The complainant Nisha 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 Oriental Insurance Co. Ltd., and another (here-in-after referred to as opposite parties).
Briefly stated, the case of the complainant is that complainant is having a saving account with Punjab National Bank, Bibiwala Road, Bathinda. Punjab National Bank Bathinda Branch offered the complainant to take a PNB-Oriental Royal Mediclaim Policy, which was taken by complainant vide policy No. 233200/48/2017/1037 and was valid from 14-7-2016 to 13-7-2017, thereafter it was renewed from 14-7-2017 to 13-7-2018. Originally it was purchased on 14.07.2015. Thereafter the policy was renewed from time to time. Punjab National Bank used to deduct the premium from the account of complainant from time to time.
It is alleged that complainant was provided health insurance through Punjab National Bank, Bibiwala Road, Bathinda, where she is having saving bank account and Insurance Company has issued the policy to indemnity the medi-claim of complainant and her husband Vinod Kumar Garg, who was also covered under this this policy for all medical expenses.
The complainant alleged that her husband Vinod Kumar Garg suddenly felt pain in his abdomen. He was diagnosed to have problem of Hepatic Flexure Growth. Due to said problem, he was admitted to Kalra Multispecialty Hospital, Bathinda, where he had undergone treatment for the ailment from 12.06.2017 to 16.06.2017. In the meantime husband of complainant had got another problem of Empyema Gall Bladder and he was admitted to Dayanand Medical College and Hospital, Ludhiana, (here-in-after referred to as DMC) where he undergone treatment for ailment from 18.06.2017 to 26.06.2017.
It is also alleged that the complainant submitted claim with the opposite parties for an amount of Rs.28,112/- for the treatment taken at Kalra Multispecialty Bathinda and Rs.99,917/- for the treatment at DMC. The insurance Company demanded some documents which were submitted on 17-7-2017.
The complainant alleged that she got served legal notice upon the opposite parties for settlement of claim and for payment of damages. After receipt of legal notice, the opposite parties paid medical bill of Rs. 28,112/- for the treatment taken at Kalra Hospital but the other claim of Rs. 99,917/- was declined by the opposite parties on flimsly grounds.
It is alleged that at the time of effecting insurance, the opposite parties assured the complainant that all types of diseases are covered under the scheme and the policy is cashless and complainant will not be required to pay anything in case of emergency. The Insurance Company has wrongly denied the genuine claim of the complainant without any valid reason.
The complainant alleged that at the time effecting insurance, complainant was medically examined by the doctors of the opposite party and there was no disease at the time of purchase of insurance policy. The opposite party is liable to make payment of Rs. 99,917/- for the treatment of Empyema Gall Bladder at DMC.
On this backdrop of facts, the complainant has prayed for directions to the opposite parties to make payment of Rs. 2,21,917/- (99,917/- against treatment of Empyema Gall Bladder at DMC, and pay Rs.50,000/- as damages and Rs. 50,000/- as compensation plus Rs.22,000/- as litigation expenses) with interest @18% p.a. till realization.
Upon notice, the opposite parties appeared through counsel and contested the complaint by filing written reply raising preliminary objections that complaint not maintainable in its present form. That the complainant does not have any cause of action. That this Commission does not have the jurisdiction to try and entertain the present complaint.That the complainant has filed this false and fictitious complaint against the opposite parties and has unnecessarily harassed by draging them into uncalled for litigation. That the complainant is not entitled to the relief prayed for. That the complainant is not consumer as defined under the 'Act'. That the complainant is estopped by his own act and conduct from filing the present complaint. That there is no deficiency of service on part of the opposite parties.
It is pleaded that actual facts of the case are the complainant had purchased PNB Oriental Royal Mediclaim Policy No. 233200/48/2017/1037 for floater sum insured of Rs. 5.00 Lacs, having policy period from 14-07-2016 to 13-07-2017 and thereafter renewed from 14-07-2017 to 13-07-2018 covering the risk for herself and her husband. At the time of issuance of the policy, the insured had been supplied with the copy of the policy and the terms and conditions of the same for which she and her family were bound. The claim, if any, was payable subject to rules and regulations and terms and conditions of the said policy. During subsistence of said policy period, insured lodged a reimbursement claim for Rs. 28,117/- and Rs.99,112/- for the alleged treatment of her husband from Kalra Multispeciality hospital and DMCH Ludhiana respectively.
The opposite parties further pleaded that as per procedure adopted with the opposite party No. 1, the matter is referred to the TPA which in this case is opposite party No. 2 and it is only after taking the opinion of the experts of the TPA, the payment of claim if any recommended by them is made. As per the TPA, on acknowledgement of claim documents, their panel experts scrutinised and processed the claim in accordance to policy norms. After analysing the various investigation reports which have been produced coupled with the discharge summary etc., it was revealed by the opposite party No. 2 to opposite party No. 1 that the claim was not payable due to following reason :
"this claim pertains to treatmeant pertaining to the ailment Empyema Gall Bladder fo LAP Cholecystectomy. As the insurance is w.e.f. 14-07-2015 (Second year of policy) the surgery of gallbladder and procedures related to that are not covered under the policy for 2 years from the date of inception. Hence claim recommended for repudation under the exclusion 4.2 (xiii) of the policy. We also reserve the right to repudiate the claim under any other ground/s available to us subsequently."
Clause 4.2 (xiii) reads as under :- Clause 4.2 (xiii) - during the period of insurance cover, the expenses on treatment of surgery of gallbladder and the bile duct excluding malignancy for specified period of 2 years are not payable if contracted and/or minifestival during the currency of the policy.
Accordingly, based on the recommendations of opposite party No. 2 as mentioned above, the opposite party No. 1 issued a letter dated 05/09/2017 to the complainant/her husband informing the above stated facts and fully explaining that her claim was not admissible for the reasons mentioned above. Complainant was also asked that if she has any other information or documents to substantiate admissibility of the claim, she should provide the same within 15 days of receipt of the said letter to the opposite party No. 1. The complainant was also informed that in terms of the redressal of public grievances rules, 1998, she may approach the office of the Ombudsman if she was not satisfied with the decision of the company.The complainant neither provided any other information or documents to substantiate the admissibility of the claim as mentioned above, nor did she approach the grievance cell or the Ombudsman, thus agreeing to the non-admissibility of the claim.
On merits, the opposite parties have reiterated their stand as taken in preliminary objections, detailed above. After controverting all other averments, the opposite parties prayed for dismissal of complaint.
In support of his complaint, the complainant has tendered into evidence her affidavit dated 4-1-2018 (Ex. C-1), photocoy of legal notice & postal receipts (Ex. C-2 to Ex. C-5), photocopy of medi-claim policy schedule (Ex. C-6), photocopy of discharge summary (Ex. C-7), photocopy of payment receipts (Ex. C-8 to Ex. C-11), photocopy of receipt (Ex. C-12), photocopy of letter (Ex. C-13), photocopy of claim form (Ex. C-14), photocopy of letter (Ex. C-15).
In order to rebut the evidence of complainant, the opposite parties tendered into evidence affidavit dated 26-3-2018 of Sh.R L Baleem (Ex. OP-1/1), photocopy of policy (Ex. OP-1/2), photocopy of terms and conditions (Ex. OP-1/3), photocopy of discharge summary (Ex. OP-1/4), photocopy of letter of TPA to OIC (Ex. OP-1/5) and photocopy of letter of TPA to Vinod Garg (Ex. OP-1/6).
The learned counsel for the parties reiterated their stand as taken in their respective pleadings.
We have heard learned counsel for the parties and gone through the record.
In the case in hand, the pleading of the complainant is that she purchased PNB Oriental Royal Medical Policy on 14-7-2015 covering health insurance of complainant and her husband Vinod Kumar Garg. The said policy was subsequently renewed by her for the period from 14-7-2016 to 13-7-2017 and then 14-7-2017 to 13-7-2018. Vinod Kumar Garg, husband of the complainant suddenly felt pain in his abdomen and he was diagnosed to have problem of Hepatic Flexure Growth. Vinod Kumar Garg undergone treatment at Kalra Superspeciality Hospital, Bathinda and remained admitted there for the period from 12-6-2017 to 16-6-2017 wherein he incurred expenses to the tune of Rs. 28,112/-. In the meantime he suffered from another problem of Empyema Gall Bladder for which he took treatment from DMC, Ludhiana and remained admitted there for the period from 18-6-2017 to 26-6-2017. At DMC, he spent Rs. 99,917/-. The opposite parties reimbursed the amount of Rs. 28,112/- spent at Kalra Superspeciality Hospital but denied the expenses of Rs. 99,917/- incurred at DMC for treatment, vide repudiation letter dated 3-9-2017 (Ex. C-15).
A perusal of repudiation letter Ex. C-15 reveals that ground taken by the opposite parties for repudiation of claim of the complainant is that :
“The claim pertains to treatment pertains to the ailment Empyema Gall Bladder for LAP Cholecystectomy. As the insurance is w.e.f. 14-7-2015 (second year of the policy) the surgery of Gall Bladder and procedures related to that are not covered under policy for two years from the date of inception. Hence, claim recommended for repudiation under the Exclusiuon 4.2 (xiii) of the policy. We also reserve the right to repudiate the claim under any other ground/available to us subsequently. ”
Clause 4.2(xiii) of policy reveals that during the period of insurance cover, the expenses on treatment of surgery of gallbladder and the bile duct excluding malignancy for specified period of 2 years is not payable if contracted and/or manifested during the currency of policy.
A perusal of file reveals that the opposite parties have not placed on file even a single document to prove that complainant was supplied terms and conditions alongwith policy. When no terms and conditions were supplied to the complainant, she is not bound by such conditions.
Hon'ble State Commission, Haryana, in the case titled Star Health and Alied Insurance Co. Ltd., Vs. Asha and others 2015 (1) CLT 590 has held that :
“It is well settled that the company, who is taking specific plea about repudiation of any claim, has to prove that the exclusion clause was explained to the consumer – Once the insurer failed to prove this fact, it cannot take any benefit from such an exclusion clause.”
Hon'ble National Commission in the case titled National Insurance Co. Ltd., Vs. Radhey Shyam Balwada and another 2014(2) CPJ 201 held :
“Insurer is under obligation to act in good faith, which obliges him to enter into contract without concealing material fact like exclusion clause.”
Moreover, it is admitted fact of the parties that complainant purchased the first policy on 14-7-2015, which was subsequently got renewed by complainant. Vinod Kumar Garg, husband of the complainant undergone treatment/surgery in question at DMC, Ludhiana, on 18-6-2017 i.e. after about 1 year 11 months of purchase of 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.”
Therefore, as discussed above, opposite parties did not supply terms and conditions of policy in question to complainant and now they cannot take shelter of any exclusion clause. Moreover, in the case in hand, the insured Vinod Kumar Garg suffered from disease after 1 year and 11 months. Further more, the wording mentioned on repudiation letter Ex. C-15 that “We also reserve the right to repudiate the claim under any other ground/available to us subsequently ” is such which ofcourse losses the faith of insured. This act of the Insurance Companies shows that their priority is to repudiate the claim for one reason or the other which amounts to gross deficiency in service.
Therefore, denial of claim by the opposite parties on the ground that expenses of disease/surgery for which complainant took treatment for the period of two years are not payable, is without any basis. Thus, there is deficiency in service on the part of the opposite parties in rejecting the genuine claim of the complainant. Moreover, terms and conditions on the basis of which claim has been repudiated pertains to PNB Oriental Royal Medi-claim Insurance Policy UIN:IRDA/NL-HLT/OIC/P-H/V-1/455/13-14 but the policy in question bears No. IRDA/NL-HLT/OIC/P-H/V-1/454/13-14.
The complainant has claimed Rs. 99,917/- being expenses on treatment of Empyema Gall Bladder whereas he has placed on file bills (Ex. C-8 to Ex. C-11) amounting to Rs. 43,150/-.
In view of what has been discussed above, this complaint is partly allowed against the opposite parties with Rs. 10,000/- as cost and compensation. The opposite parties are directed to settle and pay the claim in question of the complainant as per bills submitted by her for treatment taken by her husband Vinod Kumar Garg at DMC, Ludhiana.
The compliance of this order be made by the opposite party within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record.
Announced :
10-2-2022
(Kanwar Sandeep Singh)
President
(Shivdev Singh)
Member
(Paramjeet Kaur)
Member
