it is clear that the treatment of the complainant was conducted during the currency period of the policy. The complainant spent Rs.67,834/- on his treatment, this fact is proved from document Ex.C-14 on the record.

11. The Hon'ble Punjab and Haryana High Court Chandigarh in case titled New India Assurance Company Ltd Vs Smt. Usha Yadav & Ors. 2008(3) RCR (Civil) Page-111 held as under.-

:It seems 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. 5,000/- for luxury litigation being rich.”

This citation is fully applicable to the present case as in the present matter also the opposite party No. 2 has earned premium from the complainant but when he applied for his genuine claim then they have not paid the same on flimsy grounds so there is deficiency in service and unfair trade practice on their part and complainant is entitled to insurance claim from the opposite parties. 

12. From perusal of documents produced by complainant including Ex.C-14, terms and conditions of the policy Ex.OP-2/3 and in view of the period of currency of the policy, by not refunding the amount of the details of bills Ex.C-14 to the tune of Rs. 67,834/- the OPs are deficient in service and unfair trade practice. Consequently, we accept the complaint of the complainant against the opposite party No. 2 and opposite party No. 2 is  directed to pay the amount of Rs. 67,834/- to complainant, which he has spent on his treatment during the validity of the policy. The opposite party No. 2 is also directed to pay Rs. 3,000/- to the complainant as litigation expenses. Compliance of order be made within the period of 30 days from the date of the receipt of the copy of this order, failing which the opposite party No. 2 is directed to pay the above mentioned amount of Rs. 67,834/- to the complainant alongwith interest at the rate of 6% per annum from the date of order till actual realization. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.

  ANNOUNCED IN THE OPEN FORUM:

19th Day of August 2019

 

 

            (Kuljit Singh)

           President

 

 

           (Tejinder Singh Bhangu)                Member

 

 

(Manisha)

Member