Order by:

Sh.Amrinder Singh Sidhu, President

1.       The  complainant  has filed the instant complaint under section 35 of Consumer Protection Act, 2019 on the allegations that  he purchased Mediclaim policy bearing No..36110034209500000014 from Opposite Party No.1 which was valid for the period w.e.f. 01.10.2020 (12.00.01 AM) to 30.09.2021 (11.59.59 PM) having sum insured of Rs. 5 lakhs against the payment of premium of Rs.42,473. This is the continuous policy of previous policy bearing No. 36110034209500000026 which was valid for the period 01.10.2019 to 30.09.2020 and the Complainant has been purchasing this policy from the last so many years continuously and paid a hefty amount more than 5 lakhs to the Opposite Parties on account of premiums till date. It is pertinent to mention over here that prior to proposal and issuance of the policy in question, the doctors of the Opposite Parties duly medically checked up to the Complainant and after full satisfaction of the doctors of the Opposite Parties, the Opposite Parties issued the policy to the Complainant. This is the mediclaim Policy. Hence, the Complainant is consumer of the Opposite Parties under the Consumer Protection Act.  Further alleges that unfortunately, during the policy period, on 12.02.2021 the Complainant felt uneasy due to breathlessness and chest pain and he immediately rushed to Fortis Hospital, Chandigarh Road, Ludhiana, where the treating doctor diagnosed the complainant as patient presented with breathlessness and chest pain and admitted to FHL for further medical management where he remained admitted upto 14.02.2021. The treating hospital  charged Rs.2,01,211/-  from the Complainant. After discharge from the hospital, the Complainant lodged the claim No.9052021770015 with the Opposite Parties under the policy in question for the reimbursement of his claim and also completed all the formalities and submitted the requisite documents to the Opposite Parties as per their requirement and also took the bank account of the Complainant for making the claim amount. The Opposite Parties thoroughly gone through the claim of the Complainant and admitted the claim of the Complainant, but lateron made the part payment of the claim amounting to Rs.1,29,312/- only on 04.05.2021 directly in the bank account of the Complainant without the consent of the Complainant. The Complainant immediately approached the office of the Opposite Parties to know the reason for retaining the remaining amount of the claim amount, but the officials of the Opposite Parties kept mum and did not disclose any reason for retaining the remaining genuine claim of the Complainant. Thereafter, the Complainant visited the office of the Opposite Parties on so many occasions   and made  requests to make the remaining amount of his claim. Initially, the Opposite Parties lingered on the matter, but at last, the Opposite Parties refused to admit  the rightful claim of the Complainant without explaining any reason.  In view of this, there is deficiency in service on the part of the Opposite Parties and they have illegally repudiated the genuine and legal claim of the complainant  without explaining any reason.   Not only this, the Complainant has nowhere signed any discharge voucher for the receipt of part payment which the Opposite Parties have arbitrarily made directly in his account.   Moreover, as stated above, the Complainant has been purchasing the medi-claim policies continuously from the Opposite Parties from the last more than 15 years, and till date paid more than 5 lakhs to the Opposite Parties on account of premiums which is obvious for the complainant to claim for sum assured in case of reimbursement of medical expenses incurred by him because since about 2003, a period  of 18 years  has already elapsed and the complainant was competent to claim the sum assured vide insurance policy, wherein the insured sum was to the tune of Rs.5 lacs under the policy in question. There is no dispute inter se parties regarding the expenses incurred by the complainant on the treatment for which the complainant has also produced on record. In view of this, there is deficiency in service on the part of the Opposite Parties and they have illegally retained the balance  genuine and legal claim of the complainant without explaining any reason. Furthermore, at the time of issuing the policy in question as mentioned above, alongwith this cover note, the Opposite Parties never issued any terms and conditions of the policy documents. As such, the alleged  terms and conditions, particularly the exclusion clause of the policy in question is not binding upon the insured. That regarding the aforesaid medical reimbursement of his genuine claim regarding and the Complainant is suffering in the hands of the Opposite Parties from the date of  submission of his claim in the last week of February, 2021 and till date, the Opposite Parties did not dare to bother  and in this way, the Complainant  also remained under mental tension and harassment.  The complainant approached the Opposite Parties time and again for the reimbursement of his  genuine remaining medical claim, but  the Opposite Parties  flatly refused to reimburse the total claim of the complainant, as such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.

a)       The Opposite Parties may be directed to reimburse the remaining medical claim of the complainant amounting to Rs. 74,700/- alongwith interest thereon  @ 12 % per annum from the date of payment to the respective hospitals till its actual realization.

 b)     The amount of Rs.2,00,000/- be allowed to be paid by the opposite parties on account of compensation due to mental tension and harassment caused by the complainant.

c)       The cost of complaint amounting to Rs.20,000/- may please be allowed.

d)      And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.       

2.       Opposite Party No.1 appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the complaint of the complainant is liable to be dismissed.  The claim of the complainant was settled vide claim settlement voucher dated 6.5.2021 and the complainant was paid an amount of Rs.1,29,312/- as per the agreed rate of charges by the Fortis Hospital, and therefore, the claim was  settled on the recommendation of Raksha TPA and hence, there is no deficiency in service on the part of the Opposite Party No.1.   On merits, Opposite Party No.1 took up almost the same and similar please as taken up by them in the preliminary objections. Hence, it is prayed that the   complaint may be dismissed with costs.   

3.       None has come present on behalf of Opposite Party No.2 and hence, Opposite Party No.2 was proceeded against exparte.   

4.       In order to  prove  his  case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents  Ex.C2 to Ex.C11 and  closed the evidence on behalf of the complainant.

5.       On the other hand,  to rebut the evidence of the complainant,  Opposite Party No.1 also tendered into evidence the affidavit of Ms.Sunita Mahajan, DM Ex.OP1/1 alongwith copies of documents Ex.OP1/ 2 (38 pages), Ex.OP1/3 (29 pages), Ex.OP1/4 (4 pages) and  closed the evidence.

6.       We have heard the ld.counsel for the parties and also  gone through the documents placed  on record.

7.       During the course of arguments, ld.counsel for the Complainant as well as ld.counsel for Opposite Parties   have mainly reiterated the facts as narrated in the complaint as well as in the written statements respectively. We have perused the rival contentions of  the parties and also gone through the record on file. The main contention of the ld.counsel for Opposite Party No.1 is that immediately on receipt of the claim, it was duly registered and entertained and thereafter, as per the recommendation of Raksha TPA, the claim of the complainant was settled vide claim settlement voucher dated 6.5.2021 and the complainant was paid an amount of Rs.1,29,312/- as per the agreed rate of charges by the Fortis Hospital, and hence, there is no deficiency in service on the part of the Opposite Party No.1. But we do not agree with the aforesaid contention of the ld.counsel for Opposite Party No.1 on the ground. In this regard, our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.1105 of 2014 decided on 25-04-2017 in case titled as Sukhdev Singh Nagpal Vs. New Karian Pehalwal Cooperative Agriculture service Society & Others has held that TPAs have no authority to recommend or  settle the claim- such power lies, exclusively with the Insurance Companies (Para No.25 to 27). The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same. The claim of the complainant was illegally and arbitrarily rejected by the TPA, against the instructions of the IRDA. In view of this, the repudiation merely on the basis of report of the TPA is not legal.  

8.       The case of the complainant is that after discharge from the hospital, the Complainant lodged the claim No.9052021770015 with the Opposite Parties under the policy in question for the reimbursement of his claim and also completed all the formalities and submitted the requisite documents to the Opposite Parties as per their requirement and also took the bank account of the Complainant for making the claim amount. The Opposite Parties thoroughly gone through the claim of the Complainant and admitted the claim of the Complainant, but lateron made the part payment of the claim amounting to Rs.1,29,312/- only on 04.05.2021 in the bank account of the Complainant without the consent of the Complainant and withheld the claim of Rs.73,700/- illegally. On the other hand, the contention of the ld.counsel for Opposite Party No.1 is that immediately on receipt of the claim, it was duly registered and entertained and as per the recommendation of the TPA,  the claim of the complainant was approved of Rs. 1,29,312/- and accordingly, said amount has been paid to the complainant to his bank account as full and final settlement. The complainant has duly received the said amount as full and final settlement and now  nothing is due against the Opposite Parties. On the other hand, ld.counsel for the complainant has denied this fact with regard to receipt of claim amount as full and final settlement,  because no discharge voucher has ever been signed by the complainant. Rather the Opposite Parties took the account of the complainant on the excuse that they have to make the entire claim amount  in his account and on such assurance, the complainant has given the account number to the Opposite Party in which the Opposite Parties made the part payment through NEFT, but there is no such discharge voucher placed on record by the Opposite Parties. The Complainant has nowhere signed any discharge voucher for the receipt of part payment which the Opposite Parties have arbitrarily made directly in his account.  Moreover, recently Hon’ble National Consumer Disputes Redrssal Commission, New Delhi in case  Prabha Tyagi vs National Insurance Co. Ltd. REVISION PETITION NO. 568 OF 2017 (Against the Order dated 07/12/2016 in Appeal No. 215/2013 of the State Commission Uttaranchal) Decided on  on 18 September, 2018 has clearly held that even if the discharge voucher is signed by the policy holder even, still the  execution of such vouchers does not foreclose the rights of policy holder to seek higher compensation before any judicial fora or any other fora established by law. The relevant portion of the judgement is reproduced as under:-

“The learned counsel further argued that execution of discharge voucher for settlement of earlier claim of Rs.1,00,000/- does not debar the complainant to pursue his remaining claim of Rs.1,00,000/- in a court of law like the consumer forum.  In this regard, the learned counsel relied upon the following pronouncements:-

(1)     Ramdas Sales Corporation Vs. New India Assurance Company Ltd., III (2016) CPJ 40 (NC).  It has been held that:-

"3.  The learned counsel for the complainant has placed before us a Circular No.IRDA/ NL/CIR/Misc/ 173/09/2015 dated 24.09.2015 issued by Insurance Regulatory Development Authority of India (IRDA) to all the General Insurance Companies, with regard to the use of discharge vouchers in settlement of claim.  The said circular reads as under:-

"The Insurance Companies are using 'discharge voucher' or "settlement intimation voucher" or in some other name, so that the claim is closed and does not remain outstanding in their books.  However, of late, the Authority has been receiving complaints from aggrieved policyholders that the said instrument of discharge voucher is being used by the insurers in the judicial fora with the plea that the full and final discharge given by the policyholders extinguish their rights to contest the claim before the Courts.

While the Authority notes that the insurers need to keep their books of accounts in order, it is also necessary to note that insurer shall not use the instrument of discharge voucher as a means of estoppel against the aggrieved policy holders when such policy holder approaches judicial fora. Accordingly insurers are hereby advised as under:

Where the liability and quantum of claim under a policy is established, the insurers shall not withhold claim amounts.  However, it would be clearly understood that execution of such vouchers does not foreclose the rights of policy holder to seek higher compensation before any judicial fora or any other fora established by law.

All insurers are directed to comply with the above instructions."

9.       Not only this, Hon’ble Supreme Court of India in this regard in case United India Insurance Vs. Ajmer Singh Cotton & General Mills & Ors., II (1999) CPJ 10 (SC) has held as under:-

"The mere execution of the discharge voucher would not always deprive the consumer from preferring claim with respect to the deficiency in service or consequential benefits arising out of the amount paid in default of the service rendered.  Despite execution of the discharge voucher, the consumer may be in a position to satisfy the Tribunal or the Commission under the Act that such discharge voucher or receipt had been obtained from him under the circumstances which can be termed as fraudulent or exercise of undue influence or by misrepresentation or the like.  If in a given case the consumer satisfies the authority under the Act that the discharge voucher was obtained by fraud, mis-representation, under influence or the like, coercive bargaining compelled by circumstances, the authority before whom the complaint is made would be justified in granting appropriate relief.  However, where such discharge voucher is proved to have been obtained under any of the suspicious circumstances noted hereinabove, the Tribunal or the Commission would be justified in granting the appropriate relief under the circumstances of each case.  The mere execution of the discharge voucher and acceptance of the insurance claim would not estopple insured from making further claim from the insurer but only under the circumstances as noticed earlier.      ............................." 

10.     In such a situation the repudiation made by the Opposite Party-Insurance Company regarding remaining genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold 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.

11.     It is not disputed that the  complainant  purchased Mediclaim policy bearing No..36110034209500000014 from Opposite Party No.1 which was valid for the period w.e.f. 01.10.2020 (12.00.01 AM) to 30.09.2021 (11.59.59 PM) having sum insured of Rs. 5 lakhs and it is also not disputed that the complainant has lodged the claim of Rs.2,03,012/- for reimbursement with the Opposite Parties on account of  hospitalization charges and out of which, the Opposite Parties have paid only Rs.1,29,312/- on 04.05.2021 directly in the bank account of the complainant and the balance amount of Rs.73,700/- has been retained without any reasonable explanation.     

12.     In view of the above discussion, we hold that the Opposite Party-Insurance Company have  wrongly and illegally rejected the remaining claim of the complainant and hence,  we partly allow the complaint of the Complainant and direct Opposite Party No.1-Insurance Company to reimburse the remaining medical bills of the complainant  of Rs.73,700/- (Rupees Seventy Three Thousands Seven Hundred only) to the complainant alongwith interest @ 8% per annum from the date of filing of the present complaint i.e. 23.12.2021 till its actual  realization.  The compliance of this order be made by the Opposite Party No.1-Insurance Company   within 60 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Consumer Commission. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Commission.