Haryana

Ambala

CC/377/2021

Mahesh Jain - Complainant(s)

Versus

New India Assurance Co Ltd. - Opp.Party(s)

Naresh Kumar Gupta

16 Jun 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	377/2021
Date of Institution	:	13/12/2021
Date of decision	:	16.06.2023

 

1. Mahesh Jain aged about 61 years son of Late Shri Nem Chand Jain,
2. Purnima Jain aged about 58 years wife of Shri Mahesh Jain resident of G-23-24, Mahesh Nagar, Ambala Cantt.

          ……. Complainants

                                                Versus

1. New India Assurance Company Ltd, through its Divisional Manager, 5406, Shree Complex, 2nd Floor, Cross Road No.3, Punjabi Mohalla, Ambala Cantt.  (Haryana)-133001
2. M/s Raksha Health Insurance TPA Pvt. Ltd., through Mr. Pawan Bhalla, Executing Officer, c/o Escort Cooperate Centre, 15/5, Mathura Road, Faridabad (Haryana)
3. M/s Raksha Health Insurance TPA, Pvt. Ltd, through its Director/Authorized Signatory, SCO No.39, Ist Floor, Madhya Marg, Above Barbee Que Nation, Sector- 26, Chandigarh-160019.

                                                                                                    ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Rishi Gupta, Advocate, counsel for the complainants.

                     Shri Dev Batra, Advocate, counsel for the OP No.1.

                   OPs No.2 and 3 ex parte vide order dated 15.03.2022.

Order:         Smt. Neena Sandhu, President.

1.                Complainants have filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’), praying for issuance of following directions to them to pay the claim amount of Rs.94,621/-, besides interest @ 24% per annum from the date of submission of claim till the date of realization of the above said amount besides amount of Rs.3 lakhs for causing mental and physical torture; and Rs.25,000/- as cost of litigation.

2.             Brief facts of the case are that the officials of the OP No.1 approached the complainants for selling of Mediclaim policy. On the assurance of the representative of OP No.1, complainant no.1 purchased Mediclaim policy in the year 2006 and also purchased top up Mediclaim policy in the year 2016 for himself and also for the benefit of complainant no. 2. The complainants are holders of the policies bearing no.35350134212800000077 and 35350134217800000032 valid for the period from 24-5-2021 to 23-5-2022 covering the risk up to Rs. 5 lacs and Rs.10 lacs and are paying regular premiums. Complainant no.2- Mrs. Purnima Jain was advised by the doctor to undergo replacement of hip and on that advise, complainant no.2- Mrs. Purnima Jain was operated at Apollo Spectra Hospital, Nehru Enclave, New Delhi for which the OPs paid Rs.6 lacs only under cash less policy. The complainants who are senior citizens also borne pre-medical and post medical expenses and as such submitted the claim of Rs.94,621/- i.e., for pre and post medical expenses alongwith bills to the OPs but they rejected the said claim. Every effort made by the complainants in the matter went in vain. The complainants served a Regd. A.D. notice dated 17- 11-2021 to the OPs and also emails in the matter but the same went unanswered.   Hence this complaint.
3.           Upon notice, the OP No.1 appeared and filed written version and raised preliminary objection to the effect that this Commission has no jurisdiction to entertain & try the present complaint; the complaint has been filed by the complainants on false, frivolous and vague grounds and no cause of action either arose in favour of the complainants; the present complaint is not maintainable on the ground that the complainants have not come to this Commission with clean hands and suppressed/concealed the material facts  etc. On merits, it has been stated that the entire claim was referred to TPA for processing the same and for approval as per terms and conditions. However after processing the entire claim of the complainants, the legible claim was released & rest as claimed being not maintainable was repudiated. Claim under complaint, was recommended for repudiation by TPA for SI exhausted in base policy - 35350134212800000077. Infact as per verification of the documents and in view of terms and conditions it was recommended that the claim is for pre-post expenses. There is no provision of Pre-post hospitalization expenses in Top up policy. In Top Up policy only Hospitalization expenses are being considered for settlement. The Claim Ref. No. 9052122301277, having Member ID Number N9012278969, for amount of Rs.94,621/- is neither claimable nor payable and hence has been rightly and legally repudiated. The payable claim has already has been released & nothing is pending. Rest of the averments of the complainants were denied by the OP No.1 and prayed for dismissal of the present complaint.
4.           Upon notice, none appeared on behalf of the OPs No.2 and 3, before this Commission, therefore, they were proceeded against ex-parte vide order dated 15.03.2022.
5.           Learned counsel for the complainants tendered affidavit of the complainant no.1 as Annexure CW1-A alongwith documents as Annexure C-1 to C-48 and closed the evidence on behalf of complainants. On the other hand, learned counsel for the OP No.1 tendered affidavit of Mona Bagga, Sr. Divisional Manager of OP No.1 Company-New India Assurance Company Ltd. and Dr. Amandeep Singh, RM of Raksha Health Insurance TPA Pvt. Ltd., as OP1/A and OP2/A respectively alongwith documents as Annexures OP-1/1 to OP-1/6  and closed evidence on behalf of the OP No.1
6.           We have heard the learned counsel for the complainants and the learned counsel for the OP No.1 and have also carefully gone through the case file.
7.           Learned counsel for the complainants submitted that since the complainant no.2 was also covered under the policy in question therefore she was entitled to get the claim amount reimbursed, towards pre and post hospitalization charges, spent on her towards her treatment during existence of the policy in question, yet, her genuine claim has not been considered by the OPs, which act amounts to deficiency in providing service, negligence and adoption of unfair trade practice on their part. 
8.           On the contrary, learned counsel for the OP No.1 submitted that the claim filed for pre and post hospitalization of complainant no.2 was rightly rejected by OP No.1 as per condition no.2.12 of the policy in question, as such, the OP No.1 is neither deficient in providing service nor adopted any unfair trade practice.
9.           Since, neither the issuance of the policy in question; nor the treatment taken by  complainant no.2, referred to above; nor the claim amount of Rs.6 lacs paid by the OP No.1 to the complainants towards indoor treatment of hip replacement of complainant no.2 are in dispute, as such, the only moot question which falls for consideration is, as to whether,  the OPs were justified in rejecting the claim amount of Rs.94,621/- raised by the  complainants for pre and post hospitalization of complainant no.2 or not. It is significant to mention here that the complainants have obtained two policies details of which are given below:-
   1. New India Floater Mediclaim Policy bearing no. 35350134212800000077 valid for the period from 24-5-2021 to 23-5-2022 covering risk of Rs.5 lacs. (Annexure C-2)
   2. New India Top-UP Mediclaim Policy bearing no. 35350134217800000032 valid for the period from 24-5-2021 to 23-5-2022 covering the risk up to Rs. 15 lacs. (Annexure C-3)

 

10.           It is not in dispute that the complainants had already exhausted the sum assured of Rs.5 lacs qua the New India Floater Mediclaim Policy bearing no. 35350134212800000077 (Annexure C-1 and C-2).  This fact is also coming from the cashless authorization letter dated 16.06.2021, Annexure C-37.  It is further coming out from the record that though the complainants had exhausted the entire sum assured of Rs.5 lacs out of the said Policy bearing no. 35350134212800000077 (Annexure C-1), yet, they again  raised claim dated 22.07.2021, Annexure C-6 to the tune of Rs.94,621/- under the same policy, which was not legally justified. Thus, irrespective of the fact that under this Policy bearing no. 35350134212800000077, as per condition no.5 (e) and (f), (Annexure C-4), the complainants were entitled to get the pre and post hospitalization charges, yet, since the entire sum assured of Rs.5 lacs under the said policy stood exhausted by them, they were legally not entitled to claim anything more than Rs.5 lacs under this policy.  
11.           Now coming to the New India Top-UP Mediclaim Policy bearing no. 35350134217800000032 valid for the period from 24-5-2021 to 23-5-2022 covering the risk up to Rs. 15 lacs. (Annexure C-3). It may be stated here that we have gone through condition no. 2.12  of the Policy bearing no.35350134217800000032, Annexure C-5 relevant part of the which is reproduced below:-
    1.  

-It shall not include other expenses including Pre-Hospitalisation or Post-Hospitalisation Expenses even if incurred in connection with such Illness or Injury.

- The admission in the Hospital shall have occurred during the Period of Insurance……..”

12.           A bare perusal of condition No.2.12 of Policy bearing no. 35350134217800000032 clearly says that Pre-Hospitalisation or Post-Hospitalisation Expenses are not included. However, despite the fact that it was agreed to by the complainants, by way of clause 2.12 referred to above of Policy bearing no.35350134217800000032 that they are not entitled to get any pre and post hospitalization charges, still they raised the claim in respect thereof, which was righty rejected by the OPs.  The insurance policy between the insurer and the insured represents a contract between the parties and the insured cannot claim anything more than what is covered by the insurance policy. Our this view is supported by the ratio of law laid down by the Hon’ble Supreme Court of India in Oriental Insurance Co. Ltd Vs Sony Cherian (II 1999 CPJ 13 SC) wherein it was held that- ― “..The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein…”.
13.           In view of peculiar facts and circumstances of this case, it is held that because the complainants have failed to prove their case, therefore, no relief can be given to them. Resultantly, this complaint stands dismissed with no order as to cost. Certified copies of the order be sent to the parties concerned as per rules.  File be annexed and consigned to the record room.

Announced:- 16.06.2023

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President