Chandigarh

DF-I

CC/500/2021

Jasbir Singh - Complainant(s)

Versus

The New India Insurance Co. Ltd. - Opp.Party(s)

Umesh Kumar Kanwar

01 Dec 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/500/2021
Date of Institution	:	30/07/2021
Date of Decision	:	01/12/2023

 

Jasbir Singh since deceased through legal representative :-

1. Satwinder Kaur widow of late Jasbir Singh, resident of H.No.407, Sector 45-A, Chandigarh.

… Complainant

V E R S U S

1. The New India Insurance Company Ltd., through its General Manager, Regd. Head Office Office at 87, Mahatama Gandhi Road, Fort Mumbai 400001.
2. The New India Insurance Company Ltd., through its Manager, Office SCO No.75, Sector 30-C, Chandigarh.

… Opposite Parties

3. Harminder Singh son of late Jasbir Singh at present resident of H.No.122, RUE, D’ Etreat, le Havre, 76600, France.
4. Navpreet Kaur daughter of late Jasbir Singh, resident of H.No.3205, East Washington Avenue, Francisco, USA.
5. Gurpreet Kaur daughter of late Jasbir Singh, resident of H.No.82, Laburnum Road, Hayes, Middlesex, UB3 4JZ United Kingdom.

… Performa Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	Sh. Umesh Kumar Kanwar, Advocate for complainant
	:	Sh. Jaswinder Singh Bagga, Advocate for OPs 1 & 2
	:	Complaint against Proforma OPs 3 to 5 dismissed as withdrawn vide order dated 6.3.2023.

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Jasbir Singh (since deceased) through his LR Satwinder Kaur, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that, in the year 2001, complainant had purchased a medi claim insurance policy for himself and his wife Smt. Satwinder Kaur commencing w.e.f. 1.12.2001 to 30.11.2002 (Annexure C-1). The said policy was renewed on yearly basis, without any break, and lastly the same was renewed w.e.f. 1.12.2020 to 30.11.2021 (Annexure C-2) (hereinafter referred as “subject policy”).  Before 2014-15, complainant did not make any claim. However, in the year 2014-15, the complainant fell ill and he had taken treatment and raised medi claim and the same was duly considered and settled by the OP/insurer. The complainant remained under cancer treatment from the year 2014 to 2017-18.  Again when the complainant fell ill in the year 2020 and was examined by the doctor, it was found by the doctor that the complainant has to continue his cancer treatment and accordingly the complainant had taken treatment from Max Super Specialty Hospital (hereinafter referred to as “treating hospital”) wherein he remained admitted on 14.12.2020, 10.3.2021 and 2.4.2021 and the copies of the discharge summary and prescription slip are Annexure C-3 to C-5.  The treating hospital had raised medical bills to the tune of ₹1,97,000/-. Copies of the bills are Annexure C-6A to C-44 whereas the claim form is Annexure C-45.  However, cashless request of the complainant from 15.12.2020 to 10.3.2021 was denied by the OP (Annexure C-46) and the complainant paid the bill amount from his own pocket. In the month of May 2021, complainant had again raised a claim of ₹1,08,335/- with OPs/insurer, but, the same has also not been settled till date.  In this manner, the aforesaid acts of the OPs/insurer amount to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs 1 & 2/insurer resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability and cause of action.  However, it is alleged that the claim of the complainant was settled after making permissible deduction i.e. 25% of the bill amount etc. as per the terms and conditions of the subject policy and against the total claim of ₹1,97,030/-, an amount of ₹59,733/- has already been paid to the complainant and the complete details of deduction have been mentioned in Ex.OP-1 and the complainant has no cause of action to proceed with the present consumer complaint.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Vide order dated 6.3.2023 of this Commission, the consumer complaint against OPs 3 to 5, who are otherwise also proforma OPs, was dismissed as withdrawn.
4. In replication, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the first medi claim policy in the year 2001 from the contesting OPs/insurer, as is also evident from Annexure C-1, and had renewed the same continuously on yearly basis and the subject policy (Annexure C-2) was valid w.e.f. 1.12.2020 to 30.11.2021 covering the complainant and his wife with sum assured of ₹7.00 lacs each, and the complainant had taken treatment from the treating hospital where he was admitted and discharged on 25.1.2021, as is also evident from the discharge summary (Annexure C-3, at page 48) and the complainant was again admitted and discharged on 10.3.2021 and 2.4.2021, as is evident from the discharge summaries Annexure C-4 and C-5 respectively, and during this period he was treated for the cancer disease and the treating hospital had raised bill to the tune of ₹1,97,000/-, as is also evident from Annexure C-6A to C-44, and the cashless facility was denied to the complainant by the OPs vide Annexure C-46 and further, during the pendency of the present consumer complaint, OPs had partially settled the claim of the complainant by paying an amount of Rs.59,733/- out of the total after making deduction of 25% from the bill amount for chemotherapy and some other deductions as per the terms and conditions of the subject policy, the case is reduced to a narrow compass as it is to be determined if the OPs/insurer are unjustified in partially repudiating the claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the contesting OPs/insurer  have rightly settled the claim of the complainant after making deductions, as per terms & conditions of the subject policy, and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the contesting OPs/insurer.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy (Annexure C-49) as the very short point now involved in the present consumer complaint, in order to determine the real controversy between the parties, is if the OPs/insurer, while partially settling the claim of the complainant, have made deduction, as per terms and conditions of the subject policy.
   3. As per the defence of OPs, during the currency of the subject policy (Annexure C-2), which was valid w.e.f. 1.12.2020 to 30.11.2021, there is a cap upto which the claim lodged by the insured is payable by the insurer and the relevant portion of the same is reproduced below for ready reference :-

       “3.11 COVERAGE FOR MODERN TREATMENTS or PROCEDURES :

        The following procedures will be covered (wherever medically indicated) either as in patient or as part of day care treatment in a hospital up to the limit specified against each procedure during the policy period.

S.No	Treatment or Procedure	Limit (Per Policy Period)
xxx	xxx	xxx
3.11.5	Immunotherapy Monoclonal Antibody to be given as injection	Upto 25% of Sum Insured subject to a Maximum of Rs.2 Lakh
xxx	xxx	xxx”

4. Admittedly, the complainant was treated for cancer disease and Immunotherapy Monoclonal Antibody injection was to be given to the insured patient and it is clear from clause 3.11.5 that the total claim amount raised during the policy period was payable by the insured upto 25% of the sum insured subject to maximum of ₹2.00 lacs.  It is an admitted case of the parties that three different claims were lodged by the complainant in the policy period of the subject policy, as is also evident from Annexure C-X, which are tabulated as under :-

Sr. No.	Claim No.	Lodged on	Claim paid
	MDI 6006268	06.09.2021	59,733/-
	MDI 6177950	07.09.2021	1,06,551/-
	MDI 6646904	16.10.2021	17,466/-
		Total	1,83,750/-

5. It is further an admitted case of the parties that the insured patient (i.e. the deceased) was insured with the OPs/insurer with sum insured of ₹7.00 lacs with cumulative bonus amount of ₹35,000/- and 25% of the same i.e. on the total amount of ₹7,35,000/-, comes to ₹1,83,750/-.  It is further an admitted case of the parties that the OPs/insurer have already paid the total amount of ₹1,83,750/- against all the aforesaid three claims lodged by the complainant on different dates, during the pendency of the instant consumer complaint. However, when it has come on record that the OPs/insurer have wrongly denied the cashless facility to the complainant, knowing fully well even at the time of lodging of the first claim that complainant was entitled for the claim amount of ₹1,83,750/-, and released the same only after filing of the instant consumer complaint, by holding the genuine claim of the complainant for more than one year without any reason, the said act of the OPs/insurer clearly amounts to deficiency in service on their part.  Accordingly, the present consumer complaint deserves to succeed partly and the complainant is entitled for compensation to that extent for the harassment suffered by her.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs 1 & 2/insurer are directed as under :-

1. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
2. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OPs 1 & 2 within forty five days from the date of receipt of its certified copy, failing which, the payable amount, mentioned at Sr.No.(i) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(ii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/12/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member