State Consumer Disputes Redressal Commission
The Oriental Insurance Company Limited vs Amrik Singh on 21 November, 2024
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
First Appeal No. 199 of 2024
Date of institution : 22.04.2024
Reserved on : 29.10.2024
Date of Decision : 21.11.2024
1. The Oriental Insurance Company Limited, Registered Office,
Oriental House, Post Box No. 7037, A-25/27, Asaf Ali Road, New
Delhi (110002) through its Authorized Signatory
2. The Oriental Insurance Company Limited, Registered Office
situated at The Mall, First Floor, Opposite Town Hall, Ferozepur City
152 002 through its Authorized Signatory.
3. M/s Medi Assist Insurance, situated at Plot No. 4/1 IBC
Knowledge Park, Tower "D", 4th Floor, Bannerghatta Road, Bangalore
560 029 through its Authorized Signatory.
Now all through their Authorized Signatory Satpal Singh, Deputy
Manager, The Oriental Insurance Company Limited, Regional Office,
SCO No. 109-111, Sector 17D, Chandigarh
....Appellants/Opposite Parties
Versus
Amrik Singh aged about 70 years son of Sh. Joginder Singh, resident
of Village and Post Office Rukna Begu, Tehsil and District Ferozepur.
Mobile No. 98888-57047
....Respondent/Complainant
First Appeal under Section 41 of the
Consumer Protection Act, 2019 against the
order dated 12.03.2024 passed by the District
Consumer Disputes Redressal Commission,
Ferozepur.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Mr. Vishav Kant Garg, Member
1) Whether Reporters of the Newspapers may be allowed to see the Judgment? Yes/No First Appeal No. 199 of 2024 2
2) To be referred to the Reporters or not? Yes/No
3) Whether judgment should be reported in the Digest? Yes/No Present:-
For the appellants : Sh. J.P. Nahar, Advocate
For the respondent : Sh. P.K. Bansal, Advocate
VISHAV KANT GARG, MEMBER :
Appellants/Opposite Parties i.e. The Oriental Insurance Company Limited, have filed the present Appeal through its Deputy Manager to challenge the impugned order dated 12.03.2024 passed by the District Consumer Disputes Redressal Commission, Ferozepur (in short, "the District Commission"), whereby the Complaint filed by the Respondent/Complainant-Amrik Singh has been partly allowed.
2. It would be apposite to mention here that hereinafter the parties will be referred, as were arrayed before the District Commission.
3. Briefly, the facts of the case as made out by the Respondent/Complainant in the Complaint filed before the District Commission are that the Complainant was having Bank Account with Punjab National Bank, Branch Ferozepur Cantt and the said Bank had a tie-up with OPs No.1&2 for selling their insurance policies. The Complainant had purchased Medi-claim Insurance Policy No. 233700/48/2023/945, valid for the period 08.08.2022 to 07.08.2023 wherein sum insured was provided as Rs.5 lakh. During the subsistence of the said policy, the Complainant suffered pain in his stomach and had suddenly fallen on the road. The Complainant was admitted with the said problem in Dhingra Hospital on 06.10.2022, from where he was referred to DMC & Hospital Ludhiana on 11.10.2022 for further treatment. The Doctor First Appeal No. 199 of 2024 3 of DMC Hospital had initially provided him the oral treatment for 2 months. Thereafter, on 02.01.2023 his major surgery of Multiple Herinial defects, Heaptic Hemangioma and Urinary Bladder Wall was conducted at DMC & Hospital, Ludhiana and he had spent an amount of Rs.1,80,865/- on the said treatment. The Complainant had lodged his claim with the OPs, who approved only a claim of Rs.40,000/- while denying to pay Rs.1,40,865/-. On enquiry, OPs told him that for such type of treatment only an amount of Rs.40,000/- was applicable whereas in the policy no such type of limit has been mentioned. It was averred that while settling his claim, only the treatment of Ventral Harnia has been considered. As the sum insured under the policy was Rs. 5 Lakh, therefore, the Complainant was entitled for whole of the expenses incurred on the treatment.
4. Stating such an act of the opposite parties to be a case of deficiency in service and unfair trade practice, it was prayed in the Complaint that the opposite parties be directed to pay the remaining amount of Rs.1,40,865/- along with interest @ 9% p.a., Rs.50,000/- be granted as compensation on account of suffering harassment and mental agony at the hands of the opposite parties and Rs.11,000/- as litigation expenses.
5. Upon issuance of notice in the Complaint, the Appellants/ Opposite Parties had filed written statement by raising certain preliminary objections that the Complaint was not maintainable as the claim of the Complainant had been rightly paid as per terms and conditions of the policy. Neither any deficiency in service nor unfair trade practice had arisen on the part of the OPs whereas the Complainant had not approached the District Commission with clean hands. On merits, it was pleaded that the Complainant had purchased the medi-claim insurance policy through the Branch of Punjab National Bank. The Complainant has First Appeal No. 199 of 2024 4 stated that he had spent an amount of Rs.1,80,865/- on the Hernia treatment at DMC, Ludhiana. The OPs had considered his claim as per terms and conditions of the insurance policy in question and under Plan A, the limit of Rs.40,000/- was fixed for all types of Hernia treatment. Therefore, his claim had been approved for such an amount and the same had been paid. As the claim had already been settled and due amount had been paid, therefore, there was no reason with the Complainant to approach the District Commission and had unnecessarily involved the OPs in litigation. It was prayed that the Complaint being devoid of any merit, be dismissed.
6. After considering the contents of the Complaint and the reply thereof filed by the Opposite Parties as well as on hearing the oral arguments raised on behalf of both the sides, the Complaint filed by the Complainant was partly allowed by the District Commission vide order dated 12.03.2024. The relevant portion of the said order as mentioned in Para-12 is reproduced as under:
"11. The Commission has observed that it is admitted case of the parties that the complainant has taken insurance policy from the opposite parties. It is also admitted fact that the complainant duly intimated regarding the treatment. The disputed fact is that whether the policy terms and conditions were supplied to complainant or not and according to which the mediclaim was settled. The counsel for complainant contended that the said policy terms and conditions were not explained/supplied to the complainant and the opposite parties did not pay the remaining mediclaim amount of the complainant. We observed that as per the insurance policy, which is placed on file as Ex.C1, which shows that complainant obtained insurance policy from OP No.1 for sum insured Rs.5,00,000/-. As per the said document in the column Risk Details it is mentioned that sum insured Rs.5,00,000/- plan type "Plan A". Moreover, when the insurance policy has conditions or options to chose at the time of taking insurance policy, the same must be specifically brought to the notice of the insured and are required to be got it signed to show that such conditions or options have been brought to his/her notice. The insurance company cannot take shelter under the umbrella of so called First Appeal No. 199 of 2024 5 terms and conditions of policy if the same were not supplied at the time of taking of the insurance policy. In the present case there is nothing on the file to show that the terms and conditions were brought in the notice of complainant by the opposite parties at the time of taking of insurance policy. So, in the absence of specific consent of the complainant regarding the capping clause in question, the same cannot be applicable in the mediclaim policy. Hence, in our view deducting the amount Rs.1,40,865/- out of Rs.1,80,865/- from the mediclaim of the complainant on the basis of capping clause No. 2.17 is illegal and arbitrary. The complainant spent Rs.1,80,865/- on his treatment and all the relevant record is also available with the opposite parties. Therefore, the complainant is entitled for the remaining claim amount without any deductions.
12. Therefore as a sequel of above said facts, circumstances and discussion, the Commission is of considered opinion that the present complaint is partly allowed. The opposite parties no.1&2 are directed to pay remaining mediclaim amount of Rs.1,40,865/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint i.e. 16.02.2023 till its realization. The said opposite parties shall comply with this order within 45 days from the date of receipt of copy of order. The said opposite parties are also directed to pay Rs.5000/- as consolidated compensation for mental pain agony and harassment as well as litigation expenses. Complaint against opposite party no.3 stands dismissed."
7. The aforesaid order dated 12.03.2024 passed by the District Commission has been challenged by the Appellants/Opposite Parties by way of filing the present Appeal by raising a number of arguments.
8. Mr. J.P. Nahar, Advocate, learned Counsel for the Appellants has submitted that the Complainant had purchased Oriental Insurance Bank Sathi Policy i.e. Group Insurance Policy as he has Bank Account with PNB. During the subsistence of the policy, the Complainant had taken his Hernia treatment from DMC, Ludhiana and claimed Rs.1,80,865/- as treatment charges. Whereas the said disease was covered under Clause No.2.17 of the Policy, wherein capping of Rs.40,000/- has been mentioned under Plan 'A', which option the Complainant had chosen under the policy. The said amount of Rs.40,000/- First Appeal No. 199 of 2024 6 as admissible had already been reimbursed to the Complainant so he was not entitled for any other amount. The Complainant two times earlier also had lodged the claim under the same policy in the year 2016 and 2017, which had already been paid, therefore, there was no reason with him that he was not aware of the terms and conditions of the policy. The claim had already been processed and settled as per terms and conditions of the policy, therefore, there was no ground with the Complainant to file the Complaint before the District Commission. The District Commission had wrongly and illegally allowed the Complaint, ignoring the terms and conditions of the policy, therefore, the impugned order needs to be set aside. It was also prayed that the Appeal be allowed and the impugned order be set-aside.
9. On the other hand, Sh. P.K. Bansal, Advocate, learned Counsel for the Respondent has submitted that the sum insured of each person under the policy was Rs.5,00,000/-. The major surgery of the Complainant had done during the existence of the policy. Rs.1,88,865/- incurred on the treatment, has liable to be paid by the OPs as the sum insured was upto Rs.5,00,000/-. Surgery of Ventral Hernia in Right Lumbar Region had not only been conducted whereas the other problems related to Prostomegaly with thickened urinary bladder Wall, Hepatic Hemangioma were also treated, therefore, the case of the Complainant does not fall under Plan 'A' of the policy conditions. The other treatments had not been considered by the OPs while settling the claim of the Complainant. As the policy was group insurance policy, therefore, neither the terms and conditions of the same including exclusion clauses had been explained to the Insured nor the copy of the same had been provided. No documentary evidence has been placed on record in this regard. OPs-Insurance Co. illegally and wrongly denied the remaining amount. The District First Appeal No. 199 of 2024 7 Commission after thoroughly considering all the aspects, passed the well- reasoned order. It was prayed that the Appeal being without any merit be dismissed.
10. We have heard the arguments of the learned Counsel for both the parties and have also carefully perused the impugned order passed by the District Commission, written arguments submitted by the parties and all relevant documents available on the file. We have also gone through the judgments cited by both the parties.
11. Undisputedly the Complainant was insured under Oriental Insurance Bank Sathi Policy of the OPs and during the subsistence of the policy, he had undergone for surgery. On the treatment he had spent an amount of Rs.1,80,865/- and claimed the same from the OPs. OPs considering the said claim reimbursed Rs.40,000/- only for Hernia treatment, for which he was eligible under Plan 'A' of the policy.
12. Being dissatisfied with this action of the OPs, the Complainant filed the Consumer Complaint and claimed the remaining amount of Rs.1,40,865/- from the OPs stating the action of the OPs was illegal and arbitrary.
13. First grouse of the Complainant was that the terms and conditions of the policy had neither been supplied nor explained to him, therefore, the same were not applicable in his case. In reply to this, the Appellants have stated that the Complainant had purchased the said policy since long and he had earlier also received the claim of his previous treatment two times in the year 2016 and 2017, therefore, it is unbelievable that the Complainant was not aware about the terms and conditions of the policy. It is also stated that duly stamped policy had been delivered to the Complainant. The Insured during the policy term had never communicated First Appeal No. 199 of 2024 8 to the OPs that they had not received the Insurance Policy or its terms and conditions. On the Policy Schedule, the Company had provided Toll Free No. for convenience and lodging complaint, if anybody had any grievance. The Complainant had purchased the said policy since long, therefore, it is unbelievable that he did not know about the terms and conditions of the policy in so many years. There is a judgment of the Constitutional Bench of the Hon'ble Apex Court i.e. "General Assurance Society Limited versus Chandmull Jain" 1966 (7) CPSC 44 wherein it was observed by the Court that it is immaterial whether the policy is delivered or not. When the contract of insurance is complete between the parties then the parties are governed by the terms and conditions of the policy. Relevant extract of para No. 11 of the judgment is as under:-
".....The policy not only defines the risk and its duration but also lays down the special terms and conditions under which the policy may be enforced on either side. Even if the letter of acceptance went beyond the cover notes in the matter of duration, the terms and conditions of the proposed policy would govern the case because when a contract of insuring property is complete, it is immaterial whether the policy is actually delivered after the loss and for the same reason the rights of the parties are governed by the policy to be, between acceptance and delivery of the policy. Even if no terms are specified the terms contained in a policy customarily issued in such cases, would apply."
14. The Complainant had not brought any document to prove that he had informed the OPs that he has not received the terms and conditions of the Insurance Policy. The judgment relied upon by the Respondent/Complainant is not applicable in the present case because it is clear that the Complainant was covered under the policy since long and received the claims earlier, therefore, he was very much aware about the terms and conditions of the same. This Commission in F.A. No. 198 of 2020 "Oriental Ins. Co. Ltd. Vs. Deepak Mittal & Anr.", decided on First Appeal No. 199 of 2024 9 10.11.2020 held that 'if the Complainants would have been aggrieved for non-supply of the policy terms they would have agitated for the same immediately after receiving of 1st policy or 2nd policy but not after the lapse of so many years.' After the purchase of the Insurance Policy, the parties are governed by the terms and conditions of the policy, therefore, the same are fully applicable in the present case and the Complainant cannot take the shelter that the terms and conditions were not supplied to him.
15. Admittedly, the Complainant was diagnosed with the problem of 'Right Lumbar Hernia' and his surgery of Ventral Hernia in Right Lumbar Region, Prostomegaly with thickened Urinary Bladder Wall and Hepatic Hemangioma was done. To examine the question whether all these problems related to hernia only or not, we have searched the said disease on 'google search engine':-
"Ventral Hernia is a bulge in the abdomen that occurs when tissue or an organ pushes through a weakness in the abdominal wall. Prostatomegaly i.e. enlarged prostate and a thickened bladder wall can be related to a Hernia.
Hepatic Hemangioma (Herniation) : An abdominal incisional hernia is a rare phenomenon that has been seldom reported in the medical literature.
16. From the above, it is clear that all the above said problems are inter-connected with Hernia, therefore, it is clear that the surgery of the Complainant was done for Hernia problem.
17. The issue is as to whether there was any 'deficiency in service' or 'unfair trade practice' on the part of the OPs while approving the claim of the Complainant of Rs.40,000/- or not?
18. To examine this, we have seen Policy No.233700/48/2023/945, which was valid for the period 08.08.2022 to 07.08.2023 (Ex.C-1). In the said policy under the column 'RISK DETAILS', it is clearly mentioned that the sum insured was Rs.5,00,000/- and Plan chosen as 'PLAN A'. Therefore, it is clear that the claim has only been First Appeal No. 199 of 2024 10 settled under the capping of 'Plan A'. Now we have seen the terms and conditions of Oriental Insurance Bank Sathi Policy (Ex.OP-1&2/3 and Annexure A-4). Clause 2.17 of the said policy relates to Limit of Indemnity fixed under the policy for claims relating to different disease. The said Clause is reproduced for reference:-
Sr. Name of the Disease/ Procedure Limit of Indemnity (INR) No. Plan A Plan B 1 Cataract (including Lens) 32000 40000 2 Unilateral Total Knee Replacement 135000 165000 (excluding implant) 3 Unilateral Total Hip Replacement 135000 165000 (excluding implant) 4 Piles, Fistula, Fissure, Tonsillitis, 20000 30000 Sinusitis 5 Benign Prostatic hypertrophy, 40000 50000 Hernia (all types of Hernia)
6. Appendicitis, Gall Bladder Stones 30000 40000
7. Hysterectomy 40000 50000 SI upto INR SI above 10 Lacs 10 Lacs I Internal congenital diseases, genetic Per policy Per policy diseases or disorders period 10% of period 10% SI, subject to of SI, maximum of subject to INR 50,000. maximum of INR 1,50,000 II Age related macular degeneration Per policy Per policy (ARMD) period 10% of period 10% SI, subject to of SI, maximum of subject to INR 50,000 maximum of INR 1,50,000 From the above, it is clear that under the Policy for treatment of different types of diseases, Capping of paying the maximum amount has been fixed. As the ailment and treatment of the Complainant was related to Hernia, therefore, under Plan 'A', which the Complainant had opted in the policy, the maximum capping was fixed as Rs.40,000/-. The OPs considered the claim of the Complainant under the terms and conditions of the policy and paid the amount as entitled to the Complainant. Hon'ble Supreme Court of India in "Suraj Mal Ram Niwas Oil Mills Vs. United First Appeal No. 199 of 2024 11 India Ins. Co." (2010) 10 SCC 567, observed that it is not open for the Court to add, delete or substitute any word in the terms and conditions of the policy. Further in "Vikram Greentech (I) Ltd. and Anr. Versus New India Assurance Co. Ltd." 2009 (4) CLT 313, the Hon'ble Supreme Court of India observed that Court while construing the terms of the policy, it is not expected to venture into extra liberalism that may result in re-writing the contract or substituting the terms which were not intended by the parties. Therefore, it is clear that the parties are bound by the terms and conditions of the policy and the claim should be settled under the same.
19. When it is not disputed that the Complainant had undergone for surgery during the subsistence of the Insurance Policy then it is clear that he is entitled for claiming the insurance amount, which he had claimed. But as discussed above, the parties are bound by the terms and conditions of the policy, therefore, his claim can only be considered under the terms and conditions of the policy.
20. The District Commission has not rightly considered the fact that claim had been rightly approved by the OP under the terms and conditions of the Insurance Policy. It was wrongly observed that the terms and conditions of the Insurance Policy had not been explained to the Complainant, whereas when the Complainant had previously received the claims under the same policy from the OPs, therefore, it was wrongly observed that the Complainant was not knowing the terms and conditions of the policy. There is no doubt that sum insured under the policy was Rs.5 lakh but capping for the treatment of 'Hernia' under Plan 'A' was maximum upto Rs.40,000/-. Under Plan 'A' of the policy, OPs were liable to pay maximum amount of Rs.40,000/-, which they had already paid to the Complainant. As the OPs had dealt with the claim of the Complainant as per the terms and conditions of the Insurance Policy, therefore, there was First Appeal No. 199 of 2024 12 no 'deficiency in service' or 'unfair trade practice' established on the part of the Appellants/OPs and we hold that the claim had rightly been settled by the Insurance Company.
20. Keeping in view the aforesaid observations, documents available on the file, we deem it appropriate to set-aside the impugned order passed by the District Commission. Accordingly, the present Appeal is allowed and the impugned order dated 12.03.2024 is set-aside. Consequently, the Complaint filed by the Complainant is dismissed for the reasons referred above. No order as to costs.
21. Since the main case has been disposed off, so all the pending Miscellaneous Applications, if any, are accordingly disposed off.
22. The Appellants had deposited a sum of Rs.77,888/- at the time of filing of the Appeal. Said amount, along with interest which has accrued thereon, if any, shall be remitted by the Registry to the District Commission forthwith. The concerned party (appellants) may approach the District Commission for the release of the same and the District Commission may pass appropriate order in this regard in accordance with law.
23. The Appeal could not be decided within the statutory period due to heavy pendency of Court Cases.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER (VISHAV KANT GARG) MEMBER November 21, 2024.
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