DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/138/2023
Date of Institution: 07.11.2023
Date of Decision: 18.12.2024
Dayal Chand son of Sh. Basant Lal resident of H.No. 37, 22 Acre Scheme Bus Stand Road, Barnala, District Barnala, Punjab.
…Complainant
Versus
1. New India Assurance Co. Ltd., Bldg. 87 Blgd., 87 MG Road, Fort Mumbai-400001 through its Authorized Signatory/ Director.
2. New India Assurance Co. Ltd., Near Street No.6, KC Road, Barnala through its Branch Manager/ Authorized Signatory.
3. M/s Raksha TPA Private Limited, 15/5, Mathura Road, Faridabad- 121003 through its Branch Manager.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Rajesh Mittal Adv counsel for complainant.
Sh. Gurpreet Singh Toor Adv counsel for opposite parties No. 1 & 2.
Opposite party No. 3 exparte.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against New India Assurance Co. Ltd., Bldg. 87 Blgd., 87 MG Road, Fort Mumbai-400001 through its Authorized Signatory/ Director & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant intended to purchase a Health Insurance policy in year 2015, as such the complainant along with his wife visited OP No. 2 where the representative of OP No.2 allured the complainant of their Medical insurance policy by narrating the complainant best insurance policy and services. As such, the complainant purchased an Insurance Policy in year 2015 from the OPS in the name of himself and his wife Vanita Rani under Product Name - New India Mediclaim Policy for a sum Insured of Rs.1,00,000/- and paid the requisite premium with the Ops and all the details /documents as asked by the Ops were provided by the complainant. It is further alleged that thereafter at the time of renewal of policy in year 2021, the complainant was told by OP No.2 that in case the complainant renew the said policy in New India Mediclaim Floater policy then the new features in the said policy will be benefited for the complainant apart from other benefits of prior policy New India Medical policy being the continuity of the same medical policy and the policy of the complainant was shifted to New India Mediclaim Floater policy in year 2021 and the same was renewed continuously by the complainant. It is further alleged that on 04.08.2023, the complainant fell ill and he was admitted to Hero DMC Heart Institute Ludhiana on 04.08.2023 and remained admitted till 18.08.2023 and being the cashless policy, the hospital authorities informed the Ops for the prior approval from the Ops for the cashless benefits of the complainant, upon which the claim of the complainant was lodged vide claim No.90222324349113 by the Ops and Ops initially approved an amount of Rs.13,000/- on 05.08.2023 and then Rs.87,000/- on 07.08.2023 for cashless treatment of the complainant and vide letter dated 07.08.2023 the Ops made a payment of Rs. 1 lac to the said hospital by narrating that applicant sum insured Rs.1 lac has exhausted. It is further alleged that thereafter the hospital authorities again moved a request with the Ops for further prior approval of Rs.2,75,000/- on account of the diagnose and treatment of the complainant and after going through the terms and conditions of the policy and considering the request of the complainant the Ops approved the total amount of Rs.3,75,000/- the amount equivalent to the sum insured of the policy of the complainant and sent a message on the registered mobile of the complainant that amount of Rs.3,75,000/- approved by Raksha for Dayal Chand Id.@UHID on 14.08.2023. It is further alleged that an amount of Rs.6,27,892.97/- was spent on the treatment of the complainant and the Ops made only the amount of Rs. 1 lac on account of the cashless treatment of the complainant to the hospital out of the said expenditure and the remaining amount of Rs.5,27,873.97/- was paid by the complainant from his own pocket. It is further alleged that thereafter the complainant received a letter dated 18.08.2023 for cashless authorization letter mentioning therein that SI Exhausted. Sum Insured Exhausted, enhance is not applicable. It is further alleged that the complainant was shocked on receipt of said letter dated 18.08.2023 while the Ops vide their text message has conveyed the complainant that Rs.3,75,000/- being the amount equivalent to the Sum insured of the policy has been approved. But later on the Ops vide their letter dated 18.08.2023 mentioned that enhance is not applicable. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to make the payment of Rs. 2,75,000/- the amount equivalent to the sum insured after deducting the amount of Rs. 1,00,000/- made by the opposite parties alongwith interest @ 12% from the date of making the payment till realization.
- To pay an amount of Rs. 50,000/- as compensation for causing physical pain and harassment to the complainant and Rs. 15,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties No. 1 & 2 appeared and filed written version by taking legal objections on the grounds that the complainant has no cause of action to file the present complaint. The opposite parties have been dragged into unnecessary litigation. That in the present complaint complicated question of law and facts are involved and the same could not be decided in summary proceedings etc.
4. On merits, it is admitted to the extent that on 04.08.2023, the complainant fell ill and he was admitted to Hero DMC Heart Institute Ludhiana on 04.08.2023 and remained admitted till 18.08.2023 and being the cashless policy the opposite parties received request for cashless treatment from Hospital authorities and upon which the claim of the complainant was lodged and opposite parties No.1 and 2 approved an amount of Rs. 13,000/- on 05.08.2023 and Rs. 87,000/- on 07.08.2023 for cashless treatment of the complainant. It is further admitted to the extent that the Hospital Authorities moved a request to OPs No.1 and 2 for further prior approval of Rs. 2,75,000/- on account of diagnosis and treatment of complainant. It is further admitted that the opposite parties No.1 and 2 sent message on the registered mobile of the complainant that an amount of Rs. 3,75,000/- has been approved, but subject to policy terms and conditions. It is further alleged that the complainant is not entitled for enhanced amount from the opposite parties as per clause 4.1 of the insurance policy pre-existing disease waiting period is 48 months and the same has not been lapsed. It is further alleged that as per clause 4.1 of the policy complainant had not entitled for further enhanced amount, the complainant has previously admitted to the Hero Heart DMC Hospital on 24.06.2019 and discharged on 27.06.2019 and the complainant did not disclose his pre existing disease to the opposite parties, therefore the Ops have not paid enhancement amount to the complainant. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. The opposite party No. 3 was proceeded against exparte vide order dated 3.1.2024 due to non appearance.
6. The complainant filed rejoinder to the written version of opposite parties No. 1 & 2 and denied the averments mentioned in the written version.
7. The complainant tendered into evidence affidavit of complainant as Ex.C-1, copy of policy for the year 5.3.2020 to 4.3.2021 (4 pages) as Ex.C-2, copy of policy for the year 5.3.2021 to 4.3.2022 as Ex.C-3 (4 pages), copy of policy dated 5.3.2022 to 4.3.2023 as Ex.C-4 (5 pages), copy of policy as Ex.C-5 (3Pages), copy of discharge summary Ex.C-6 (2 Pages), copy of bill Ex.C-7, copy of cashless Authorization Letter Ex.C-8 (2 pages), copy of text Messages Ex.C-9 to Ex.C-11, certificate cum affidavit U/s 63 of BSS Ex.C-12 and closed the evidence.
8. The opposite parties No. 1 & 2 tendered into evidence affidavit of Preeti as Ex.O.P1.2/1, copy of policy as Ex.O.P1.2/2, copy of policy schedule as Ex.O.P1.2/3 (4 pages), copy of collection receipt as Ex.O.P1.2/4, copy of mediclaim policy as Ex.O.P1.2/5, (33 pages), copy of customer information sheet as Ex.O.P1.2/6 (8 pages) and closed the evidence.
9. We have heard the learned counsel for the parties and have gone through the record on the file.
10. It is admitted case of the opposite parties No. 1 & 2 that on 04.08.2023 the complainant fell ill and he was admitted to Hero DMC Heart Institute Ludhiana on 04.08.2023 and remained admitted till 18.08.2023 (as per Ex.C-6) and being the cashless policy the opposite parties received request for cashless treatment from Hospital authorities and upon which the claim of the complainant was lodged and opposite parties No.1 and 2 approved an amount of Rs. 13,000/- on 05.08.2023 and Rs. 87,000/- on 07.08.2023 for cashless treatment of the complainant (as per Ex.C-8). It is further admitted case of the opposite parties that the Hospital Authorities moved a request to opposite parties No.1 and 2 for further prior approval of Rs. 2,75,000/- on account of diagnosis and treatment of complainant. It is further admitted case of the opposite parties that they sent message on the registered mobile of the complainant that an amount of Rs. 3,75,000/- has been approved as per terms and conditions of the policy (as per Ex.C-10).
11. Ld. Counsel for the complainant argued that the complainant purchased an Insurance Policy in year 2015 from the opposite parties in the name of himself and his wife Vanita Rani under Product Name - New India Mediclaim Policy for a sum Insured of Rs.1,00,000/-. It is further argued that thereafter at the time of renewal of policy in year 2021 the complainant was told by opposite party No.2 that in case the complainant renew the said policy in New India Mediclaim Floater policy then the new features in the said policy will be benefited for the complainant apart from other benefits of prior policy New India Medical policy being the continuity of the same medical policy and the policy of the complainant was shifted to New India Mediclaim Floater policy in year 2021 and the same was renewed continuously by the complainant (as per Ex.C-2 to Ex.C-5). It is further alleged that on 04.08.2023 the complainant fell ill and he was admitted to Hero DMC Heart Institute Ludhiana on 04.08.2023 and remained admitted till 18.08.2023 and being the cashless policy the hospital authorities informed the opposite parties for the prior approval for the cashless benefits of the complainant and upon which the claim of the complainant was lodged vide claim No.90222324349113 by the opposite parties and they initially approved an amount of Rs.13,000/- on 05.08.2023 and then Rs.87,000/- on 07.08.2023 for cashless treatment of the complainant and vide letter dated 07.08.2023 the Ops made a payment of Rs. 1 lac to the said hospital by narrating that applicant sum insured Rs.1 lac has exhausted. It is further argued that thereafter the hospital authorities again moved a request with the opposite parties for further prior approval of Rs. 2,75,000/- on account of the diagnose and treatment of the complainant and after going through the terms and conditions of the policy and considering the request of the complainant the opposite parties approved the total amount of Rs.3,75,000/- the amount equivalent to the sum insured of the policy of the complainant and sent a message on the registered mobile of the complainant that amount of Rs.3,75,000/- approved by Raksha for Dayal Chand Id.@UHID on 14.08.2023 (as per Ex.C-10). It is further argued that an amount of Rs. 6,27,892.97/- was spent on the treatment of the complainant (as per Ex.C-7) and the opposite parties made only the amount of Rs. 1 lac on account of the cashless treatment of the complainant to the hospital out of the said expenditure and the remaining amount of Rs.5,27,873.97/- was paid by the complainant from his own pocket. It is further argued that thereafter the complainant received a letter dated 18.08.2023 for cashless authorization letter mentioning therein that SI Exhausted and Sum Insured Exhausted and enhance is not applicable.
12. On the other hand, Ld. Counsel for the opposite parties No. 1 & 2 argued that the complainant is not entitled for enhanced amount from the opposite parties as per clause 4.1 of the insurance policy pre-existing disease waiting period is 48 months and the same has not been lapsed. It is further argued that as per clause 4.1 of the policy complainant had not entitled for further enhanced amount, the complainant has previously admitted to the Hero Heart DMC Hospital on 24.06.2019 and discharged on 27.06.2019 and the complainant did not disclose his pre-existing disease to the opposite parties, therefore the opposite parties have not paid enhancement amount to the complainant.
13. We have gone through the facts and evidence produced by both the parties. It is the specific plea of the opposite parties No. 1 & 2 that as per clause 4.1 of the policy complainant had not entitled for further enhanced amount as the complainant had previously admitted to the Hero Heart DMC Hospital on 24.06.2019 and discharged on 27.06.2019 and the complainant did not disclose his pre-existing disease to the opposite parties, therefore the opposite parties have not paid enhancement amount to the complainant and the complainant is not entitled for enhanced amount from the opposite parties as per clause 4.1 of the insurance policy pre-existing disease waiting period is 48 months and the same has not been lapsed. Ld. Counsel for the opposite parties No. 1 & 2 further argued that the insured had pre-existing disease and this fact has not been disclosed by the insured/complainant at the time of filing the proposal form or at the time of purchasing the policy or at the time of renewing the policy in question which amounts to misrepresentation/non-disclosure of material facts. But the opposite parties have failed to place on record the proposal form to prove the fact that the complainant has not disclosed regarding the pre-existing disease at the time of taking the policy in the year 2015 in the proposal form. So, we are of the view that the above said plea of the opposite parties is not tenable. The complainant has taken the treatment of “Total Arterial complete revascularization with bilateral IMA OPCABGx2 LIMA to LAD LIMA RIMA Composite Graft RIMA to OM1 +Aortic valve replacement with 25mm Perimount magna ease aortic valve” and as per clause 4 there is nowhere mentioned that the said treatment covered after 48 months. Moreover, from the file it shows that the complainant has purchased the above said policy in the year 2015 and after that the said policy was renewed regularly, so at this stage how the opposite parties could have raised the objection that the complainant has pre-existing disease prior to the policy inception date. We have further gone through the Discharge Summary of Dayal Chand produced by the complainant i.e. Ex.C-6 in which in the column of Presenting History it is mentioned that “Patient presented with complaints of burning sensation in epigastrium which increased on exertion after having food and relieved with taking sorbitrate. History of intermittent palpitations present. Patient came here for further management”. We are of the view that it was in the hands of insurance company to see and not to issue or renew the policy where person is not entitled to claim on account of treatment of Pre-existing disease. Moreover, there is nothing on record from the side of opposite parties that they have conducted the medical examination/investigation of the insured at the time of issuing the policy or at the time of porting the policy or at the time of renewing the policy in question. So, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
14. On the other hand, Ld. Counsel for the complainant further argued that the terms and conditions were not supplied to the complainant alongwith policy, therefore the same are not part of contract. We have carefully gone through the copy of policy in question placed on record by the complainant for the period from 5.3.2023 to 4.3.2024 i.e. Ex.C-5 which are containing 5 pages and the terms and conditions are not the part of the policy in question. On the other hand, the opposite parties have failed to place on record any postal receipt or any document to prove that they have supplied the terms and conditions of the policy to the insured/complainant alongwith policy in question. Moreover, the opposite parties have also placed on record copy of insurance policy for the period 5.3.2021 to 4.7.2022 i.e. Ex.O.P1.2/3 and the terms and conditions of the policy are not the part of insurance policy. Therefore, the terms and conditions on which the opposite parties have relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”.
15. From the above discussion, it is proved that the opposite parties (insurance company) wrongly deducted an amount of Rs. 2,75,000/- (as the Floater Sum Insured + Floater Cumulative Bonus is Rs. 3,75,000/-) on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
16. The complainant to prove his case has placed on record copy of Final Bill Ex.C-7 which shows the total bill amount as Rs. 6,26,154.97/- has been spent on the treatment of complainant in the above said hospital.
17. In view of the above discussion, the present complaint is partly allowed against the opposite parties No. 1 & 2 and the opposite parties No. 1 & 2 are directed to pay an amount of Rs. 2,75,000/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties No. 1 & 2 are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. 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 COMMISSION:
18th Day of October, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
