DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/49

Date of Institution   : 22.01.2018/29.11.2021

Date of Decision    : 04.07.2022

Mr. Tarlok Singh son of Sh. Jassa Singh resident of 1799, Verka Patti Hardass, Amritsar.     

                …Complainant Versus

The Oriental Insurance Company Limited through its Chairman/Managing Director/Principle Officer through its Branch Office at Dwarka Deesh Complex, Queens Road, Amritsar through its Branch Manager. 

                  …Opposite Party

 

Complaint Under Section 12 and 13 of Consumer Protection Act, 1986. As Amended Upto Date.

 

Present: Sh. Deepinder Singh Adv counsel for complainant.

Sh. Subodh Salwan Adv counsel for opposite party.

 

Quorum:-

1. Sh. Ashish Kumar Grover : President

2.Sh. Navdeep Kumar Garg : Member 

 

(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):

1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 12 & 13 of the Consumer Protection Act, 1986 (as amended upto date) against The Oriental Insurance Company Limited (hereinafter referred as opposite party).

2. Brief facts of the case are that the complainant got Health Benefit mediclaim insurance for himself, his wife and daughter from the opposite party covering the risk period 28.9.2016 to 27.9.2017. It is alleged that the complainant unfortunately fell ill and was to be hospitalized at Smt. PAARVATI DEVI HOSPITAL, AMRITSAR from 2.1.2017 to 6.1.2017 and the treatment cost of the said hospital came to Rs. 35,689/- and the opposite party was immediately informed about the said hospitalization as the said policy was issued on cashless basis and the complainant was insured for the medical benefit for Rs. 2 lacs. It is further alleged that the opposite party instead of making the said payment repudiated the genuine claim of the complainant on the frivolous ground vide repudiated letter dated 21.11.2017 after a long time when the policy period lapsed on the ground of PRE-EXISTING disease. The above said repudiation is made arbitrarily by the opposite party. It is further alleged that no such terms and conditions were conveyed to the complainant. The above said act of the opposite party amounts to deficiency in service and unfair trade practice on its part. Hence, the present complaint is filed for seeking the following reliefs.- 

i) To pay the amount of Rs. 35,689/- alongwith interest @ 12% per annum from 6.1.2017 till the realization. 

ii) To pay Rs. 50,000/-  as compensation on account of mental agony and harassment alongwith litigation expenses.    

3. Upon notice of this complaint, the opposite party appeared and filed written version by taking preliminary objections interalia on the grounds of complaint is baseless & frivolous, act and conduct, no consumer dispute, complainant has not come with clean hands etc. On merits, it is alleged that the complainant was suffered from “EMPHYSEMA” and the complainant has “H/O STENTING 18 MONTHS BACK” and “EMPHYSEMA” is a chronic lung disease and therefore the claim of the complainant has rightly been repudiated vide repudiation letter dated 21.11.2017 keeping in view the clause 4.1 of the terms and conditions of the policy in question, which is reproduced hereunder:-

“As per Clause 4.1:- Pre-existing health condition or disease or ailment/injuries: any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured persons upto 3 years off this policy being in force continuously. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered, provided the renewal have been continuous and without any break in period, subject to portability condition. This exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries. Such complications shall be considered as a part of the pre-existing health conditions or disease”. 

It is further alleged that Clause 3.13 of terms and conditions of the policy clearly manifests about discretions of the TPA in providing cashless facility to the insured. It is denied that the copy of insurance policy alongwith terms and conditions were not conveyed to the complainant. All other allegations are denied by the opposite party and prayed for the dismissal of complaint. 

4. In support of his case the complainant tendered into evidence his own affidavit Ex.C1, copy of the repudiation letter Ex.C-2, copy of the policy Ex.C-3, copy of the discharge summary Ex.C-4, copy of medical bill Ex.C-5 and closed the evidence. 

5. To rebut the case of the complainant the opposite party tendered into evidence affidavit of Naresh Singla Senior Divisional Manager Ex.O.P1/A alongwith documents Ex.O.P1/1 to Ex.O.P1/7 and closed the evidence.  

6. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties.  

7. It is not disputed between the parties that the complainant got Health Benefit mediclaim insurance for himself, his wife and daughter from the opposite party covering the risk period from 28.9.2016 to 27.9.2017 Ex.C-3. It is also not disputed between the parties that the complainant hospitalized at Smt. PAARVATI DEVI HOSPITAL, AMRITSAR from 2.1.2017 to 6.1.2017 Ex.C-4. Ld. Counsel for complainant argued that the complainant on his treatment spent Rs. 35,689/-, whereas the above said policy was issued on cashless basis and the complainant was insured for the medical benefit for Rs. 2 lacs. It is further argued by the Ld. Counsel for complainant that the opposite party instead of making the said payment repudiated the genuine claim of the complainant vide repudiated letter dated 21.11.2017 Ex.C-2 on the ground of PRE-EXISTING disease. 

8. On the other hand, Ld. Counsel for opposite party argued that the complainant was suffered from “EMPHYSEMA” and the complainant has “H/O STENTING 18 MONTHS BACK” and “EMPHYSEMA” is a chronic lung disease, therefore the claim of the complainant has rightly been repudiated vide repudiation letter dated 21.11.2017 Ex.O.P1/1 keeping in view the clause 4.1 of the terms and conditions of the policy in question. It is further argued by the Ld. Counsel for opposite party that the insurance policy alongwith terms and conditions were supplied/conveyed to the complainant. 

9. From the perusal of the record it is proved that the complainant fell ill and was admitted in Smt. Paarvati Devi Hospital on 2.1.2017 and discharged on 6.1.2017 Ex.C-4. It is also proved on the file that the complainant at the time of treatment was insured with the opposite party as the policy was valid from 28.9.2016 to 27.9.2017 Ex.C-3. The complainant alleged in his complaint that on his treatment he has spent Rs. 35,689/- and placed on record Patient Discharge Bill Ex.C-5. But on the perusal of the Bill Ex.C-5 it shows that the complainant has paid the amount of Rs. 29,600/- to the hospital. On the other hand, the opposite party has repudiated the claim of the complainant on the ground of Pre-existing disease as the complainant was suffered from “EMPHYSEMA” and the complainant has “H/O STENTING 18 MONTHS BACK” and “EMPHYSEMA” is a chronic lung disease. But to prove this fact the opposite party has failed to placed on record any document or medical history of the complainant which shows that the complainant was suffered from EMPHYSEMA since long. Further, the opposite party has placed on record Patient Discharge Summary Ex.O.P1/6. But from the perusal of this document nothing has been proved that the complainant was suffered from EMPHYSEMA for long time. The learned counsel for the complainant also relied upon the judgment of Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied. 

10. From the above discussion, it established that the claim of the complainant was repudiated by the opposite party on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite party. Therefore, the present complaint is partly allowed against the opposite party and the opposite party is directed to pay Rs. 29,600/- alongwith interest @ 6% per annum from the date of filing the present complaint. The opposite party is further directed to pay Rs. 2,200/- on the account of compensation and Rs. 1,100/- on account of litigation expenses to the complainant. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.  

ANNOUNCED IN THE OPEN COMMISSION:

       4th Day of July, 2022

 

 

            (Ashish Kumar Grover)

            President             

 

(Navdeep Kumar Garg)

Member