Complaint No: 233 of 2017.
Date of Institution: 28.04.2017.
Date of order: 14.9.2023
- Subhash Khullar aged about 66 years S/o Sh.Guru Dutt Khullar
- Madhu Khullar aged about 63 years W/o Mr.Subhash Khullar Both residents of H.No.14, Ward No.30, Anand Vihar Colony Batala, District Gurdaspur.
.....Complainants.
VERSUS
- The Oriental Insurance Co. Limited, Jalandhar Road, Kapurthala, through its Branch Manager.
- Branch Manager, The Oriental Insurance Co. Limited, Jalandhar Road, Kapurthala.
- Punjab National Bank, Prem Nagar Railway Road, Batala, through its Branch Manager.
….Opposite parties.
Complaint U/s 12 of the Consumer Protection Act, 1986.
Present: For the Complainants: Sh.Rajiv Kaura, Advocate.
For the Opposite Parties No.1 and 2: Sh.A.K.Joshi, Advocate.
For the Opposite Party No.3: Sh.Pushkar Nanda, Advocate.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President
Subhash Khullar & Madhu Khullar, Complainants (here-in-after referred to as complainants) has filed this complaint under section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act') against The Oriental Insurance Company Ltd. etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the complainant No.1 who is the husband of the complainant No.2 is the account holder in Punjab National Bank Prem Nagar Railway Road, Batala i.e. with opposite party No.3 since long. It was submitted that the complainant No.1 visited the bank i.e. opposite party No.3 for the operation of his account and he was informed by the officials of opposite party No.3 that Punjab National Bank has made the collaboration with the Oriental Insurance Company Limited i.e. the opposite party No.1 and 2 and a new health policy named as PNB-Oriental Royal Mediclaim policy schedule has been introduced and requested to the complainant to obtain the Health Insurance policy from the opposite parties on the payment of premium from his bank account. It was further submitted that on the request of opposite party No.3 the complainant No.1 obtained one health insurance policy for himself and his spouse i.e. the complainant No.2 vide cover note No.233106/48/2015/298 from opposite parties No.1 to 3 commencing with effect from 22.08.2014 to mid-night of 21.08.2015 which was renewed in the next year vide policy No.233106/48/2016/374 with effect from 22.08.2015 to mid-night of 21.08.2016 and paid the premium of Rs.6930/- from his account lying with the bank. It is further pleaded that said insurance policy covered both the complainants as well and the complainants are covered within the definition of consumer. It is further pleaded that at the time of obtaining the insurance policy complainant No.2 was not suffering from any sort of disease. It was further submitted that on 16.10.2015 complainant No.2 got the routine checkup from Fortis Escort hospital Majitha-Verka Bye pass Amritsar 143004 Punjab due to sudden illness complaining against chest pain whereas the complainant No.2 was not having any sort of health problem earlier and she had/has no previous history of heart problem. It was further submitted that on the day of admission i.e. 16.10.2015 the coronary Angiography and Coronary Angioplasty (Single Vessel) with Alpha Trancell deluxe was done by the Doctors of Fortis Escort hospital, Amritsar was done. It is further pleaded that complainants had to pay/spent the amount of Rs.2,01,119.80/- against receipts duly issued by the above mentioned hospital for the treatment of the complainant No.2 in the above said hospital with effect from 16.10.2015 to 18.10.2015. It was further submitted that the complainant No.2 is covered well within the risk of his health claim as the insurance policy obtained by complainants is/was operative and effective when the complainant No.2 was got admitted in the above mentioned hospital where her heart treatment of coronary Angiography and Coronary Angioplasty (Single Vessel) with Alpha Trancell deluxe was done by the doctors of the above mentioned Hospital. It was further submitted that complainants filed the health claim under the PNB-Oriental Mediclaim policy No.233106/48/2016/374 and completed all the required formalities and submitted all the necessary documents desired by opposite parties. It is further pleaded that the complainant’s was asked by the opposite parties vide letter dated 18.10.2015 regarding the denial of cash less facility and to file the full claim papers for reimbursement of the claim amount. It was alleged that to the utter surprise and shocking to complainants that the just, legal and valid claim of complainant No.2 for the reimbursement of Rs.2,01,119.80/- (the medical expenses incurred on the heart treatment of complainant and other incidental charges) has been repudiated by opposite parties vide repudiation letter dated 19.04.2016 and also the claim of post heart treatment expenses on the lame excuse of alleged ailment of hypertension whereas there was no previous history of any hypertension of the mild nature even. It was further alleged that the best course to be adopted by opposite parties was to contact the Fortis Escort hospital, Amritsar (Punjab) and to make the proper investigation by appointing some competent investigator before coming to any conclusion but opposite parties have without going through the truth of the matter have repudiated the health claim of complainant No.2. It was further alleged that the opposite parties have repudiated the just, legal and valid health claim of complainant No.2 illegally, unlawfully, in utter disregard and violation of the terms and conditions of the policy and in a high handed and unwarranted manner. It was further alleged that the opposite parties have further renewed the medical policy of the complainants for the period w.e.f. 22.08.2016 to 21.08.2017 and charged the premium from the account of the complainant No.1 lying in the opposite party No.3. It was further alleged that it is very surprising that when the policy was introduced opposite parties were in search of the customers and when the number of clientage including complainant's has attached with opposite parties now the opposite parties have repudiated the just and legal claim of complainant's on the basis of presumptions and assumptions. Due to this illegal act and conduct of the opposite parties the complainants has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. So, there is a clear cut deficiency in service on the part of the opposite parties.
On this backdrop of facts, the complainants has alleged deficiency and negligence in service and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to make the payments to the complainants of Rs.2,01,119.80/- with interest thereon at the rate 18% P.A. w.e.f. 18.10.2015 till the actual date of payment and Rs.1,00,000/- as compensation for harassment and mental agony caused to the complainants by the opposite parties. The opposite parties may also pay Rs.22,000/- as litigation expenses to the complainants, in the interest of justice.
3. Upon notice, the opposite parties No.1 and 2 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the present complaint of the complainant is not maintainable. It is further pleaded that as soon as the claim of the complainant was received by the replying OP’s insurance company, the same was referred to ‘M/s MEDI ASSIST INDIA PVT.LTD.’ for settling the claim as per the terms and conditions of the policy and as per the required record/documents. It is further pleaded that 'M/s MEDI ASSIST INDIA PVT. LTD.', is the claim settling authority, who settles the Claims under the terms and conditions of policy. It was pleaded that on scrutinizing all the documents including medical treatment record, 'M/s MEDI ASSIST INDIA PVT. LTD.’ found that the patient Madhu Khullar was admitted in Fortis Escorts Hospital, Majitha-Verka Bye Pass, Amritsar on 16.10.2015 and discharged on 18.10.2015 and during hospitalization the diagnosis was CORONARY ARTERY DISEASE, SINGLE VESSEL DISEASE, RECENT INFERIOR WALL MI, TYPE 2 DM AND HYPERTENS1ON and the policy inception date is 22.08.2014 and according to the policy condition 4.2 (xvii) and 4.2 (xviii), there is waiting period of two years for diabetes and hypertension. It is further pleaded that policy of the insured is the second year policy, which does not cover the claim of the insured. It is further pleaded that the claim of the complainant is not covered under the terms and conditions of the policy and the replying opposite parties Company has rightly repudiated the claim of the complainant under the terms and conditions of policy. It was further pleaded that as per the clause 4.2 (xvii) and 4.2 (xviii) or the terms and conditions of the policy in question,
- 4.2 (xvii) “ During the period of insurance cover, the expenses on treatment of Hypertension for specified period of two years are not payable if contracted and/or manifested during the currency of the policy.”
- 4.2 (xviii) “ During the period of insurance cover, the expenses on treatment of Diabetes for specified period of two years are not payable if contracted and/or manifested during the currency of the policy.”
Hence, the present claim petition is not maintainable and liable to be dismissed on this score only. It was further pleaded that the present complaint is bad for mis-joinder and non-joinder of necessary parties. ‘M/s MEDI ASSIST INDIA PVT.LTD.' is necessary party for the proper and complete adjudication of the complaint.
On merits, the opposite parties No.1 and 2 have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in services on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Upon notice, the opposite party No. 3 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complaint as against the opposite party No. 3 is not maintainable in the present form as no services were ever hired by the complainant from opposite party No. 3 at any point of time relating to the alleged matter in question and thus there is no deficiency in service on the part of the opposite party No. 3 in the alleged matter in question. It is further pleaded that alleged matter involved if any in the case is in between the complainant and opposite parties No.1 and 2 and the opposite party No. 3 has been made as unnecessary party for none of its involvement in any manner in the alleged matter in question and thus the opposite party No. 3 has no concern with the same.
On merits, the opposite party No.3 have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in services on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
5. Learned counsel for the complainants has tendered into evidence affidavits of Subhash Khullar and Madhu Khullar, (Complainants) as Ex.C-1 and Ex.C-2 alongwith other documents as Ex.C-3 to Ex.C-11.
6. Learned counsel for the opposite parties No.1 and 2 has tendered into evidence affidavit of Sh.Karam Singh (Senior Divisional Manager, Oriental Insurance Co. Ltd., Pathankot) as Ex.OP-1,2/1 alongwith other documents as Ex.OP-1,2/2 to Ex.OP-1,2/8.
7. Learned counsel for the opposite party No.3 has tendered into evidence affidavit of Sh.Pardip Kumar (Senior Divisional Manager of Opposite Party No.3) as Ex.OP-3/1 alongwith reply.
8. Rejoinder not filed by the complainant.
9. Written arguments filed by the complainants and opposite parties No.1 & 2 but not filed by the opposite party No.3.
10. Counsel for the complainant has argued that complainant had purchased a health policy from opposite party No.1 through opposite parties No.2 and 3. It is further argued that during the continuation of policy of insurance, complainant No.2 Smt.Madhu Khullar suffered heart problem and remained admitted at Fortis Escort Hospital Majitha-Verka Bye pass Amritsar Coronary Angiography and Coronary Angioplasty (Single Vessel). It is further argued that amount of Rs.2,01,119.80P. was spent by the complainant but cashless was refused by the opposite parties and thereafter claim lodged by the complainant was repudiated vide letter dated 19.04.2016 with the excuse that hypertension, heart disease is not covered within two years of inception of policy which amounts to deficiency in service.
11. Counsel for the opposite parties No.1 and 2 has argued that policy inception date is 22.08.2014 as per term conditions No.4.2 (xvii) and 4.2 (xviii) there is waiting period of two years for diabetes and hypertension and accordingly claim was rightly repudiated by the opposite parties No.1 and 2.
12. Counsel for the opposite party No.3 has argued that complaint as against the opposite party No. 3 is not maintainable in the present form as no services were ever hired by the complainant from opposite party No. 3 at any point of time relating to the alleged matter in question and thus there is no deficiency in service on the part of the opposite party No. 3 in the alleged matter in question.
13. We have heard the Ld. counsels of for the parties and gone through the record.
14. It is admitted fact that complainant obtained health insurance policy from opposite party No.1 commencing from 22.08.2014. It is further admitted fact on being renewed it was valid upto 21.08.2016. It is further admitted fact that the said policy was again renewed by the opposite party No.1 w.e.f. 22.08.2016 to 21.08.2017. It is further admitted fact that complainant No.2 Smt.Madhu Khullar remained admitted in Fortis Escort Hospital Majitha-Verka Bye pass Amritsar from 16.10.2015 to 18.10.2015 and during hospitalization she was diagnosed for Coronary Angiography and Coronary Angioplasty (Single Vessel) disease with Alpha Trancell deluxe and hypertension. The only disputed question before this Commission is that whether the opposite party No.l was within its right to repudiate the claim by taking excuse of policy conditions No.4.2 (xvii) and 4.2 (xviii) wherein waiting period of two years is prescribed for diabetes and hypertension.
15. Perusal of policies of insurance shows that the claim has been repudiated by relying upon the policy terms and conditions as mentioned in Ex.OP-1,2/8 wherein clause No.4.2 (xvii) and 4.2 (xviii) there is waiting period of two years for diabetes and hypertension but the evidence on record and perusal of written statement shows that it is nowhere proved on record that the said terms and conditions as mentioned in Ex.OP-1,2/8 were ever supplied to the complainant with the policy document or the said terms and conditions were ever read over and explained to the complainants and since there is no such evidence to prove above referred facts. As such opposite party No.1 cannot deny the claim by taking excuse of waiting period of two years for diabetes and hypertension. Moreover, it is not also a case of concealment of pre-existing disease. Moreover hypertension and diabetes are life style diseases which can occur at any point of time during the life of a common man due to the change in living life style of the human beings. We are of the view that insurance companies are only interested in collecting premium and when it comes to pay the claim they find one excuse or the other to dey the claim by taking shelter under exclusion clauses.
16. From the aforesaid discussion, it transpires that the genuine claim of the complainant has been repudiated by the opposite parties without any reasonable excuse. It is usual with the insurance companies to show green pastures to the consumers when they are to sell their policies. But however when it comes to the payment for claim, they invent all sort of excuses to deny the claim. Reliance in this connection can be had on 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 the 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.
17. 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, Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich".
18. We placed reliance upon judgment of Hon'ble Supreme Court of India reported in 2022 LiveLaw (SC) 506 wherein it was held by the Hon'ble Supreme Court of India as under
"Insurance Insurance companies refusing claim on flimsy rounds and or technical grounds While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. Para 4.1".
19. We are of the view that health policy was obtained by the complainant for medical emergency and if unreasonable policy conditions as mentioned in 4.2 (xvii) and 4.2 (xviii) are forced upon the insured person shows totally business mal practice on the part of opposite party No.1. As such we are of the view that complainant was fully within his right to lodge the claim with the opposite parties No.1 within two years and is entitle to receive reimbursement of Rs.2,01,119.80P. from the opposite party No.1.
20. Accordingly, present complaint is partly allowed and opposite party No.1 is directed to pay Rs. 2,01,119.80P. alongwith interest @ 9% P.A. from the date of filing of the complaint till its realization. Complaint against opposite parties no.2 and 3 is dismissed. Opposite party No.1 is further directed to pay Rs.10,000/- for mental tension and harassment suffered by the complainant including Rs.5,000/- as cost of litigation. Entire exercise shall be completed within 30 days from the date of receipt of copy of this order.
21. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
22. Copy of the order be communicated to the parties free of charges. File be consigned.
(Lalit Mohan Dogra)
President.
Announced: (B.S.Matharu)
Sept. 14, 2023 Member.
*YP*
