| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 202 of 01-08-2019 Decided on: 30-08-2022 Sadhu Ram Garg aged about 66 years S/o Banwari Lal, Ward No.15, Near Geeta Bhawan, Maur Mandi, Distt. Bathinda-151509. ........Complainant Versus New India Assurance Co. Ltd., B.O.: Mall Godown Road, Rampura Phul-151103, Through its Branch Manager. Raksha Health Insurance TPA Pvt. Ltd., C/o Escorts Corporate Centre, 15/5, Mathura Raod, Faridabad-121003, through its
Cheif Executive Officer.
.......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.Kanwar Sandeep Singh, President Smt. Paramjeet Kaur, Member Present For the complainant : Sh. Sahil Bansal, Advocate. For opposite parties : Sh. M.L. Bansal, Advocate. Opposite party No.2 ex-parte. ORDER Kanwar Sandeep Singh, President:- The complainant Sadhu Ram Garg (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against The New India Assurance and another (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that he was previously insured with Oriental Insurance Co. Ltd., continuously for the last 3 years. The opposite parties renewed the previous Insurance policy under OBC- Oriental Royal Medi-claim Policy Schedule vide Insurance Certificate No. 36060434180400000073 w.e.f. 17.01.2019 to 16.01.2020. The opposite parties took copies of previous policies from the complainant issued by Oriental Insurance Co. Ltd. and mentioned the details of the previous policies in Insurance Certificate as per the terms of renewal of the opposite parties. It is alleged that opposite parties insured the complainant Sadhu Ram Garg and his wife Sushma Rani through PNB Maur being their agency and got commission from opposite parties. The opposite parties also declared and stated that this is continuous Insurance as the previous Insurance was with Oriental Insurance Co. Ltd. which expired on 16.01.2019 and the opposite parties renewed the same w.e.f. 17.01.2019 to 16.01.2020. The opposite parties insured the complainant and his wife for Rs. 5,00,000/- and charged Rs.10,251/- on 11.01.2019. The opposite parties assured the complainant that this is the cashless insurance i.e. New India Flexi Floater Group Medi-claim Policy. The opposite parties also assured that in case of any problem, total treatment in any hospital in India, is free and total medical bills upto Rs.5,00,000/- will be paid. It is further alleged that complainant suffered some problem in his left eye. He consulted Dr. Kiran Sarwal of Kiran Eye Care Centre, Rampura Phul and said doctor diagnosed Cataract in left eye and advised surgery on 16.04.2019. The complainant was admitted in the said hospital and surgery was performed on the same day and he was discharged from the hospital on 17.04.2019. The complainant spent Rs.50,000/- on treatment and Medicine charges etc. The complainant further alleged that thereafter he submitted all the original bills with original treatment file to the opposite parties on 30.04.2019 for reimbursement. The complainant requested the opposite parties to release his claim but on 21-6-2019, opposite parties rejected the claim of the complainant on flimsy grounds under Exclusion Clause No. 4.3 wherein it is mentioned that cataract is not covered in the 1st year of insurance whereas the insurance of the complainant is a continuous one. It is also alleged the agents of the opposite parties renewed the insurance and the opposite parties mentioned the detail of the previous insurances in the Insurance Certificate. No terms & conditions were supplied to the complainant till date. The amount of Rs.50,000/- is still pending with the opposite parties and due to non-payment of this amount, the complainant has suffered mental agony and pain for which he claims compensation to the tune of Rs.15,000/-. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay claim amount of Rs. 50,000/- along with interest loss @ 18% P.A. in addition to Rs.15,000/- besides Rs. 10,000/- as litigation expenses. Upon notice, opposite party No. 1 appeared through counsel and opposite party No. 2 put an appearance through authorized representative. After filing written version, none appeared on behalf of opposite party No. 2. As such, exparte proceedings were taken against opposite party No. 2. In written version, opposite party No.1 raised legal objections that the present complaint has been filed only to injure the goodwill and reputation of the opposite party. Even otherwise, the complaint is false, frivolous and vexatious. That intricate questions of law & facts are involved in the present complaint, which requires voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act' and appropriate remedy, if any, lies only in the Civil Court. That the complainant has concealed material facts and documents from this Commission, therefore, the complainant is not entitled to any relief. It has been pleaded that the true facts are that on receipt of claim of the complainant, the same was forwarded by the opposite party to opposite party No. 2, which is deputed as TPA (Third Party Administrator) to decide the medi-claim cases. While processing the claim, TPA/opposite party No. 2 found that earlier, the complainant has purchased medi-claim policies for a period of three years from Oriental Insurance Co. Ltd. i.e. policy No.233200/48/2016/3113 effective from 08.01.2016 to 07.01.2017, policy No. 233200/48/2017/3227 effective from 08.01.2017 to 07.01.2018 and policy No. 233200/48/2018/3608 effective from 17.01.2018 to 16.01.2019 and in this way, there is a gap of 10 days while getting 3rd year policy. And thereafter, the complainant voluntarily got himself medically insured with the opposite party and purchased a fresh policy. Accordingly, opposite party issued fresh policy No. 36060434180400000073 effective from 17.01.2019. The opposite parties issued the policy in question while treating it to be in 1st year and old policies numbers have been mentioned in the cover note/policy only for the purpose of reference and since the claim in hand arose in first year of policy issued by the opposite party, so as per clause 4.3, the claim is not payable. Accordingly, the claim of the complainant was repudiated by the competent authority and an intimation in this respect was given to the complainant/insured vide letter dated 21.06.2019. All the aforesaid material facts have been concealed by the complainant from this Commission. Further legal objections are that the complainant is estopped by his own act, conduct & acquiescence from filing the complaint. That complainant has no locus standi or cause of action ; the complaint is not maintainable and that there is no deficiency in service or unfair trade practice on the part of the opposite party. On merits, the opposite party No. 1 has pleaded that it has never assured the complainant that it shall issue the policy in continuity of all the aforesaid three policies as alleged. The opposite party issued the policy in question on the request of complainant as fresh policy while treating the policy to be in first year and not in continuity of earlier policies issued by OIC Ltd. The policy in question was issued strict and subject to terms & conditions of the policy and the claim was/is always payable subject to terms & conditions of the policy. Since the claim is not payable as per terms & conditions of the policy, so the same has already been recommended by opposite party No.2 as Non-payable and accordingly, the claim of the complainant has already beer repudiated by the competent authority keeping in view exclusion clause 4.3, as detailed above, and as intimation in this regard has already been given to the complainant vide letter dated 21.06.2019. The claim of the complainant has rightly been repudiated as per terms & conditions of the policy. After controverting all other averments of the complainant, the opposite party prayed for dismissal of complaint. The opposite party No. 2 put an appearance through authorized representative and filed written version stating therein that medi-claim policy under which complainant has filed claim, was issued by opposite party No. 1. It has been pleaded that complainant was covered under the group medi-claim policy No. 36060434180400000073 for the period from 17-01-2019 to 16-01-2020 issued by opposite party No. 1 and the claim in respect of Mr. Sadhu Ram hospitalized in Kiran Eye Care Centre – Rampuraphul for the treatment of left eye cataract during 16-4-2019 to 17-4-2019 was processed and not paid in accordance with the policy terms and conditions laid by the opposite party No. 1 as per clause No. 4.3 of the policy terms and conditions, as this ailment falls under two years exclusion list and insured's policy is running in first year. Thus, claim was recommended to insurer as non-tenable as per terms and conditions of opposite party No. 1. It has been pleaded that complainant was earlier having a policy issued by OBC-OIC, which as per administrative guidelines issued by PNB-NIA (the present insurer) cannot be migrated. Hence, the present claim No. 9051920113758 of the complainant on his policy No. 36060434180400000073 issued by PNB- The New India Assurance Co. Ltd., is treated to have been lodged on the fresh policy and clause No. 4.3 is applicable. Therefore, as per terms and condition of the policy, the claim is non-payable and recommended to opposite party No. 1 on 24-5-2019 for their further action. After controverting all other averments of the complainant, the opposite party No. 2 also prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit (Ex.C-1), and the documents (Ex.C-2 to C-10). To rebut the claim of the complainant, opposite party No.1 has tendered into evidence affidavit of Ashish Pal dated 18.09.2019, (Ex.OP-1/3) and documents (Ex.OP-1/1 to Ex.OP-1/2) We have heard learned counsel for parties and gone through the file carefully. Learned counsel for parties have reiterated their stand as taken in their respective pleadings and detailed above. In the case in hand, the opposite parties have closed the file of complainant vide letter dated 21-6-2019 (Ex. C-10) on the ground that as per clause 4.3 of the policy during the first year of insurance cover the expenses on treatment of cataract disease is not payable. The opposite party No. 1 in para No. 3 of reply admitted that complainant purchased mediclaim policies for a period of three years from oriental insurance Co. Ltd., i.e. Policy No.233200/48/2016/3113 effective from 08.01.2016 to 07.01.2017, policy No. 233200/48/2017/3227 effective from 08.01.2017 to 07.01.2018 and policy No. 233200/48/2018/3608 effective from 17.01.2018 to 16.01.2019 and in this way, there is a gap of 10 days while getting 3rd year policy and thereafter, complainant voluntarily got himself medically insured with the opposite party and purchased a fresh policy bearing No. 36060434180400000073 effective from 17.01.2019. The opposite party No. 1 has further mentioned that opposite parties issued policy in question while treating it to be in 1st year and old policies numbers have been mentioned in the cover note/policy only for the purpose of reference. The ground taken by the opposite parties for closing the claim file of the complainant that complainant obtained fresh policy due to which claim of the complainant is not payable, is without any basis. A perusal of policy in question (Ex.OP-1/1) reveals that under Special Conditions all the three previous policies have been mentioned. The plea taken by the opposite parties is that these policies have been mentioned only for the purpose of reference and policy in question is a fresh policy, is of no value as these policies numbers have been mentioned on the policy issued by the opposite parties for the purpose of portability. Under Clause 17.1 of policy in question, it is specifically mentioned that “This policy is subject to portability guidelines issued by IRDA.” Perusal of document produced by opposite parties as Ex.OP-1/2 itself reveals that as per clause 10.0 (c) (RENEWAL CLAUSE) opposite parties may accept renewal of the policy if it is effected within 30 days (grace period) of the expiry of the period of insurance. On such acceptance of renewal, opposite parties, however shall not be liable for any claim arising out of illness contracted or injury sustained or hospitalization commencing in the interim period after expiry of policy and prior to date of commencement of subsequent policy. In case in hand there is gap of only 10 days in renewal of policy and policy was renewed within 30 days of grace period. So, this Commission is of the view that the policy is continuing one and complainant is entitled to the benefits of this policy. Insurance Regulatory and Development Authority (IRDA) vide circular “ Ref No. IRDA/HLTH/MISC/CIR/216/09/2011 Dated 20-09-2011 directed All life insurers and non-life insurers : “The Insurers” decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.” Keeping in view the evidence placed on file by the parties, this Commission is of the considered opinion that there is deficiency in service on the part of the opposite parties in rejecting the genuine claim of the complainant without any valid ground. Resultantly, this complaint is partly allowed with Rs.10,000/- as cost and compensation against the opposite parties. The opposite parties are directed to pay Rs.24,000/- (limit for payment for cataract under clause 2.7 of policy) with interest @ 8% per annum w.e.f. 21-06-2019 till realization. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within statutory period due to Covid pandemic and heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced:- 30-08-2022 (Kanwar Sandeep Singh)
President (Paramjeet Kaur) Member
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