Punjab

Faridkot

CC/17/163

Om Parkash Garg - Complainant(s)

Versus

The Oriental Insurance Co. Ltd. - Opp.Party(s)

ANIL KUMAR CHAWALA

20 Feb 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     163 of 2017

Date of Institution: 11.05.2017

Date of Decision :   20.02.2019

 

Om Parkash Garg son of Sh Sedhu Mal c/o Aggarwal Cotton Ginning Factory, Factory Road, Kotkapura Tehsil Kotkapura, District Faridkot.

                                                                                   .........Complainant

Versus

1. Oriental Insurance Co. Ltd. Near Old Grain Market, Kotkapura Tehsil Kotkapura, District Faridkot through its Branch Manager.
2. Park Mediclaim TPA Pvt Ltd. Sona Complex, Room No.11, 2^nd Floor, G T Road, Miller Ganj, Ludhiana through its Manager.                                                                         

.............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt  Param Pal Kaur, Member.

 

Present: Sh Anil Chawla, Ld Counsel for Complainant,

              Sh Deep Chand Goyal, Ld Counsel for OP-1.

              OP-2 Exparte.

 

ORDER

(Ajit Aggarwal, President)

                                        Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make remaining payment of Rs.39,353/- on account of insurance claim with interest and for further directing OPs to

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pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.10,000/-.

2                                                Briefly stated, the case of the complainant is that complainant purchased a Family Medicare Policy from OPs and for sum assured of Rs.1.50 lacs valid for the period from 10.03.2015 to 9.03.2016 and during the subsistence of said policy, wife of complainant suffered from cataract and on recommendations of doctor, cataract surgery was conducted on her eye and complainant spent about Rs.63,653/-on treatment of her wife and thereafter, complainant completed all the formalities and submitted the claim of Rs.63,353/-with OPs, but OPs reimbursed the amount of Rs.24100/-to complainant and withheld the remaining amount of Rs.39,353/- vide letter dt 7.09.2015 without disclosing any reason. Complainant made several requests to OPs to make payment of remaining amount but all in vain, which amounts to deficiency in service and trade mal practice on the part of OPs. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief of making payment of remaining claim amount. Hence, the complaint.

3                                                         The counsel for complainant was heard with regard to admission of the complaint and vide order dated 19.05.2017, complaint was admitted and notice was ordered to be issued to the OPs.

 

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4                                                         On receipt of the notice, the OP-1 filed reply wherein admitted that wife of complainant suffered from cataract and she has undergone cataract surgery, but denied all the allegations of complainant that he spent an amount of Rs.63.353/-on treatment of his wife and the record produced by complainant is false and not genuine. As per OP-1, record produced by complainant regarding treatment is false and is procured in connivance with doctors. OP-1 brought before the Forum that as per discharge slip issued by Brar Hospital, Kotkapura, complainant was admitted and discharged on 25.05.2015, but later on complainant obtained false certificate that his wife got discharged on 26.05.2015. In discharge slip also known as discharge summary, the follow up date was given as 26.05.2015, second date was 6.06.2015 and 3^rd follow up date was3.06.2016, which   shows that certificate dated 26.05.2015 is false and procured one.                                          Ld counsel for OP-1 averred that no cause of action arises against them as claim of complainant has already been considered and there is no deficiency in service on the part of OP-1 as after considering and processing the claim of complainant, they have already made payment of reasonable amount of Rs.24,100/- to complainant. Complainant is wrongly claiming Rs.39,353/-without disclosing any cogent reason. In fact, after receiving the amount of Rs.24,100/-, he became greedy and out of greed he filed the present complaint. The excess claim was rightly repudiated by OPs. It is admitted by OPs that wife of complainant was covered under the policy in question. Complainant is not entitled for

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more amount as sought by him. It is reiterated that there is no deficiency in service on the part of OP-1. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                              Registered cover containing notice and copy of complaint alongwith relevant documents was sent to OP-2, the same has not been received back undelivered and is presumed to be served. Even after expiry of statutory period, no body appeared in the Forum either in person or through counsel, therefore, vide order dated 13.07.2017, OP-2 was proceeded against exparte.

6                                                        Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-5 and then, closed their evidence.

7                                                      In order to rebut the evidence of the complainant, Counsel for OP-1 tendered in evidence affidavit of Ashwani Kumar as Ex Op-1/1 and documents Ex OP-1/2 to OP-1/7 and closed the evidence.

8                                               We have heard the ld counsel for complainant as well as OP-1 and have carefully gone through evidence and documents placed on record by respective parties.

 

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9                                              From the careful perusal of the record and after going through the evidence and documents, it is observed that               

10                                             The case of the complainant is that wife of complainant was insured under the policy in question. She got conducted her cataract operation at Brar Hospital, Kotkapura and complainant spent about Rs.63,353/-on her treatment. Complainant lodged claim with Ops, but Ops made payment of Rs.24,100/-only and withheld the reimbursement of remaining amount. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of remaining claim amount to complainant which amounts to deficiency in service. He has prayed for accepting the complaint. In reply, OP-1 have stressed mainly on the point that they have already paid the reasonable amount admissible as per rules and as per terms and conditions of policy and nothing is due towards them. Complainant is not entitled for further relief of claim amount as sought by him. Moreover, they have stressed on the point that documents produced by complainant regarding discharge of complainant from Brar Hospital are false and are not genuine ones. Complainant has procured the discharge slip in connivance with doctors to obtain undue advantage of monitory gains. It is reiterated that there is no deficiency in service on the part of OPs and prayed for dismissal of complaint with costs.

11                                                          From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that she was insured with them as per Family Medicare Policy. OP-1 argued that as per policy terms and conditions and reasonable rate for the treatment under policy in question, the complainant is entitled only for Rs.24,100/-as reimbursement for treatment at Brar Hospital, Kotkapura and she is not entitled for any other amount than this and this amount has already been paid to complainant and now, complainant is not entitled for anything else. OP-1 has made payment of Rs.24,100/-to complainant, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement that how they calculated this amount on their own. Admittedly, the complainant spent Rs.63,353/- for treatment of his wife and paid this amount to hospital authorities, the Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the persons.

12                                                            Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance

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Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The 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 the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

13                                                    From the above discussion and case law produced by the complainant, we are of considered opinion that OPs have wrongly and illegally deducted this amount, on false grounds of

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terms and conditions of policy and reasonable rates out of entire amount, spent on treatment by complainant, which was covered under the Mediclaim insurance policy. From the documents produced by the complainant it is proved that he spent Rs.63,353/-for treatment of his wife, which is also admitted by the OPs. The OPs have failed to prove that how they assessed Rs.24,000/-as reasonable rate. Hence, present complaint is hereby accepted and OPs are directed to pay Rs.39,353/-to complainant, which was wrongly deducted by them out of amount spent by complainant on treatment of his wife. They are directed to pay Rs.3,000/-to complainant as consolidated compensation for harassment and mental agony suffered by him and as litigation expenses. Compliance of this order be made within prescribed period of 30 days of receipt of the copy of this order, failing which complainant shall be entitled for interest at the rate of 9 % per anum per anum on the award amount from the date of order till final realization. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 20.02.2019

 

(Param Pal Kaur)              (Ajit Aggarwal)

                                        Member                          President