State Consumer Disputes Redressal Commission
Oriental Insurance Co. Ltd. vs Prince Mangla on 6 November, 2024
FA. NO./331/2019 ORIENTAL INSURANCE CO. LTD. VS. MR. PRINCE MANGAL D.O.D.: 06.11.2024
IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL
COMMISSION
Date of Institution: 23.05.2019
Date of Hearing: 30.09.2024
Date of Decision: 06.11.2024
FIRST APPEAL NO. - 331/2019
IN THE MATTER OF
ORIENTAL INSURANCE CO. LTD.,
REGIONAL OFFICE - II,
1ST FLOOR, SCOPE COMPLEX,
LAXMI NAGAR, DELHI - 110092.
(Through: Mr. B.S. Arora &
Mr. Mohit Arora, Advocate)
...Appellant
VERSUS
MR. PRINCE MANGLA (DECEASED),
THROUGH ITS LR'S:
1. MS. SAPNA MANGLA (WIFE OF RESPONDENT),
2. MR. OJAS MANGLA (SON OF RESPONDENT),
3. MR. GARV MANGLA (SON OF RESPONDENT),
ALL R/O A1/205, PRINTERS APARTMENT,
SECTOR 13, ROHINI,
DELHI - 110085.
...Respondent
DISMISSED PAGE 1 OF 8
FA. NO./331/2019 ORIENTAL INSURANCE CO. LTD. VS. MR. PRINCE MANGAL D.O.D.: 06.11.2024
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)
HON'BLE MS. PINKI, MEMBER (JUDICIAL)
Present: Mr. Kanwar Kochhar, counsel for the Appellant on VC.
None for the Respondent.
PER: HON'BLE JUSTICE SANGITA DHINGRA SEHGAL,
PRESIDENT
JUDGMENT
1. The facts of the case as per the District Commission record are as under:
"1...the complainant has taken a Mediclaim Insurance policy from OP bearing no. 272100/48/2014/1804 for more than a decade without any discontinuity and the complainant and his family members are covered under the Gold Plan of Happy Family Floater policy schedule from OP for the assured amount of Rs.6,00,000/- On 31.08.2014, the complainant got admitted in Max Super Specialty Hospital where he was diagnosed with a case of Myocardial Infraction or ACS on 01.09.2014 and the doctor advised for an Angioplasty. As it is a costly procedure, his brother namely Sh. Prashant Mangla called up OP to ask whether OP can get this procedure value be paid under the Mediclaim Policy or not and the representative of OP said yes for the same and stated that he would get the complete value without any conditions and the complainant decided & then the Angioplasty done. On 04.09.2014, the complainant was waiting for the TPA approval and the TPA desk in the hospital informed his brother that Medical consumable Stunt amount to Rs.1,98,000/- and the same was approved for the amount of Rs.1,18,000/- only as this is a cashless facility and this is a DISMISSED PAGE 2 OF 8 FA. NO./331/2019 ORIENTAL INSURANCE CO. LTD. VS. MR. PRINCE MANGAL D.O.D.: 06.11.2024 set package under GIPSA and GIPSA was not mentioned in the policy and even clause 3.12 and the complainant filed a complaint regarding the same to OP bearing Authorization no.04AOIA0915088, claim no. 1501A2352 for policy no.272100/48/ 2014/1804 and file no. 15CBOLOIA1928 and the complainant and his family members were shocked as OP asked him to pay the difference amount of Rs.80,000/- via e- mail dated 22.10.2014. The complainant further alleged that the complainant belong to a middle class family & to pay the amount in 10 minutes was not possible and the complainant directed the executive of OP to approve the balance amount of Rs.80,000/- at the earliest in order to resolve the matter but even after that no positive response has been taken by OP and the complainant even sent an application to OP on 08.09.2014 to get the approval of Rs.80,000/- but of no avail and has caused a lot of trouble to the complainant and OP has made false promise to the complainant that the full amount would get approved. Thereafter, the complainant has been trying to communicate with OP but there has been no response from their side, the complainant is entitled for undisrupted and honest services by them and their act of nuisance cannot under any circumstances be overlooked. The complainant further alleged that the complainant tried to resolve the dispute amicably by sending a letter dated 05.06.2015 to OP but to no avail and OP has failed to release the claim despite repeated requests of the complainant and approach of OP amounts to deficiency in services and unfair trade practice.
2. On these allegations the complainant has filed the present complaint praying for direction to the OP to apologize DISMISSED PAGE 3 OF 8 FA. NO./331/2019 ORIENTAL INSURANCE CO. LTD. VS. MR. PRINCE MANGAL D.O.D.: 06.11.2024 for all the inconvenience caused to the complainant, to refund the amount of Rs.80,000/- as well as compensation of Rs.50,000/- for causing damages for mental pain, agony, harassment and has also sought Rs.1,000/- towards cost of litigation."
2. The District Commission after taking into consideration the material available on record passed the order dated 28.03.2019, whereby it held as under:
"6. This forum has considered the case of the complainant as well as OP in the light of evidence and documents placed on record by the complainant. The documents and evidence of the parties shows that the complainant was admitted in MAX Super Specialty Hospital, Shalimar Bagh, Delhi on 31.08.2014 and was discharged from the hospital on 04.09.2014 and due to Myocardial Infraction or ACS. On the other hand, the copy of rates placed on record by OP contains the names of Escorts Okhla, Jessa Ram/Escorts Faridabad & Fortis Vasant Kunj/Shalimar Bagh/Noida and thus it shows that copy of rates placed on record by OP does not show about any agreement of rates with MAX Super Specialty Hospital, Shalimar Bagh, New Delhi. So, OP cannot derive any benefit from the copy of agreement of rates agreed with the hospital which has been placed on record. Accordingly, we are of opinion that there is no merit in the defence of OP and OP ought not to have repudiated the claim of the complainant. Since OP has not released the said amount to the complainant, so, while refusing the claim, OP has indulged in unfair trade practice and deficiency in service. Thus, OP is held guilty accordingly.
DISMISSED PAGE 4 OF 8 FA. NO./331/2019 ORIENTAL INSURANCE CO. LTD. VS. MR. PRINCE MANGAL D.O.D.: 06.11.2024
7. Thus, holding guilty for the same, we direct the OP as under:
i) To pay to the complainant an amount of Rs.80,000/- being the balance amount for hospitalization and medical treatment expenses paid by the complainant.
ii) To pay to the complainant an amount of Rs.40,000/- as compensation for harassment and mental agony suffered.
iii) To pay to the complainant an amount of Rs. 1,000/-
towards cost of litigation.
8. The above amount shall be paid by the OP to the complainant within Foruins 30 days from the date of receiving copy of this order failing which OP Mo shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of receiving copy of this order till the date of payment. If OP fails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986."
3. Aggrieved by the aforesaid order of the District Commission, the Appellant has preferred the present appeal contending that the District Commission erroneously held the Appellant liable for the deficiency of service as the District Commission failed to appreciate and consider that the Appellant has already settled the claim of the Respondent as per the terms and conditions of the policy and as per the GIPSA packages rate. The Appellant further submitted that an amount of Rs. 2,59,000/- has already been paid to the alleged DISMISSED PAGE 5 OF 8 FA. NO./331/2019 ORIENTAL INSURANCE CO. LTD. VS. MR. PRINCE MANGAL D.O.D.: 06.11.2024 hospital. The Appellant further submitted that the District Commission has erred in not relying upon the terms and conditions as mentioned in the Policy which clearly states any no-covered or unreasonable expenses must be borne by the insured. Pressing the aforesaid submissions, the Appellant prayed for setting aside the order of the District Commission.
4. The Respondent, on the other hand, has failed to file the reply to the present Appeal till date.
5. The written arguments on behalf of both the parties are record, wherein the Appellant has reiterated the submissions mentioned in the present Appeal and further prayed for the setting aside the impugned order passed by the District Commission. The Respondent has also filed the written submissions wherein the Respondent has denied all the allegations of the Apellant and submitted that there is no error in the impugned order as the entire material available on record was properly scrutinized before passing the said order.
6. We have perused the material available on record and heard the counsel appeared on behalf of the Appellant.
7. The main question for consideration before us is whether the District Commission has erred in establishing deficiency on the part of Appellant/Opposite Party.
8. On perusal of record, we find that the Respondent availed a Mediclaim policy from Appellant which was valid from 09.01.2014 to 08.01.2015. Further, the Respondent got admitted to Max Super Speciality Hospital on 31.08.2014 wherein he was diagnosed with Myocardial Infraction or ACS, and advise to undergo Angioplasty and to confirm insurance coverage, the brother of Respondent contacted the Appellant, who assured full coverage without conditions under the medi-claim insurance where Appellant agreed to provide the entire claim amount. However, later the TPA desk informed his brother that only an amount of Rs. 1,18,000/- out of Rs. 1,98,000/- for medical consumables was approved, as it was cashless facilities under GIPSA DISMISSED PAGE 6 OF 8 FA. NO./331/2019 ORIENTAL INSURANCE CO. LTD. VS. MR. PRINCE MANGAL D.O.D.: 06.11.2024 guidelines and the claim has been settled in accordance with the clause 3.12 of the policy.
9. Furthermore, on perusal of record, we find that the Respondent had annexed the copy of the policy before the District Commission where no such clause has been mentioned. However, the Appellant has filed the copy of the terms and conditions of the policy, wherein the clause 3.12 clearly specifies that:
a) For a networked hospital means the rate pre-agreed between Network Hospital and the TPΑ /Company, for surgical/medical treatment that is necessary for treating the insured person who was hospitalized
b) For any other hospital it shall mean the cost of surgical/medical treatment that is necessary and reasonable for treating the condition for which insured person was hospitalized.
10. Additionally, the list of rates submitted by the Appellant before the District Commission includes the names of Escorts Okhla, Jessa Ram/Escorts Faridabad, and Fortis Vasant Kunj/Shalimar Bagh/Noida. However, the Appellant failed to provide any evidence of pre-agreed rates specifically with MAX Super Specialty Hospital, Shalimar Bagh, New Delhi, where the Respondent underwent surgery. Therefore, we hold that the District Commission was correct in holding a deficiency of service on the part of the Appellant. Furthermore, it remains unclear whether the Appellant provided the Respondent with a copy of the terms and conditions when renewing the policy in question. It is a well-established legal principle that unless the insured (Respondent) is adequately informed of the policy's terms and conditions, exclusionary clauses within the policy cannot be enforced. Therefore, no inference can be drawn in this regard.
11. Infact, from the above discussion, we are in agreement with the reasons given by the District Commission and fail to find any cause or reason to interfere in the findings of the District Commission. Consequently, we DISMISSED PAGE 7 OF 8 FA. NO./331/2019 ORIENTAL INSURANCE CO. LTD. VS. MR. PRINCE MANGAL D.O.D.: 06.11.2024 uphold the order dated 28.03.2019 passed by the District Consumer Disputes Redressal Commission (North West), Govt. of NCT of Delhi. CSC Block-C, Pocket-C, Shalimar Bagh, Delhi-110088.
12. Accordingly, the present Appeal stands dismissed with no order as to costs.
13. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
14. FDR, if any, be released in favour of the Legal Representatives of the deceased Respondent.
15. The Judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
16. File be consigned to record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (PINKI) MEMBER (JUDICIAL) Pronounced On:
06.11.2024 LR-AJ DISMISSED PAGE 8 OF 8