State Consumer Disputes Redressal Commission
Subhash Chander Verma vs Regional Manager Raksha Tpa Pvt. Ltd. on 6 April, 2015
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH First Appeal No. : 78 of 2015 Date of Institution : 01.04.2015 Date of Decision : 06.04.2015 Subhash Chander Verma, House No.91A, Sector 17, Panchkula, Haryana, Mob.9815335553. ......Appellant/Complainant V e r s u s Regional Manager, Raksha TPA Pvt. Ltd., 2nd Floor, SCO 181, Sector 17, Chandigarh UT. Branch Manager, The New India Assurance Co. Ltd., SCO No.804, NAC, Manimajra. The Regional Manager, The New India Assurance Co. Ltd., SCO 36-37, Sector 17A, Chandigarh 160017. ....Respondents/Opposite Parties Appeal under Section 15 of the Consumer Protection Act, 1986. BEFORE: JUSTICE SHAM SUNDER (RETD.), PRESIDENT. MR. DEV RAJ, MEMBER.
MRS. PADMA PANDEY, MEMBER Argued by: Sh. Subhash Chander Verma, appellant in person.
PER JUSTICE SHAM SUNDER (RETD.), PRESIDENT This appeal is directed against the order dated 20.02.2015, rendered by the District Consumer Disputes Redressal Forum-I, UT, Chandigarh (hereinafter to be called as the District Forum only) vide which, it dismissed the complaint, filed by the complainant (now appellant).
The facts, in brief, are that the complainant obtained a Mediclaim Policy 2007 (Hospitalization Benefit Policy) Annexure-1, from the Opposite Parties, valid for the period from 10.04.2013 to 09.04.2014, for the sum insured of Rs.2,00,000/-, on payment of premium, to the tune of Rs.8,826/-. It was stated that the complete Policy document and the terms and conditions thereof were not supplied to the complainant, at any point of time. It was further stated that, on 18.02.2014, the complainant suffered brain stroke, as a result whereof, he was taken to the Alchemist Hospital, Sector 21, Panchkula. Initially, the complainant was admitted in emergency ward of the said Hospital, and, thereafter, was shifted to the Intensive Care Unit (ICU). It was further stated that, on the next day, the complainant was shifted to the private room. It was further stated that the complainant was discharged, from the Alchemist Hospital, Sector 21, Panchkula, on 21.2.2014. It was further stated that bill Annexure-2 for Rs.60,625/- was prepared by the said Hospital, in relation to the expenses incurred by the complainant on his treatment. It was further stated that the claim was lodged by the complainant, with the Opposite Parties. It was further stated that the complainant was shocked to receive letter Annexure-3, from Opposite Party No.1, whereby it agreed to pay Rs.26,926/- only, out of the aforesaid amount.
It was further stated that, as per the directions of the concerned Doctor of the said Hospital, in the discharge certificate, the complainant continued getting treatment in the OPD. However, the complainant was again hospitalized in the Alchemist Hospital, Sector 21, Panchkula, from 10.03.2014 to 15.03.2014 for treatment. The said Hospital again charged Rs.59,967/-, for treatment of the complainant, vide bill Annexure 5. It was further stated that when the complainant submitted claim with the Opposite Parties, he was again issued letter Annexure R-6, by Opposite Party No.1, whereby it agreed to pay Rs.35,935/-, against Rs.59,967/-. It was further stated that on 15.05.2014, the complainant visited the office of Opposite Party No.1 and delivered the supplementary claim bill of Rs.89,167/-, but it made payment of Rs.31,435/- against the same (Rs.89,167/-).
It was further stated that, as such, the complainant sent notice to the Opposite Parties, vide email dated 21.08.2014 (Annexure 9), with a request to pay the remaining amount. It was further stated that, in response, the Opposite Parties, vide email dated 01.09.2014 (Annexure 10) refused to pay the same. It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed, seeking various reliefs.
Notice of the complaint was served upon the Opposite Parties. Though, Sh. J.P. Nahar, Advocate, put in appearance, on behalf of the Opposite Parties, yet written version and evidence, were filed, on behalf of Opposite Parties No.2 and 3 only.
Opposite Parties No.2 and 3, in their joint written version, admitted that the complainant obtained a Mediclaim Policy 2007 (Hospitalization Benefit Policy) Annexure-1, from them, valid for the period from 10.04.2013 to 09.04.2014, for the sum insured of Rs.2,00,000/-, on payment of premium, to the tune of Rs.8,826/-. It was denied that the terms and conditions of the Policy were not supplied to the complainant. It was also denied that the complainant was not made aware of the terms and conditions of the Policy. It was also admitted that the complainant was hospitalized twice, for the period from 18.02.2014 to 21.02.2014 and 10.03.2014 to 15.03.2014. It was stated that bill No.13-14CR2106 (Annexure-2) was not for Rs.60,261/- but for Rs.60,626/-. It was further stated that the amount of Rs.26,925/- was the admissible amount, which was paid to the complainant, after making necessary deductions, as per the terms and conditions of the Policy. It was further stated that the complainant was again hospitalized in the said Hospital, for the period from 10.03.2014 to 15.03.2014, for which bill of Rs.59,967/- was submitted. It was further stated that deductions were made, as per the terms and conditions of the Mediclaim Policy (2007). It was further stated that the insured had the liberty to choose the sum insured, at the time of taking the Insurance Policy. It was further stated that the Insurance Policy is a contract and both the parties to the same (contract) are bound by the terms and conditions thereof. It was further stated that the complainant was not entitled to get the amounts, as demanded by him. It was further stated that neither there was any deficiency, in rendering service, on the part of Opposite Parties No.2 and 3, nor they indulged into unfair trade practice. The remaining averments, were denied, being wrong.
In the rejoinder, filed by the complainant, he reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties No.2 and 3. It was stated in the rejoinder, that the complainant took the Mediclaim Policy for the first time, in the year 2000 and, thereafter, got it renewed regularly for 13 years. It was further stated that the complainant never took any claim except once in the year 2006, when he got cataract operation of his left eye done and obtained full reimbursement, without any deduction.
The complainant and Opposite Parties No.2 and 3, led evidence, in support of their case.
After hearing the complainant, in person, Counsel for the Opposite Parties, and, on going through the evidence, and record of the case, the District Forum, dismissed the complaint, as stated above.
Feeling aggrieved, the instant appeal, has been filed by the appellant/complainant.
We have heard the appellant, in person, and, have gone through the evidence, and record of the case, carefully.
The appellant/complainant, in person, submitted that infact, the Policy terms and conditions were never supplied to him, nor was he made aware of the same. He further submitted that he had taken the first Mediclaim Policy, in the year 2000, and had been getting the same renewed, year after year for 13 years. He further submitted that the District Forum was wrong, in coming to the conclusion, on the basis of Annexure-1, Policy Schedule, Mediclaim Policy 2007 (Hospitalization Benefit Policy), that the terms and conditions of the same (Policy) were supplied to him. He further submitted that since the terms and conditions of the Policy were not supplied to him, the question of invoking the exclusion Clauses contained therein, or making deductions, referred to above, did not at all arise. He further submitted that, in the absence of supply of the terms and conditions of the Policy, at any point of time, to him, the deductions made by the Opposite Parties, from the claims submitted by him could be said to be illegal and arbitrary. He further submitted that the District Forum was wrong, in relying upon the Policy document Annexure R-1, produced by the Opposite Parties, which was never supplied to him. He further submitted that he was entitled to the full amount of the claims submitted by him. He further submitted that the order of the District Forum, therefore, being illegal and invalid, is liable to be set aside.
After giving our thoughtful consideration, to contentions, advanced by the appellant, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed, at the preliminary stage, for the reasons, to be recorded hereinafter. In the rejoinder, in paragraph no.6, it was in clear-cut terms, stated by the complainant that for the first time, he took the Policy, in the year 2000. He also admitted, in the rejoinder, that he had been getting the same regularly renewed, from time to time, and the last renewal of the Mediclaim Policy 2007 (Hospitalization Benefit Policy), Annexure-1, was for the period from 10.04.2013 to 09.04.2014, for the sum assured of Rs.2 lacs. This Policy was taken by the complainant from the Opposite Parties. The crucial question, that falls for consideration, is, as to whether, the complainant was supplied the terms and conditions of the Policy or not. Annexure-1 is the Policy Schedule, which was produced by the complainant, himself. It is in two pages. It is evident from the second page of the Policy, that "This Policy is subject to Mediclaim Policy (2007) Clause as attached". This clearly established that the detailed terms and conditions were attached with the Policy Annexure 1/R-1 by the Opposite Parties. In case, as per the Clause aforesaid, the terms and conditions of the Policy were not attached with the same (Policy), it was required of the complainant to write to the Opposite Parties, immediately to send the same to him. There is nothing, on record, that right from the year 2000 till 12/15.05.2014, the complainant ever wrote to the Opposite Parties, that he had not been supplied the terms and conditions of the Policy. It was for the first time vide letter dated 12/15.05.2014 Annexure-8, when the deductions were made, from the claimed amount that he came up with the plea that he was not supplied the terms and conditions of the Policy. It could not be believed that a person will sleep over the matter for about 14 years, when the Policy for the first time incepted, and would not ask for supply of the terms and conditions thereof, in case, he had not received the same. Had the complainant written any letter or sent any communication to the Opposite Parties immediately after the inception of the Policy or renewal thereof on 10.04.2013, regarding the non-receipt of the terms and conditions of the same (Policy), the matter would have been different. It appears that the complainant concocted a plea, after about 14 years, to the effect that he did not receive the terms and conditions of the Policy, especially when there was endorsement on Annexure-1/R-1 at page 14 of the District Forum file that "This Policy is subject to Mediclaim Policy (2007) Clause as attached". The District Forum was, thus, right in holding that the terms and conditions of the Policy were supplied to the complainant and he was fully made aware of the same. The findings of the District Forum, in this regard, therefore, being correct are affirmed. The submission of the appellant, to the contrary, being devoid of merit, must fail, and the same stand rejected.
The next question, that falls for consideration, is, as to whether, the deductions, from the amount of claims submitted by the complainant had been made, in accordance with the terms and conditions of the Policy, by the Opposite Parties, or not. Perusal of the terms and conditions of the Policy, attached with Annexure R-1 reveals that the deductions were made, from the bills submitted by the complainant, in accordance with the same (terms and conditions of the Policy). Since the Insurance Policy is a contract, it was for the complainant to chose a Policy of either Rs.2,00,000/- or Rs.6,00,000/-Since the complainant chose the Policy of Rs.2,00,000/- and not Rs.6 lacs, he could not claim that he should be given the benefits of the Policy of the sum insured of Rs.6,00,000/-. Bill No.13-14CR2106 (Annexure-2) was for a sum of Rs.60,626/- and not for Rs.60,261/-. The admissible charges out of the same came to be Rs.26,925/-after making deductions, and the same were paid to the complainant. The complainant was again hospitalized for the period from 10.03.2014 to 15.03.2014, for which bill of Rs.59,967/- was submitted by him. The deductions were made, as per the terms and conditions of the Mediclaim Policy (2007), which was for the sum insured of Rs.2 lacs. Thus, in respect of the second bill Annexure R-5, for a sum of Rs.59,967/-, after deductions, a sum of Rs.35,935/-, vide letter Annexure-6 was paid to the complainant. Against the supplementary bill of Rs.89,167/-, Rs.31,435/- were paid to the complainant, after making necessary deductions, as per the terms and conditions of the said Policy. Since the complainant entered into a contract of Insurance, with the Opposite Parties, he was bound by the terms and conditions thereof. The submission of the appellant/complainant to the effect that deductions, from the amounts, claimed by him, were illegally made by the Opposite Parties, therefore, has no legs to stand. Since the Opposite Parties acted strictly, in accordance with the terms and conditions of the Policy, the complainant was not entitled to the more amount than the one paid to him, after making necessary deductions, as per the terms and conditions of the Policy. Hence, by making the necessary deductions, as per the terms and conditions of the Policy, the Opposite Parties, were neither deficient, in rendering service, nor indulged into unfair trade practice.
No other point, was urged, by the appellant.
In view of the above discussion, it is held that the order passed by the District Forum, being based on the correct appreciation of evidence, and law, on the point, does not suffer from any illegality or perversity, warranting the interference of this Commission.
For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District Forum is upheld.
Certified copies of this order, be sent to the parties, free of charge.
The file be consigned to Record Room, after completion.
Pronounced.
06.04.2015 Sd/-
[JUSTICE SHAM SUNDER (RETD.)] PRESIDENT Sd/-
(DEV RAJ) MEMBER Sd/-
(PADMA PANDEY) MEMBER Rg