Punjab

Faridkot

CC/16/363

Vijay Kumar - Complainant(s)

Versus

United India Insurance Co. Ltd - Opp.Party(s)

Anil Kumar Chawla

06 Jun 2017

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     363

Date of Institution: 26.12.2016

Date of Decision :   6.06.2017

 

Vijay Kumar aged about 47 years son of Sh Amar Nath r/o Back side Telephone Exchange, Dhanna Basti, Kotkapura Tehsil Kotkapura District Faridkot.

                                                                                        ...Complainant

Versus

 

United India Insurance Co. Ltd. Near Old Bus Stand Jaitu Road, Kotkapura, now at Moga Road, Kotkapura through its Branch Manager.

 

                                                                                  .......Ops

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

                Sh P Singla, Member.

 

Present: Sh Anil Chawla, Ld Counsel for complainant,

              Sh Ashok  Kumar Monga, Ld Counsel for OP.

 

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 payment of insurance claim worth Rs. 46,885/- pertaining to mediclaim insurance policy of complainant and for further directing OPs to pay Rs.40,000/- as compensation for harassment, inconvenience, mental agony and Rs.10,000/- as litigation expenses.

2                Briefly stated, the case of the complainant is that complainant purchased Family Medicare Policy worth Rs. One lac from OP at first effective from 1.09.2011 to 31.08.2012 and continued the same from 1.09.2012 to 31.08.2013, from 1.09.2013 to 31.08.2014, 1.09.2014 to 31.08.2015 and further for the period from 1.09.2015 to 31.08.2016 and this time, increased the sum assured from one lac to two lacs and again continued the same from 1.09.2016 to 31.08.2017. It is further submitted that complainant suffered heart problem and was admitted in Max Super Specialty Hospital, Bathinda on 22.08.2016 and after proper checking, the stent RCA done and hospital bill and medicine charges came out to Rs.1,46,885/-.At the time of discharge, hospital authorities sent bill for treatment of complainant to OP, but on assurance of Op that they would pass the claim for expenses later on, he paid medical expenses from his own pocket. Thereafter, he submitted the claim for Rs.1,46,885/-, but earlier they repudiated the claim on pretext that one year has not been completed to the purchase of policy, but after representation by complainant that policy is in continuance since 1.09.2012 without any gap and is  extended upto Rs two lacs from 1.09.2015 to 31.08.2016 and on his representation, OP paid Rs one lac on account of insurance claim to him after a period of two months of treatment and withheld the remaining amount of Rs.46,885/-. Complainant approached OP and made several requests to make payment of remaining claim amount,    but all in vain. All this amounts to deficiency in service and trade mal practice on the part of OPs and has caused harassment and mental agony to him. He has prayed for directions to Ops to pay the remaining insurance claim and Rs.40,000/- as compensation besides Rs.10,000/- as cost of litigation. Hence, the present complaint.

3                                             The counsel for complainant was heard with regard to admission of the complaint and vide order dated 20.12.2016, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                            On receipt of the notice, OPs filed reply taking preliminary objections that present complaint is not maintainable as complainant has concealed the material facts from the Forum and Ops regarding his ailment at the time of renewal and enhancement of risk under the policy. Complaint is mala fide and is filed to extract undue advantage from OP. It involves the complex questions of law and facts, which cannot be decided in this Forum having limited jurisdiction and limited time span. Moreover, as per exclusion clause no. 4 and sub clauses thereof and condition no. 5 and 5.14 regarding enhancement of risk of insurance policy, complaint is not maintainable. Rs one lac has been rightly paid to complainant as per terms and conditions of policy and deduction of Rs.42,065/- from Surgeon fee, Rs50/- as registration charges and Rs.4770/-as pre hospitalization expenses have been done rightly as per terms and conditions of the insurance policy in question and sum beyond Rs one lac is not payable and thus, complaint is liable to be dismissed. Rs. One lac have been paid to complainant on 17.10.2016 within two months after thorough application of mind and due enquiry in full and final satisfaction of claim by the experts i.e Raksha TPA under due intimation to complainant and he also duly accepted the same without any protest and it cannot be reopened in any Forum. However, on merits they have reiterated the same pleadings as taken in preliminary objections and asserted that there is no deficiency in service on the part of Op either in processing the claim or in making payment to complainant. It is further averred that there is no deficiency in service on the part of OP and all the other allegations levelled have been denied being wrong and incorrect and prayed that complaint deserves to be dismissed with costs.

5                                               Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-8 and then, closed his evidence.

6                                     In order to rebut the evidence of the complainant, the opposite party tendered in evidence, affidavit of Baldev Singh as Ex OP-1, documents Ex OP-2 and 3 and then, closed the evidence.

7                                         We have heard the arguments addressed by all the parties and have also gone through the evidence and documents led by the parties.

8                                  Ld Counsel for complainant argued that  complainant purchased Family Medicare Policy worth Rs. One lac from OP at first effective from 1.09.2011 to 31.08.2012 and continued the same from 1.09.2012 to 31.08.2013, from 1.09.2013 to 31.08.2014, 1.09.2014 to 31.08.2015 and further for the period from 1.09.2015 to 31.08.2016 and this time, increased the sum assured from one lac to two lacs and again continued the same from 1.09.2016 to 31.08.2017. Further submitted that complainant suffered heart problem and was admitted in Max Super Specialty Hospital, Bathinda on 22.08.2016 and after proper checking, the stent RCA done and hospital bill and medicine charges came out to Rs.1,46,885/-. On discharge, hospital authorities sent bill for treatment of complainant to Ops, but on assurance of Op that they would pass the claim for expenses later on, complainant paid the medical expenses from his own pocket. Thereafter, complainant submitted the claim for Rs.1,46,885/-, but earlier they repudiated the claim on pretext that one year has not been completed to the purchase of policy, but after representation by complainant that policy is in continuance since 1.09.2012 without any gap and is  extended upto Rs two lacs from 1.09.2015 to 31.08.2016 and on his representation, OP paid the amount of Rs one lac on account of insurance claim to him after a period of two months of treatment and withheld the remaining amount of Rs.46,885/-. Complainant approached Ops and made several requests to make payment of remaining claim amount, but all in vain. It amounts to deficiency in service and has caused harassment to him. He has prayed for accepting the complaint.

9                                     To controvert the arguments of complainant counsel, ld counsel for Ops argued that there is no deficiency in service on their part either in processing the claim or in making payment of claim amount to complainant. It is averred that present complaint is not maintainable as complainant has concealed the material facts about his ailment at the time of renewal and enhancement of risk under the policy. Complaint is mala fide and is filed to extract undue advantage from OP. It involves the complex questions of law that cannot be decided in this Forum having limited jurisdiction and limited time span. Moreover, as per exclusion clause no. 4 and sub clauses thereof and condition no. 5 and 5.14 regarding enhancement of risk of insurance policy, complaint is not maintainable. However, it is admitted before the Forum that complainant was insured under the policy of Ops for the period from 1.09.2015 to 31.08.2016 for Rs.2,00,000/-. Rs one lac has been rightly paid to complainant as per terms and conditions of policy and deduction of Rs.42,065/- from Surgeon fee, Rs50/- as registration charges and Rs.4770/-as pre hospitalization expenses have been done rightly as per terms and conditions of the insurance policy in question and sum beyond Rs one lac is not payable and thus, complaint is liable to be dismissed. Rs. One lac have been paid to complainant on 17.10.2016 within two months after thorough application of mind and due enquiry in full and final satisfaction of claim by the experts i.e Raksha TPA under due intimation to complainant and he also duly accepted the same without any protest and it cannot be reopened in any Forum. It is further averred that there is no deficiency in service on the part of OP and all the other allegations levelled have been denied being wrong and incorrect and prayed that complaint deserves to be dismissed with costs.

10                                    From the careful perusal of record and going through the affidavits, evidence and pleadings of the parties, it is observed that grievance of complainant is that he was insured under the policy of Ops for a sum of Rs. 2 lacs and during the validity of insurance period, he underwent treatment of heart, but despite his repeated requests, Ops paid claim of only Rs.1,00,000/- only and did not pay the remaining amount of Rs.46,885/- as per his entitlement though he expenditure incurred on his treatment is of Rs.1,46,885/-. On the other hand, Ops have themselves admitted in written statement that complainant was insured with them under their policy for Rs.2 lacs and stated that they paid Rs.100,000/-as insurance claim and he is not entitled for any remaining amount as  complainant did not disclose about his ailment of heart at the time of renewal of policy and enhancement of risk covered under insurance policy in question and thereby induced them to issue the present policy. OP have  denied all the other allegations and asserted that there is no deficiency in service.          

11                                             We have carefully gone through the file and from the  above discussion, we come to the conclusion that there is no dispute about the insurance claim as it is admitted fact of Ops that complainant was insured under their insurance policy for Rs.2,00,000/- and they have themselves admitted in their written statement as well as before the Forum that they paid Rs.1,00,000/- out of total expenditure of Rs.1,46,885/-for treatment of complainant. Though the complainant got renewed his medicare insurance policy and  also enhanced the risk cover  for Rs.2 lacs but OPs did not pay the remaining amount of Rs.46,885/- paid by complainant to hospital authorities for expenses incurred by him on his treatment by paying Rs. 01 lac only, which amounts to deficiency in service and trade mal practice. Hence, present complaint is hereby allowed. OPs are ordered to pay the remaining Mediclaim worth Rs.46,885/- to complainant alongwith interest at the rate of 9% per anum from the date of filing the complaint till final realization. Ops are further directed to pay Rs 5,000/-as compensation for harassment and mental agony and Rs 3,000/-as litigation expenses to complainant. Compliance of this order be made within one month from the date of receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 6.06.2017         

 

  Member                            President

                                                  (P Singla)                      (Ajit Aggarwal)